1. Pediatric Chapter 34: Musculoskeletal Alterations
N124IN
Spring 2013

2. Part 2

3. Clubfoot Incidence and Etiology Pathophysiology
Unknown cause
Pathophysiology
One foot or both feet
Bones, ankle joints, tendons, ligaments may also be affected
Clinical Manifestations
Foot points downward, toes turned inward, bottom of foot twisted inward
Painless
Abnormal, awkward gait

5. Clubfoot, cont. Diagnosis Visual inspection Radiographs, MRI Treatment
Serial casting
Braces
Surgical intervention

6. Clubfoot, cont. Nursing Management
Provide emotional support and education to caregivers
Postsurgical care
Neurovascular checks
Assess for edema and drainage
Apply ice bags
Elevate foot or feet
Pain relief
Encourage caregivers to participate in care

7. Clubfoot, cont. Family Teaching Sponge baths
Cling film to wrap around casts during diaper change
Assessing skin
Assessing neurovascular status
Precautions for fresh casts
Signs of infection
Potential safety hazards

8. Developmental Dysplasia of the Hip (DDH)
Congenital anomaly
Femur head has abnormal relationship with acetabulum

9. DDH, cont. Incidence and Etiology Physiological factors
Ligamentous laxity
Maternal hormone secretion
Increased maternal pelvic laxity
Mechanical factors
C-section
Genetic factors
Family history

10. DDH, cont. Pathophysiology Spectrum Types of dislocated hips
Subluxated
Dysplastic
Dislocatable
Types of dislocated hips
Teratologic
Typical

11. DDH, cont. Clinical Manifestations Newborns: hip instability
Infants: limited hip abduction
Children/adolescents: limp, joint pain, osteoarthritis, gait abnormalities, unequal pelvis level .

12. DDH, cont. Diagnosis Barlow maneuver Ortolani maneuver
Examination of the hip
Radiographs
Ultrasound

13. DDH, cont. Treatment < 3 months
Abduction device (Pavlik harness)
>3 months/abduction device unsuccessful
Skin traction
Surgery
After procedure: hip spica cast

15. DDH, cont. Nursing Management Encourage reaching and pulling
Encourage bulk and bran in diet
Prevent skin breakdown
Padding, skin wrapping, position changes
If spica cast is present, trim edges
Cover all edges with moleskin or waterproof tape

16. DDH, cont. Family Teaching Encourage verbalization of fears/concerns
Cast care
Elimination, bathing, positioning
Skin traction care
Skin care, traction application
Nutritional requirements
Developmental milestones
Pavlik harness
Changing diaper, feeding in upright position, cotton undershirt/socks, no lotions/oils/powder under straps
Bring experiences to child

17. Duchenne Muscular Dystrophy (DMD)
Incidence and Etiology
X-linked recessive disease
Pathophysiology
Absence of dystrophin
Muscle degeneration
Muscle fibers replaced by fat and connective tissue

18. DMD, cont. Clinical Manifestations Progressive muscle function loss
Problems climbing stairs/running/riding bike
Waddling gait
Frequent falls
Gower’s sign
Scoliosis
Calf enlargement (pseudohypertrophy)
Wasting of the thigh muscles
Contractures
Unable to walk by 9-12 years old
Decreased respiratory function
Weak myocardium; cardiomyopathy

21. DMD, cont. Diagnosis Observation Muscle biopsy Electromyogram
Nerve conduction velocity (NCV)
Blood enzyme tests

22. DMD, cont. Treatment No cure Supportive, prevent complications
Physical Therapy (PT)
Occupational Therapy (OT)
Cough augmentation
Noninvasive ventilatory support
Steroid therapy
Surgery

23. DMD, cont. Nursing Management Monitor respiratory/cardiac status
Proper nutrition
Encourage activities in the water
Encourage activities to provide stimulation and promote normal development
Good back support/posture in wheelchair
Reposition frequently
Encourage diet high in fluid, fiber, fresh fruits/veggies
Stool softeners/laxatives

24. DMD, cont. Family Teaching Encourage discussion of feelings
Assisting with ADLs
Siblings’ needs
Include child at dinnertime
Supportive services

25. Scoliosis Deviation of the spine greater than 10 degrees
Cobb method is used to measure curvature
Mild curve: degrees
Significant curve: >25 degrees
“S” shaped spine
Can be structural (primary deformity) or functional (caused by secondary problem)

26. Scoliosis, cont. Incidence and Etiology Pathophysiology
Idiopathic scoliosis
Infantile, juvenile, adolescent
Pathophysiology
Vertebral column curves laterally
Spine/ribs rotate toward curve’s convex part
Muscles/ligaments contract and thicken on concave side
Muscles/ligaments become thin and atrophied on convex side
Compensatory curve

