1. MUSCULOSKELETAL DISORDERS
Revised, summer 2007
Differences in adult and child:
Musculoskeletal system has remarkable resilience in childhood- very forgiving & restorative
Growth process, the pediatric musculoskeletal system has potential for complications- accidental injuries– malformations/congenital anomalies—environmental insults

2. Talipes Equinovarus (Clubfoot)
Adduction and supination of forefoot with an inversion (varis) of the heel and fixed plantar flexion.
Etiology unknown
75% of abnormalities of the foot (1:1000)
May result from fetal positioning in the uterus
Genetic or loose ligaments
Occurs most often in males (2:1)
Increased risk with myelomeningocele- because of decreased mobility in utero

3. Clinical Manifestations
Focus on early detection
Rocker bottom foot
Fixed position
Diagnostic tests
Ultrasound CT
MRI
Prenatal ultrasound may provide diagnosis
Most easily assessed upon delivery- **requires long-term treatment to prevent recurrence

4. Treatment Corrective casting every 3-14 days
Dennis Browne splints- horizontal bar attached to foot plates
Treatment is started as soon aafter birth as possible. Goal is to gently stretch tightened ligaments and tendons and return the foot to a maximum anatomic position.
Long-term treatments to prevent recurrence includes:
Medical intervention
Serial manipulation-exercises & stretching- position correctly
Corrective casting- change q 3-14 days WHY??? Allow for rapid growth and ROM, and assessment of underling skin
Dennis-Browne splints- horizontal bar attached to foot plates THIS is NOT A HANDLE
Surgical intervention with casting

5. Nursing Care Care of Casts CMS assessment Keep dry/clean
Assess placement
Cast care: check the edges of the cast (rough, irritating the skin, etc); place on firm mattress when drying the cast; support the cast with pillows until dry; reposition every 2-4 hrs to ensure thorough drying, swelling generally peaks within hrs; may need to apply ice to the casted area to decrease swelling; protect the cast when bathing or showering (if plaster). Contact the dr. if the cast has any of the following: feels warm or hot with an unusual smell; drainage suddenly appears on the cast, your child c/o pain, burning, numbness or tingling, or the extremity changes color or temperature
***CMS- circulation-motor/movement-sensory
Change diapers frequently- may require taping to cast themselves
Assess placement- movement and growth may cause the cast to slip out of place and effect the corrective alignment leading to decreased circulation – may mark with permanent marker (similar to radiation marking)

6. Evaluation: Regular check-ups Prognosis ROM after removal of casts
Create a plan for readapting nursing intervention ot meet individual needs of pedi patients and family as they progress through treatment
NB- multiple castings/surgery
Toddler- age appropriate activities importance of crawling & walking with cognitive development
Older child- removal from social group- focus on positive and rapid return to peers
Prognosis: long term follow-up until the child reaches skeletal maturity is essential. Even with aggressive treatment, the foot is seldom completely normal. Lifelong atrophy of the calf is common and the affected foot is usually smaller than the other

7. ?????
An 18 month old is scheduled for application of a plaster cast to correct a clubfoot. The post-op plan should include which of the following measures?
a. Elevate the cast above the level of the heart
b. Handle cast with fingertips
c. Reposition the child every 2 hours
d. Spray the cast with an acrylic protectant
Elevate- might decrease edema- but difficult to maintain this position in an 18 month old- is it the best answer?
Handle with fingertips- handle with palms- prevent indention of cast and compartment syndrome(irritation and edema that lead to tissue necrosis) causes severe pain that is not relieved by analgesics- leads to neurovascular impairment “feels like fire ants or pins/needles”
**Reposition- decrease respiratory stasis- promote circulation and prevent skin breakdown- prevent embolism
Acrylic- TOXIC INhalant

8. Congenital Dislocation of Hip
Malrotation of the hip at birth
Improper formation or function of acetabulum
Incidence 3/1000
May result from laxity of ligaments holding the femur head within the acetabulum of the pelvis
HOW DO WE ASSESS THIS CONDITION??? Ortolani’s manuver

9. Clinical Manifestations
Gluteal folds
Ortolanis sign
Shorter femur
Prominence of femur
Unequal major gluteal folds
Ortolanis sign- click on abduction- Marius Ortolanis was an Italian orthopedic surgeon who developed the “hip click” maneuver
One leg appears shorter than the other
Femur protrudes on effected side

