1. The Child with a Musculoskeletal Disorder
Chapter 40:
The Child with a Musculoskeletal Disorder

2. The skeletal system is made up of four types of bone—long, short, flat, irregular.
During fetal life, tissue called cartilage, a type of connective tissue consisting of cells implanted in a gel-like substance, gradually calcifies and becomes bone.
Long bones grow from the long central shaft of the bone, called the diaphysis, to the rounded end of the bone, called the epiphysis.

3. Growth and Development of the Musculoskeletal System
Cartilage makes up the epiphyseal plate that is between the epiphysis and the diaphysis. As long as cartilage remains, the child’s bones continue to grow.
Bones grow in width at the same time they are growing in length. When the epiphyseal plate becomes an epiphyseal line and cartilage is no longer present, this marks the end of the growth of that bone in the child.
Bone growth takes place between birth and puberty, with most growth being complete by age 20 years.
During childhood, the bones are more sponge-like and can bend and break more easily than in adults.
Because the bones are still in the process of growing, breaks in the bone heal more quickly than do breaks in adults.

4. Fractures
A fracture, a break in a bone that is usually accompanied by vascular and soft tissue damage, is characterized by pain, swelling, and tenderness. Decreased function of the extremity is characteristic of a fracture.
In a complete fracture, the fragments of the bone are separated. In an incomplete fracture, the fragments remain partially joined.
The types of fractures seen in children are simple or closed; compound or open, where the bone penetrates the skin; spiral fractures, which twist around the bone; or greenstick fractures, another type of incomplete fracture.
Most fractures are treated by realignment and immobilization using either traction or closed manipulation and casting.

5. Types of fractures
Examples of complete fractures. (A) No penetration of the skin. (B)Penetration of the skin. (C) Twist around the bone. Incomplete fracture (D) caused by incomplete ossification.

6. Fractures (cont.)
Neurovascular checks are done in a child with a musculoskeletal disorder to monitor the child's neurovascular status to detect and prevent tissue and nerve damage.
Compartment syndrome is a serious neurovascular concern that occurs when increasing pressure within the muscle compartment causes decreased circulation.

7. Performing neurovascular checks is sometimes referred to as CMS (circulation, movement, sensation) checks
These include observing, documenting, and reporting the five P’s:
• Pain: Any sign of pain should be noted and the exact area determined.
• Pulse: If an upper extremity is involved, check brachial, radial, ulnar, and digital pulses. If a lower extremity is involved, monitor femoral, popliteal, posterior tibial, and dorsalis pedis pulses.
• Paresthesia: Check for any diminished or absent sensation or for numbness or tingling.
• Paralysis: Check hand function by having the child try to hyperextend the thumb or wrist, oppose the thumb and little finger, and adduct all fingers. Check function of the foot by having the child try to dorsiflex and plantarflex the ankles and flex and extend the toes.
• Pallor: Check the extremity and the nail beds distal to the site of the fracture for color. Paleness, discoloration, and coldness indicate circulatory impairment.

8. In addition to the five P’s:
any foul odor or drainage on or under the cast;
“hot spots” on the cast (areas warm to touch);
looseness or tightness;
or any elevation of temperature must be noted, documented, and reported.
Family caregivers should be instructed to watch carefully for these same danger signals.

9. Fractures (cont.)
The basic types of traction are skin traction and skeletal traction.
Examples of skin traction are Bryant traction, Buck extension traction, and Russell traction.
Examples of skeletal traction are 90-degree traction and balanced suspension traction.
Dunlop traction can be either skin or skeletal.

10. Types of traction.
 A. Buck extension, skin traction. B. Russell traction, skin traction. Two lines of traction (one horizontal and one vertical) allow for good bone alignment for healing. C. 90°–90° (skeletal) traction; a wire pin is inserted into the distal femur. D. Balanced suspension traction. E. Dunlop traction (skeletal).

11. External fixation is required for complicated fractures.
An infant in Bryant traction is being fed. Used for developmental hip dysplasia
External fixation is required for complicated fractures.
 B. The Ilizarov fixator is a circular apparatus usually used for complicated lower extremity fractures. The pins are smaller in diameter, more like wires, than those used in other fixators.

