1. Care OF THE pediatric patient with movement and coordination problems
Elizabeth Allen RN, MSN

2. Learning Objectives
Describe Pediatric Variations in the Musculoskeletal System
Recognize Signs and Symptoms of Infectious Musculoskeletal Disorders
Collaborate with Families to Plan Care for Child with Chronic or Long-Term Disorders
Plan Nursing Interventions to Promote Safety and Developmental Progression for Children with Braces, Casts, Traction, and Surgery
Provide Nursing Care Regarding Prevention and Treatment of Fractures in a Child

3. Musculoskeletal Differences
Child’s Bones
More porous and pliable
Less dense
Infant Skull
Fontanel closure: 18 months
Overall growth completion: 2 yrs
Child Bone Growth from Epiphyseal Plate
Muscles
Number same as adult
Only length and circumference grow
Ligaments and Tendons
Stronger than bone until puberty
Children break bones before puberty. Intervention often needed if fracture occurs through epiphyseal plate

4. Orthopedic Disorders Talipes equinovarus (Club Foot) “varus”
Figure 28–5 Parents of a child with clubfoot will have many questions. Can the condition be treated? Will the child be able to walk normally after surgery? Will parents need help caring for the infant? How much will surgery and other care cost? Will any subsequent children have a clubfoot? Modified from Staheli, L. T. (1992). Fundamentals of pediatric orthopedics (p. 5.10). New York: Raven Press.
Unknown cause- possibly intrauterine positioning, genetic or neuromuscular problems
Serial casting ASAP after birth- changed every 1-2 weeks for approx 12 weeks
If not corrected surgery between 3-12 months followed by casting for 6-12 weeks
“varus”
means inward

5. Orthopedic Disorders Genu valgum (knock- knees) Genu varum (bowlegs)
Until 2-3 years- knees are normally bowed (Varum).
Persistence of knock knees beyond 4-5 years should be evaluated
Most common causes Rickets or Blount disease (abnormal growth on medial side of top of tibia)
If severe enough, braces and then surgery
Figure 28–9 A, Genu valgum or knock-knees. Note that the ankles are far apart when the knees are together. B, Genu varum or bowlegs. The legs are bowed so that the knees are far apart as the child stands.

6. Orthopedic Structural Deformities
Hip
Dysplasia
Legg-Calve-Perthes
Slipped Capital Femoral Epiphysis (SCFE)

7. Developmental dysplasia of the hip
Pathophysiology
Femoral head and the acetabulum are improperly aligned
Hip instability
Dislocation
Subluxation
Asymmetry of gluteal folds
Girls 4x’s more than Boys
Allis’ sign
One knee lower than the other when the knees
are flexed
Ortolani-Barlow
maneuver positive
Treatment
Pavlik harness
Bryant’s traction
>6 months: closed
reduction & spica cast
This condition affects girls 4 x more often than boys. 80% of time it is unilateral- affecting only 1 hip. L hip affected 3 x as often- this is related to intrauterine position
Assessment from birth to approx 2 years of age.
Ortalani bend up 90 degrees and frog leg out- feel and hear hip slip back into socket
Barlow 1 leg up and adduct it across the body and feel hip slip out of joint
Pavlik harness allows for movement- it ensures hip flexion and abduction but does not allow adduction or extension
Most common treatment for
DDH in a child <3 months is the
Pavlik harness

8. Developmental dysplasia of the hip
Pavlik Harness
Spica Cast
(London et al., 2014)
Spica Cast after surgery for hip dysplasia

9. Slipped Capital femoral epiphysis
Pathophysiology:
Spontaneous Displacement of the proximal femoral epiphysis
Adolescent
Very tall, obese – boys more than girls
Diagnosis
Referred pain – groin, hip or knee
X-ray, bone scan, ultrasound, MRI
Treatment
Surgery to pin and fixation of epiphysis, possible traction
Weight reduction
These kids present with limp, referred pain to groin, hip or knee
Can be acute or chronic- acute with sudden onset severe pain and inability to bear weight- may be assoc with a traumatic injury

10. Slipped Capital Femoral Epiphysis
Figure 28–14 In slipped capital femoral epiphysis, the femoral head is displaced from the femoral neck at the proximal epiphyseal plate.

