MUSCULOSKELETAL DISORDERS By Marlene Meador RN, MSN Fall 2006

Talipes Equinovarus (Clubfoot) Adduction and supination of forefoot with an inversion (varis) of the heel and fixed plantar flexion. Etiology unknown 75% of abnormalities of the foot (1:1000)

Clinical Manifestations Focus on early detection Rocker bottom foot Fixed position Diagnostic tests Ultrasound CT MRI

Treatment Corrective casting every 3-14 days Dennis Browne splints- horizontal bar attached to foot plates

Nursing Care Care of Casts CMS assessment Keep dry/clean Assess placement

Evaluation: Regular check-ups Prognosis ROM after removal of casts

????? An 18 month old is scheduled for application of a plaster cast to correct a clubfoot. The post-op plan should include which of the following measures? a. Elevate the cast above the level of the heart b. Handle cast with fingertips c. Reposition the child every 2 hours d. Spray the cast with an acrylic protectant

Congenital Dislocation of Hip Malrotation of the hip at birth Improper formation or function of acetabulum

Clinical Manifestations Gluteal folds Ortolanis sign Shorter femur Prominence of femur

Clinical Manifestations cont… Limited abduction Barlow Maneuver Signs and Symptoms in older child

Diagnostic Tests: Ultrasound CT and MRI X-ray

Surgical Treatment: Release muscles and tendons Application of body- spica cast

Treatment Splinting of hip- Pavlick harness Hip maintained in flexion and abduction Deepen acetabulum from pressure of femur head

????? A parent asks why her infant must wear a Pavlik harness. The nurse responds that he purpose of this device is to: A. Provide comfort and support B. Shorten the limb on the affected side C. Maintain the femur within the acetabulum D. Provide outward displacement of the femoral head.

Treatment with Spica Cast For complex cases and older children Dislocated -some closed and open reductions

Nursing Management Case finding and referral Teach parent application of harness Protect skin Bring environment to child Safety

Spica Cast Care Use palms to handle cast Bar between the legs is not a handle! Use pillows for positioning Keep cast clean & dry

Fractures Greenstick fracture- most common type in kids < 3 years MVA -frequent cause of bone injury in 4-7 year olds Porous &

Pathophysiology Epiphyseal plate Pliable and porous

Fractures Occur as a result of direct or indirect force Repeated stress on the bone Pathologic conditions

Healing Rapid in children 1 week for every year of life up to 10 years of age

Assessment Pain (PROM) Tenderness Edema Limited movement Distortion of limb

Nursing Care Casting Traction Compartment syndrome Surgical intervention

Muscular Dystrophy Duchennes- 13 types Onset of symptoms

Prognosis Ability to walk lost by age 9-12 Death occurs 9-10 years after diagnosis 1:3500 children effected

Diagnosis Muscle biopsy Serum enzyme CK Electromyogram EEG (75% are abnormal)

Nursing Care Promote optimal health Goal: keep child ambulatory Assess muscle weakness Respiratory function Nutritional status OT, PT

Scoliosis Curve greater than 25 degrees Functional Postural Compensatory Structural Idiopathic (70-80% of all cases) Congenital Neuromuscular –Poliomyelitis –Cerebral palsy –Muscular dystrophy

???? The school nurse would screen an adolescent for scoliosis by instructing him/her to: A. Bend forward at the waist and allow upper extremities to dangle B. Lie prone on an examination table C. Stand with shoulders placed against the wall to check evenness D. Sit on a chair and raise shoulders

Manifestations Progression- 1 degree per month Observation of curves Texas response to funding issues 6 th & 8 th grades

Bracing Used for skeletally immature

???? An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen? A. Discourage participation in ADL’s. B. Teach appropriate application, removal and care of skin and brace. C. Discourage sports like golf and tennis encourage sedentary activities. D. Teach non-weight bearing techniques.

Rods: Recommended for curves >40 degrees Goal: fuse spine to prevent progression Why is surgery the recommended treatment for progressive curvature?

Post-op Care Pain management Monitor Neurovascular status Monitor H&H Log Roll, sit, ambulate Dressing changes Report vomiting WHY???

What would you teach a child to expect in the immediate post-op period? Frequent neurovascular assessments Need to CT&DB every 2 hours (IS) Possibility of IV, chest tubes Use of post-op analgesia

Discharge As sited in text No contact jarring activities for 6-12 months X-rays q 1-2 years until bone solidly fused Once fused may resume normal activity levels, skiing, sports, etc…

Osteosarcoma Most common primary malignancy of the bone Etiology: Genetic Radiation therapy

Pathophysiology Originate in bone-producing cells that invade the medullary canal of the bone Incidence is higher in most rapidly growing bones in adolescents Distal femur Proximal tibia Proximal humerus

Assessment Progressive insidious or intermittent pain Palpable mass Progressive limping Pathologic fractures at tumor (late sign)

Diagnosis X-ray CT MRI Biopsy of tumor Lab tests CBC ALP LDH

Therapeutic Management Surgery Chemotherapy Radiation Amputation

Nursing Care Site of tumor History of injuries Current activity level Psychosocial history Body image

Nursing Interventions Preoperative teaching Infection Pain Risk for hemorrhage Risk for pneumonia Post operative

Ewing’s Sarcoma Second most common bone tumor Mimics infection Etiology No know cause or genetic link

Pathophysiology No defining characteristics Invades midshaft of long bones Metastasis

Diagnosis Biopsy to differentiate from other neoplastic processes

Therapeutic Management Chemotherapy Surgery Radiation

Rabdomyosarcoma Malignancy of muscle, or striated tissue Etiology associated with familial cancer syndromes

Pathophysiology Subtypes Embryonal Alveolar Pleomorphic Prognosis depends on excision of tumor, rate of metastasis

Diagnosis Soft to hard, non-tender, immobile mass Limited range of motion in effected extremity In pelvic tumors organ function disrupted CT, bone marrow aspiration and biopsy

Treatment Chemotherapy Surgery Radiation

Nursing Considerations Palpation of tumor Family support Facilitate education Postoperative Infection Hemorrhage Edema NG tube/drains

If you have further questions Contact me via Marlene Meador RN, MSN