10. Clinical Manifestations cont…
Limited abduction
Barlow Maneuver
Signs and Symptoms in older child
Limited abduction of the affected leg
Barlow Maneuver- adduct hip and apply pressure down and back with thumbs, the femoral head may move out of the acetabulum
Later S&S – older child limp, duck waddle, shortened leg on effected side. Contractures or stiffness- limited abduction – Think assessment of broken hip in adult

11. Diagnostic Tests:
Ultrasound
CT and MRI
X-ray

12. Surgical Treatment: Release muscles and tendons
Application of body- spica cast
**release muscles and tendons to allow control of the hip joint
Application of body spica cast past surgery-**observe cast for active bleeding and CMS of toes and feet

13. Treatment with Spica Cast
For complex cases and older children
Dislocated -some closed and open reductions
Closed reductions- non surgical correction
Open reductions- surgical correction of placement with re-attachment of muscles and tendons

14. Spica cast
Spica cast pp : review the positioning of the child, body mechanics to prevent injury when lifting and turning
Because the cast covers the entire lower half of the child’s bosy, with the exception of the perineal opening, managing the child’s elimination is a challenge. Excess urine can trickle under the cast, irritating and macerating the skin, resisting drying, and becoming malodorous. Advise the family to tuck a disposable diaper underneath the cast edges at the opening. Monitor the child’s neurovascular status frequently, and tea h the family the s/s of neurovascular compromise.

15. Spica Cast Care Use palms to handle cast
Bar between the legs is not a handle!
Use pillows for positioning
Keep cast clean & dry
Never turn or lift the child using the bar between the legs!!!!
Keep the cast clean and dry- change diapers frequently and if child is continent offer toilet frequently (even if you have to wake them at night)
Remember the child needs to feel independent and allow them to have as much “control” of their positioning as possible. Remember to place the child prone (propped with pillows while eating) and provide age appropriate diversions through to confinement to the cast.
Young children need to crawl/ walk for cognitive development- again tummy time
Tell about Aunt Erna and sending to reunion without appropriate teaching- fresh broken hip (2 weeks)
How do we evaluate these interventions??
NB- return demo
Toddler- have child participate & return demo
Older child- have parents & child verbalize and return demo

16. Nursing Management Case finding and referral
Teach parent application of harness
Protect skin
Bring environment to child
Safety
Young infants need to learn to “turn over” and begin “pushing up”
This directly effects cognative development. These infants need nurturing, distraction and carry close to the care provider (difficult with the bar between the legs)
Bring environment ot child- surround with age appropriate toys
Tummy time is critical- prop with pillows think safety first page 1401 of text

17. Developmental dysplasia of the hip
Head of femur is unstable
Subluxation of the hip occurs
Dislocation of the hip can be in late stage of development
Early diagnosis and treatment is imp. to maximize the likelihood of a successful outcome. Treatment depends on the age of the child at the time of diagnosis and the severity of the dysplasia. In the neonatal period, treatment involves splinting the hips with a Pavlik harness to maintain flexion and abduction and external rotation

18. Treatment Splinting of hip- Pavlick harness
Hip maintained in flexion and abduction
Deepen acetabulum from pressure of femur head
Page 1402 of text figure 50-6 shows an infant in a Pavlik harness for 0-6 months of age
The amount of time the infant/child remains in the harness varies according to the extent of the displacement- usually 6-8 weeks

19. Pavlik harness
The Wheaton-Pavlik™ Harness is meticulously constructed to conform to prescribed orthopedic standards. It is used to treat hip dysplasia by holding the hips in a position of controlled flexion and abduction. Unlike a cast, the harness does not rigidly immobilize the hips, but allows movement in a controlled manner. This allows the head of the femur to deeply mold the acetabulum, stabilizing the hip.
The patient’s comfort is assured with the soft inner lining of the halter. Hook-and-loop fasteners allow for rapid and secure adjustment. Without bulky buckles, the child is comfortable in any position, and all adjustments to front and back straps can be made while the child is laying on his or her back. Color-coded straps help parents to avoid misapplication. A specially-designed anti-slip footpiece prevents the foot from slipping out of the harness.