27. Scoliosis, cont. Clinical Manifestations
Clothing not fitting right, uneven hemline
Unequal shoulder/hip levels
Prominence of one scapula
Curved spinal column
Truncal asymmetry
One elbow closer to iliac crest
Neck pain
Headache
Sensory losses
Absent unilateral superficial abdominal reflexes
Muscle weakness
Gait defects

29. Scoliosis, cont. Diagnosis Physical exam School screening Radiographs
Cobb method

30. Scoliosis, cont. Treatment Monitoring Bracing Surgery Boston brace
Milwaukee brace
Charleston bending brace
Surgery
Spinal fusion
Harrington rod
Cotrel-Dubousset rod

31. Scoliosis, cont.
Charleston Bending Brace
Boston Brace
Milwaukee Brace

32. Kyphosis Incidence, Etiology, and Pathophysiology Congenital Postural
One side of vertebrae develops incompletely or fails to grow
Postural
Spinal curvature occurs
Secondary to other disease
Imbalance of muscle pull on either side of spine

33. Kyphosis, cont. Clinical Manifestations
Hunchback, rounded appearance to spine
Lumbar lordosis
Pain
Diagnosis
Visualization of spine/scapular area
Comprehensive orthopedic/neurologic evaluation

34. Kyphosis, cont. Treatment
Conservative treatment if curve is not severe and no pain
Exercise program
Anti-inflammatory agents
Brace
Surgery

35. Lordosis Incidence and Etiology Normal finding in toddlers
Should disappear by school-age
Pathophysiology
Spinal muscles can’t support erect position
Ligament straining

36. Lordosis, cont. Clinical Manifestations Swayback
Protruding chest and abdomen
Lower back pain
Hip pain
fatigue

37. Lordosis, cont. Diagnosis Visualization of spine Radiographs Treatment
Manage/correct cause
Postural exercises
Bracing
Surgery

38. Legg-Calve-Perthes Disease (LCPD)
Incidence and Etiology
Unknown cause
Risk factors
Impaired/disproportionate growth, low birth weight, delayed skeletal maturity, short stature, systemic hormonal changes, low socioeconomic index, extremity active, maternal smoking while pregnant

39. LCPD, cont. Pathophysiology
Blood supply interruption to femoral capital epiphysis
Causes aseptic necrosis of femur head
4 stages:
1. Femoral head becomes more dense with potential fracture of supporting bone (2-6 months)
2. Bone fragmentation and reabsorption (1 year or more)
3. Reossification (many years)
4. Healing (many years)

40. LCPD, cont. Clinical Manifestations Pain Limp Abnormal gait
Hip range-of-motion limitations
Thigh muscle atrophy

41. LCPD, cont. Diagnosis Radiograph Bone scan Treatment Bed rest
Abduction traction
Brace, crutches, harness
Non-weight-bearing exercises
Long leg cast with abduction bar
Surgery

42. LCPD, cont. Nursing Management Family Teaching
Assess and plan interventions to maintain neurovascular integrity
Assess neurovascular status
Skin care
Family Teaching
How to use crutches
Safe home environment
Skin assessments, neurovascular status assessments, signs of muscular atrophy
Appropriate ADLs, safety measures
Promoting positive self-image

43. Osteogenesis Imperfecta
Clinical Manifestations
Severe bone fragility with multiple fractures
Associated deafness
Dental deformities
Blue sclera
Hyperlaxity of ligaments
Short stature
Kyphosis/scoliosis
Tenderness
Soft-tissue damage
Bruising easily
Frequent epistaxis
Teeth break easily

44. Osteogenesis Imperfecta, cont.
Treatment
Biphosphonates
IV pamidronate
Splints, braces, casts, surgery
Adequate nutrition
Calcium, magnesium, vitamins
Supportive and nonjudgment

45. Slipped Capital Femoral Epiphysis (SCFE)
Pathophysiology
Femoral head is displaced from femoral neck
Incidence
Early adolescence during rapid growth spurts
Unknown etiology
Obesity is common factor

46. SCFE, cont. Clinical Manifestations Unstable SCFE: can’t bear weight
Stable SCFE: change in gait, limping
Pain in the affected hip, groin, thigh, or knee

48. SCFE, cont. Diagnosis Symptoms Physical exam Radiographic studies
Limited internal rotation
Radiographic studies

49. SCFE, cont. Treatment Surgery Mild to moderate SCFE Severe SCFE
Percutaneous placement of pins across growth plate
Severe SCFE
Open correction