1. Musculoskeletal

2. Common MS disorders in Children
Developmental hip dysplasia
Clubfoot
Fractures
Scoliosis
Osteogenesis Imperfecta
Osgood-Schlatter Disease
Osteomyelitis
Muscular Dystrophy
JRA

3. Disorders of the lower extremities

4. Developmental hip dysplasia
Hereditary disorder, more common in girls, unilateral
Improper formation and function of hip socket
Head of femur is dislocated
Flat acetabulum of pelvis (prevents femur from remaining in the acetabulum and rotating adequately)

5. Congenital hip dysplasia

6. Symptoms Limited abduction of the affected hip
Asymmetry of the gluteal and thigh fat folds
Affected leg may appear shorter
Positive “Ortolani click”
Uneven gait in older children

7. Diagnosis Early detection is key for success
Treatment depends on age at diagnosis

8. Management for infants under 3 months of age
Pavlik harness: keeps hips and knees flexed, the hips abducted, and the femoral head in the acetabulum worn continuously for 3 to 6 months effective 90% of time

9. Management for infants >3 months age
Hip spica cast:
maintains abduction (frog-like position) 3-18 months age
Worn for 1 year
Must be changed as child grows
ORIF (surgical insertion of pin)
For child >18mos
Successful reduction is difficult after age 4

10. Nursing Considerations
Skin care
Hygiene
Feeding
Handling
Immobility
Elimination
Growth and Development
Clothing
Transportation

11. Clubfoot (equinusvarus)
Congenital deformity of the foot
Three areas of deformity:
The midfoot is directed downward (equinus),
the hindfoot turns inward (varus),
the forefoot curls toward the heel (adduction) and turns upward in partial supination.

12. Clubfoot Can affect one or both feet
Portions of foot and ankle are twisted out of normal position
Varying degrees of severity & combinations of abnormal positions

13. Early detection is critical Part of newborn assessment
Move foot to midline
Can range from mild to severe

14. Treatment:
Begins soon after birth, before discharge
Manipulation with serial casting for 8-12 weeks (due to rapid growth)
Cast extends above infant’s knee to ensure correction

15. Surgical correction btw 4-12 mos, realignment of bones, pin insertion, cast for 6-12 weeks
Denis Browne Splints: shoes attached to metal bar to maintain correction

16. Fractures Break in bone from stress
Frequent in children- bones are not as dense and more porous
Usually occur from
Falls
Sports
MVA
Bone disease

17. Fractures Symptoms: Pain Abnormal limb positioning Decreased ROM Edema
Ecchymosis
Crepitus
Refusal to play with extremity, guarding

18. Management Cast Surgery Pins and external devices
Traction- used to align bone
Skin
Pull is applied to the skin and muscle
Skeletal
Pull is applied to the bone pins

19. Nursing Considerations: New Cast
Inspect skin
observe for swelling, pain, discoloration, odor
keep cast free of foreign objects
Monitor Neurovascular Status
keep extremity elevated for 1st day
observe for loss of distal pulse, discoloration, loss of movement

20. Watch for Compartment Syndrome
Clinical manifestations begin about 30 minutes after tissue ischemia starts.
Paresthesia (tingling, burning, loss of two-point discrimination)
Pain (unrelieved by medication, characterized by crying in the young child)
Pressure (skin is tense or discolored, cast appears tight)
Pallor distal to cast (pale, gray, or white skin tone)
Paralysis (weakness or inability to move extremity)
Pulselessness distal to cast (weak or absent pulse)

21. Cast Care in Children Promote Mobility Promote Growth and Development
Crutches
Wheelchair
Wheeled Carts (hip spica casts)
Promote Growth and Development
promote body image
provide diversional activity
cast becomes part of body, fear removal

22. Disorders of the Spine

23. Scoliosis Most common type of spinal deformity, girls 5:1 ratio
Lateral curvature of spine
Can be congenital or develop in infancy or childhood
Dx: by observation, non painful at first
All children screened in 5th grade
Ill fitting clothes
Uneven shoulders, scapulae, hips
Scoliometer: degree of curvature

24. Treatment
Treatment will not correct the curve, but prevent it from worsening
Mild Scoliosis
Life Long monitoring
Moderate Scoliosis
Bracing
Exercises to improve posture and flexibility
Electrical Stimulation to back muscles

25. Treatment for Severe Scoliosis
Surgical correction: spinal realignment & straightening (Harrington Rod)
Followed by Milwaukee Brace . Worn 23 hr day

26. Nursing Considerations
Screen and identify children
Refer to ortho for eval and treatment
Assess respiratory, neurological, cardiovascular as rib cage deformity can affect
Promote understanding and compliance of treatment
Promote good body image and self esteem

27. Disorders of the bones

28. Osteogenesis Imperfecta
Connective tissue disorder, leads to fragile bone formation
“Brittle Bone Disease”
Causes recurrent pathological fractures
Will not have normal growth in height

29. Clinical manifestations
Multiple and frequent fractures
Thin, soft skin
Increased joint flexibility
Weak muscles
Soft, pliable, brittle bones
Short stature

30. Nursing Management
Goal: protect from trauma and reduce the number of fractures
Early intervention
Splints, Braces, Surgical Rods
Childproof home

31. Nursing Management Handle child gently.
Support trunk and extremities as child is moved.
Bathing and diapering may cause fractures
Use blanket for additional support when lifting
Never pull legs upward when changing a diaper
gently slip a hand under the hips to raise

32. Nursing Management Encourage well-balanced diet
additional vitamin C, vitamin D, and calcium to encourage healing and bone growth.
Limit calories to maintain weight
immobility can lead to overweight