11. Legg-Calve-perthes disease
Pathophysiology
Necrosis of femoral head
Boys 4x more than girls (4-10 yrs.)
Stages:
I – Initial
II – Avascular
III – Revascularization
IV – Bone healing
V – Remodeling
Diagnosis
X-ray, bone scan, MRI
Treatment
Assess
CSM, pain
Bed rest – traction
Toronto Brace
Surgery
Unknown etiology, possibly genetic. Approx 17% from mild trauma, approx 10% had breech birth. More common in low birth weight, advanced maternal age and exposure to tobacco smoke
Most common in causasian, Japanese and Chinese children
Disease lasts usually 1-4 years and then gradually revascularization begins
Diagnosis through x ray, bone scans or MRI
Treatment is traction or Toronto brace- to promote healing and prevent deformity the femoral head must be contained within the hip socket until ossification is complete. Both tx and brace maintain leg in this position (abduction).
Treatment generally takes more than 2 years

12. Orthopedic Structural Deformities
Scoliosis
More common in girls than boys
Assessment
Trunk asymmetry, 1 sided rib
hump, uneven shoulder or
hip height
Exercises
Braces (moderate curve)
Spinal surgery (Curves >40 degrees)
No bending or twisting
of the torso
Restricted from some
sports
6-8 months recovery

13. Scoliosis
Figure 28–15 A child may have varying degrees of scoliosis. For mild forms, treatment will focus on strengthening and stretching. Moderate forms will require bracing. Severe forms may necessitate surgery and fusion. Clothes that fit at an angle, such as this teenage girl’s shorts, and anatomic asymmetry of the back provide clues for early detection.

14. Fractures Prevention Types Greater risk for children
Teach use of protective equipment, safe play
Types
Closed Fracture
Casting
Open Fracture
Surgery and casting
Epiphyseal Plate
ORIF if displaced
Fracture through the epiphysis is concerning as it may affect future growth of the limb
(London et al., 2014)

15. Effects of Immobilization
Care of the Patient with Cast
Immobilize Joint and/or Bone
Perform frequent neurovascular assessment
More frequent when applied, fewer after stable
Compartment Syndrome
Elevate limb
Manage itching
Teach cast care
Care of the Patient with Traction
Force and/or Positioning to Joints and Bones
Maintain positioning and force
Protect skin from pressure, wetness
Skin Traction
Assess skin
Skeletal Traction
Pin care
Prevent infection
Respiratory Assessments
Care of the patient in a cast- frequent CMS checks and assess for compartment syndrome- 5 Ps: Pain, paresthesia, pallor, paralysis, pulselessness
Care of the patient in traction: what is the traction for? That dictates patient position (ex HOB flat or slightly elevated)
Protect skin from breakdown, lungs and maintain traction

16. Nursing Care
Figure 28–12 For infants older than 3 months of age, skin traction is commonly used for treatment of DDH

17. Nursing Care
Figure 28–16 In severe scoliosis, the child may wear a halo brace, shown here, to hold the body in position after surgery.

18. Osteomyelitis Bone Infection Etiology: Idiopathic or Nosocomial
Due to trauma, pins, unknown
Symptoms
Bone pain
Edema
Joint pain
Fever
Treatment
IV Antibiotics
Surgical debridement

19. Chronic Conditions Osteogenesis Imperfecta Achondroplasia
Brittle-bone disease, collagen defect
Thin soft skin, increased flexibility, short stature, weak muscles, hearing loss
Achondroplasia
Short stature, prominent forehead
Marfan Syndrome
Connective tissue disorder
Skeletal changes
Cardiac, respiratory, vision changes

20. Juvenile rheumatoid Arthritis
Most common Juvenile Idiopathic Arthritis
Diagnosis
younger than 16 and have initial swelling in one or more joints for at least six weeks.
Treatment Goals
Relieve pain
Reduce inflammation
Optimize child’s quality of life

21. Neuromuscular Disorders
Muscular Dystrophies
Inherited
Most common is Duchene Muscular Dystrophy (x- linked)
Progressive muscle fiber degeneration and muscle wasting
Some forms with intellectual disability
Early signs: weakness and hypotonia
Later signs: Gower’s Maneuver
Become immobile

22. Neuromuscular Disorders
Muscular Dystrophies
Diagnosis
Symptoms, muscle biopsy, EMG
Treatment
No effective treatment
Steroids and deflazacort (glucocorticoid) may preserve muscle function, walking for a time
Promote independence and mobility
Mental health support
Respiratory, GI, GU system support with progression
Progressive weakness and muscle deformity result in disabilities

23. Muscular Dystrophy
Figure 28–20 This young boy with muscular dystrophy needs to receive tube feedings and home nursing care. He attends school when possible and is able to use an adapted computer.