12. Osteomyelitis
Osteomyelitis is an infection of the bone usually caused by Staphylococcus aureus, such as a staphylococcal skin infection (impetigo), burns, a furuncle (boil), a penetrating wound, or a fracture.
Symptoms usually begin abruptly with fever, malaise, pain, and localized tenderness over the metaphysis of the affected bone. Joint motion is limited.
Diagnosis is based on laboratory findings of leukocytosis (15,000 to 25,000 cells or more), an increased erythrocyte sedimentation rate, and positive blood cultures. Radiographic examination does not reveal the process until 5 to 10 days after the onset.
IV antibiotics may be followed by administration of oral antibiotics for treatment.
Nursing care includes reducing pain by positioning the affected limb, minimizing movement of the limb, and administering medication.

13. Muscular Dystrophy
The most common form of muscular dystrophy is Duchenne (pseudohypertrophic) muscular dystrophy;
an X-linked recessive hereditary disease, occurs almost exclusively in males. Females are usually carriers.
The first signs are noted in infancy or childhood, usually within the first 3 to 4 years of life.
The characteristics include difficulty standing or walking, trunk muscle weakness, and mild intellectual disability.
Weakness of leg, arm, and shoulder muscles progresses gradually with the child usually becoming wheelchair- bound. The disease continues into adolescence and young adulthood, when the client usually succumbs to respiratory or heart failure.
No effective treatment for the disease has been found

14. Gowers sign is used to rise from the floor.
 A. First the child must roll onto his hands and knees. B. Then he must bear weight by using his hands to support some of his weight, while raising his posterior. C–E. The boy then uses his hands to “walk” up his legs to assume an upright position.

15. Legg–Calvé–Perthes Disease
Legg–Calvé–Perthes disease is an aseptic necrosis of the head of the femur.
occurs four to five times more often in boys than in girls and 10 times more often in whites than in other ethnic groups. It can be caused by trauma to the hip, but generally the cause is unknown.
The treatment includes use of a brace that holds the head of the femur in place or reconstructive surgery.
The prognosis for complete recovery without difficulty later in life depends on the child’s age at the time of onset, the amount of involvement, and the cooperation of the child and the family caregivers.
Nursing care focuses on helping the child and caregivers manage the corrective device and the importance of compliance to promote healing and to avoid long-term disability.

16. Osteosarcoma
malignant tumor seen in the long bones, such as the femur, thigh, and humerus.
An injury, such as a sports injury, may draw attention to the pain and swelling at the sight of the tumor, but the injury itself did not cause the tumor.
The treatment for osteosarcoma is to remove the bone or the limb where the tumor is found.
After an amputation, phantom pain in the amputated extremity can be relentless. Learning to live with a prosthesis may be a long and challenging process.
With early diagnosis and treatment, many children survive this diagnosis and live into adulthood.
For Ewing sarcoma, tumor found in the bone marrow of the long bones, the tumor must be removed, and radiation is done. In both disorders, chemotherapy is given.

17. Juvenile Idiopathic Arthritis
Juvenile idiopathic arthritis (JIA) is a connective tissue disease. two age levels: 1 to 3 years and 8 to 10 years
The treatment goal is to maintain mobility and preserve joint function. Treatment can include drugs, physical therapy, and surgery.
Enteric-coated aspirin had long been the drug of choice for JIA, but because of the concern of aspirin therapy and Reye syndrome, NSAIDs, such as naproxen and ibuprofen, are being used.
The primary benefit of using these drugs is their anti- inflammatory effects.
To decrease the side effects, the drugs should be administered with food or milk. Disease modifying antirheumatic drugs (DMARDs) and glucocorticoids may need to be used in severe cases of JIA.

18. Scoliosis
Scoliosis is a lateral curvature of the spine, either structural or functional.
Nonsurgical treatment includes electrical stimulation or the use of braces, such as the Boston brace or TLSO brace, or traction.
Surgical treatment includes the use of rods, screws, hooks, and spinal fusion.
Goals include minimizing the disruption of activities, preventing injury, and maintaining skin integrity and self- image.

19. Scoliosis
A. Posterior view of child’s back with lateral curvature. B. View of child bending over with prominence of scapular area and asymmetry of flank demonstrated.

20. A. Boston brace. B. Milwaukee brace. C. Nighttime bending brace.