33. Nursing Management Support normal growth and development Socialization
Swimming improves muscle tone
Wheelchairs and adaptive equipment

34. Osgood-Schlatter Disease
Thickening & enlargement of tibial tuberosity
Results from microtrauma (sports-related)
Bilateral knee pain exacerbated by running, jumping, climbing stairs

35. Nursing Management Self-limiting condition
rest, ice, heat, NSAIDs
Immobilization of limb may be necessary
Support other methods of exercise, sports

36. Osteomyelitis Bacterial infection of bone
Common in children age 1-12 years
Can follow open fractures, burns, skin abscess, foreign body
Infecting organism spreads through the bloodstream from the penetrating injury to the bone

37. Signs and Symptoms
Pain, warmth, tenderness, limited ROM localized to the area of infection
Usually in the extremities
In younger child- more subtle symptoms, irritability

38. Osteomyelitis Diagnosis: Increased WBC’s Increased sed rate
Increased C-reactive protein
Positive blood culture
MRI shows bone purulence and edema

39. Treatment 4-6 weeks of Antibiotics (PICC line)
Limit weight bearing on extremity
Aggressive therapy is needed to prevent
Disruption of the growth plate, interrupt growth
Septic arthritis and joint damage
Recurrent infection

40. Nursing Considerations
Administer IV antibiotics
Teach care of PICC line
Strict aseptic technique and transmission-based precautions during all dressing changes.
Good hygiene
Teach signs of spread of infection
increasing pain, difficulty breathing, increased pulse rate, fever

41. Nursing Considerations
Promote Development
Provide suggestions for the family if the child will be immobilized at home.
Assist the family in planning for completion of school tasks

42. Disorders of the Muscle

43. Muscular Dystrophy
Inherited disease with progressive deterioration of muscle cells
Causes progressive muscle weakness and atrophy
Several different types
All differ by age of onset and severity
The most common form of childhood muscular dystrophy is Duchenne muscular dystrophy

44. Duchenne’s Muscular Dystrophy
X-linked recessive disorder
Affects boys, symptoms by age 3
Will meet early motor milestones, but later at age 3 see:
waddling gait, difficulty climbing stairs, frequent falls; easily tired, when walking and running
toe walking, hypertrophied calves, lordosis

45. Gower’s Sign: press hands against ankles, knees & thighs to stand up

46. Duchenne’s Muscular Dystrophy
Speech & swallowing become impaired
More pronounced muscle weakness (scoliosis)
Wheelchair by junior high
Tachycardia
Pneumonia
Heart failure age 20

47. Nursing Considerations
Maintain ambulation as long as possible
Physical Therapy, Adaptive equipment
Braces to prevent contractures
Promote independence
Prevention of injury
Prevention of infection

48. Disorders of the soft tissue

49. Juvenile Rheumatoid Arthritis
Chronic inflammation of synovium with eventual erosion of articular cartilage
Cause is autoimmune
+ ANA (antinuclear antibodies)
+ RF (rheumatoid factor)
Peak: 1-3 years or 8-12 years, girls affected more

50. Follows one of three clinical courses
Systemic: elevated temperature, rash, any # of joints affected
Pauciarticular: involves 4 or less joints, usually large joints
Polyarticular: involves 5 or more joints, smaller joints or weight bearing joints

51. Symptoms Stiffness in AM Swelling Tenderness Painful to touch
Warm to touch, seldom red
Loss of motion
Increased WBC’s & sed rate

52. Juvenile Rheumatoid Arthritis
Goals of care:
Maintain joint fx (splints, ROM)
Prevent physical deformities
Relieve symptoms (pain & inflammation)
NSAID’s (aspirin, ibuprofen, naproxen)
SAARD’s Slower Acting Antirheumatic Drugs(gold, D-penicllamine)

53. Nursing Care Facilitate medication compliance
Encourage child to be as independent as possible
Moist heat (bath or whirlpool) especially in morning
Prevention of injury
Promote functioning
Most common complication
severe hip involvement with loss of function

54. Practice Questions!

55. A 3-year-old child is suspected of having Duchenne’s muscular dystrophy. Which of the following assessment findings by the nurse would support this diagnosis?
A history of delayed crawling
Outward rotation of the hips
Difficulty climbing stairs
Wasted muscle appearance

56. A child is admitted to the hospital suspecting osteomyelitis
A child is admitted to the hospital suspecting osteomyelitis. Which of the following serum laboratory values noted by the nurse supports this diagnosis? (Select all that apply)
Positive Blood Cultures
+ ANA
WBC 15,000
Sed Rate 5
Decreased C-Reactive Protein

57. An adolescent diagnosed with moderate scoliosis describes all of the following symptoms. Which one would the nurse conclude is not associated with the initial diagnosis?
Back pain
Skirts that hang unevenly
Unequal shoulder heights
Uneven waist angles

58. A 4-year-old child with osteogenesis imperfecta is admitted to the hospital unit. Which of the child’s nursing diagnosis has the highest priority?
Impaired skin integrity related to cast
Pain related to fractures
Risk for injury related to disease state
Disturbed body image related to short stature

59. Which item should the nurse remove from the bedside table of a 4-year-old child who has just been placed in bilateral long leg casts?
Legos
Etch-a-sketch
Fireman’s hat
Coloring book

60. The nurse is assessing a child in a newly applied cast to the lower leg for a tibia fracture. The nurse medicates the child for pain, which is ineffective. The nurse should further assess:
Color of toes.
Apical pulse.
Skin temperature.
Blood pressure

61. A 14-year-old states her fingers and wrists are stiff in the morning, hurt, and are swollen. The nurse suspects this adolescent will be tested for:
Osteomyelitis
Osgood-Schlatter Disease
Rheumatoid Arthritis
Fractures