1. Musculoskeletal Stressors and Adaptation

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

3. Congenital 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)

4. Diagnosis Early detection is key Affected leg may appear shorter
Asymmetry of gluteal and thigh folds
Limited hip abduction
“Ortolani click”
Uneven gait in older child

5. 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

6. 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

7. Clubfoot Congenital deformity Can affect one or both feet
Portions of foot and ankle are twisted out of normal position
Pseudo-deformity vs True-defect
Varying degrees of severity & combinations of abnormal positions

8. Part of newborn assessment
Early detection
Part of newborn assessment
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

9. If ineffective: 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

10. Nursing care Neurovascular assessment Pain assessment
Frequent diaper changes
Infection
Skin integrity
Activity
Follow-up

11. 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

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

13. Common Fractures in Children
Complete- break across entire bone
Spiral- twisting
Greenstick- compression
Comminuted- fragments
Open- through skin
Closed- not through skin

14. 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

15. Management Prevention of complications Infection Neurovascular injury
Compartment Syndrome
Immobility
Malignment
Growth and Development issues

16. Cast Care in Children
observe for swelling, pain, discoloration, movement, loss of pulses
keep extremity elevated for 1st day
keep cast free of foreign objects
cast becomes part of body, fear removal
relate it to a haircut, doesn’t hurt
“tickly” sensation, extremity may become hot from vibrating cast cutter

17. 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
All children screened in 5th grade
Ill fitting clothes
Uneven shoulders, scapulae, hips
Scoliometer: degree of curvature

18. Treatment Mild Moderate Life Long monitoring Bracing
Exercises to improve posture and flexibility
Electrical Stimulation to back muscles

19. Treatment for Severe Milwaukee brace worn 16-23 hours/day
Surgical correction: spinal realignment & straightening (Harrington Rod)
Nursing Care
Log Roll
Skin Care
Circulation and Neuro status

20. Osteogenesis Imperfecta
Connective tissue disorder, leads to fragile bone formation
Causes recurrent pathological fxs
Will not have normal growth in height
2 types:
Severe autosomal dominant form
Infant born with fxs from birth
Autosomal recessive
Occurs later in life, associated deafness and dental deformities

21. Goal: protect from trauma
Reduce the number of fractures
Early intervention
Splints, Braces, Surgical Rods
Handle child gently
Childproof home

22. Osgood-Schlatter Disease
Thickening & enlargement of tibial tuberosity, results from microtrauma (sports-related)
Bilateral knee pain exacerbated by running, jumping, climbing stairs
Treatment:
Self-limiting condition: rest, ice, heat, NSAIDs
Immobilization of limb may be necessary

23. Osteomyelitis Bacterial infection of bone
Can follow open fractures, burns, skin abscess, foreign body
Signs and Symptoms
Pain, warmth, tenderness, limited ROM localized to the area of infection
In younger child- more subtle symptoms, irritability

24. Osteomyelitis
Dx: increased WBC’s, sed rate, positive blood culture, on MRI bone purulence, edema
Treatment:
4-6 weeks of ABX (PICC line)
Limit weight bearing on extremity

25. 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

26. Duchenne’s Muscular Dystrophy
Most common type
Sex-linked recessive, boys, s/s by age 3
Will meet motor milestones, but later
Age 3 see waddling gait, difficulty climbing stairs

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

28. Duchenne’s Muscular Dystrophy
Speech & swallowing become impaired
More pronounced muscle weakness (scoliosis)
Wheelchair by junior high
Tachycardia
Pneumonia
Heart failure age 20
Treatment:
Maintain ambulation & independence
Muscular Dystrophy Association, mdausa.org

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

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

31. 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)

32. Nursing Care Facilitate medication compliance
Encourage child to be as independent as possible
Moist heat (bath or whirlpool) especially in morning
Most common complications:
severe hip involvement with loss of function
possible blindness r/t iridocyclitis (inflammation of iris & ciliary body)

33. Case Study

34. A newborn is found to have Congenital hip dysplasia prior to discharge
A newborn is found to have Congenital hip dysplasia prior to discharge. You will be the nurse caring for this baby and new mother after discharge from the nursery and will be admitting the infant to the pediatric unit.

35. What assessment findings would you expect in the newborn?

36. How will this condition be treated?

37. What teaching needs to be completed with the parents of this newborn?

38. The parents ask you about what they can expect regarding long-term consequences. How should you respond?

39. 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

40. A child is admitted to the hospital with a diagnosis of rule out osteomyelitis. Which of the following serum laboratory values noted by the nurse supports this diagnosis?
Decreased WBC
Positive Blood Cultures
Increased HCT
Increased BUN

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

42. A 4-year-old child with osteogenesis imperfecta is admitted to the hospital unit for an unrelated condition. The nurse determines that which nursing diagnosis has the highest priority for this child?
Impaired skin integrity related to cast
Pain related to fractures
Risk for injury related to disease state
Disturbed body image related to short stature

43. 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