20. ?????
A parent asks why her infant must wear a Pavlik harness. The nurse responds that he purpose of this device is to:
Provide comfort and support
Shorten the limb on the affected side
Maintain the femur within the acetabulum
Provide outward displacement of the femoral head.
C. Maintain the femur within the acetabulum

21. Nursing Management Case finding and referral
Teach parent application of harness
Protect skin
Bring environment to child
Safety
Young infants need to learn to “turn over” and begin “pushing up”
This directly effects cognitive development. These infants need nurturing, distraction and carry close to the care provider (difficult with the bar between the legs)
Bring environment ot child- surround with age appropriate toys
Tummy time is critical- prop with pillows think safety first page 1401 of text

22. Fractures Greenstick fracture- most common type in kids < 3 years
MVA -frequent cause of bone injury in 4-7 year olds

23. Pathophysiology Epiphyseal plate Pliable and porous
Growth takes place in the epiphyseal (e-piff-a-seal) plate- Why is this significant?? Injury can prevent normal growth
Children’s bones are more pliable and porous than adult’s which allows the bones to bend, buckle, or result in greenstick fracture

24. Fractures Occur as a result of direct or indirect force
Repeated stress on the bone
Pathologic conditions

25. Healing Rapid in children Good rule of thumb: one week for every year
of life up to 10 yrs

26. Assessment Pain (PROM) Tenderness Edema Limited movement
Distortion of limb
Pain on passive range of motion- Tap-test- can indicate a break more accurately than X-ray if bone is not displaced
Often children do not have edema immediately after break- can take 24 hours or more for edema. During that time an untreated break can cause increased tissue damage, including nerve and circulatory- at risk for what??? Pulmonary embolism

27. Nursing Care Casting Traction Compartment syndrome
Compartment syndrome
Surgical intervention
Casting- usually a synthetic cast- dry quickly, lighter and more water resistant than plaster. Not for swimming- keep as dry as possible. Continue to assess CMS (level II) Review cast care with parents and remind not o place anything inside the cast (sometimes young children use them to carry small toys)
Traction not used much anymore- Bryants traction **show link
Compartment Syndrome ( 5 P’s)- increased pressure causes circulatory impairment and tissue damage
S&S- pain- severe, not relieved by analgesics- like crawling fire ants or sharp pins
Pallor- of distal extremity
Pulselessness
Paresthesia- numbness or tingling (falls asleep)
Paralysis
Surgical interventions: open reduction of break with internal fixation – pins & plates

28. Muscular Dystrophy Duchennes- 13 types Onset of symptoms
Muscular dystrophy is a grouop of genetically transmitted diseases characterized by progressive symmetric wasting of skeletal muscle without evidence of neurologic involvement. In all forms of MD an insidious loss of strength occurs with increasing disability and deformity. Duchenne is a sex-linked recessive disorders usually seen only in males. There is a genetic mutation of the dystrophin gene. Dystrophin in mornal muscle cells helps to attach skeletal muscles fibers to the basement membrane, Abnormalities in dystrophin can lead to defects in the plasma membrane of muscle fiber with subsequent muscle fiber degeneration.
13 types of Duchennes is an X linked recessive disorder characterized by progressive degeneration of muscle fibers. Present at birth but does not usually become clinically apparent until at least age 3.
Symptoms begin before 5 years of age. Usually begins with symmetric muscle wasting and weakness that progresses without any loss of sensation or pain. Gower maneuver to stand (use hands to push themselves up from sitting) Have large thighs…resemble a soccer player

29. Duchenne’s (D M D) WHAT ARE THE CAUSES OF DMD?
Genes that contain codes are what are needed to form all different
thinks in the world. DMD happens when a certain gene on the X chromosome
does not make the protein dystrophin. This dystrophin is used to make
muscles throughout a persons life. If this protein is defected
the production of their muscles will slowly start to decline. Sooner or
later the bodies organs will start to shut down an and the victim will
to be on life support.
Who is effected by this Duchenne?
DMD is the most common muscular dystrophy that effects children. Boys from ages 3-5 are usually the only diagnosed with Duchenne Muscular Dystrophy, simply because it is a X- linked recessive trait that is passed on to the son from his mother. Girls can get this muscular dystrophy, but it is less likely because they have the extra X chromosome to make up for their defected gene. Girls are more likely to be carriers of this disease.

30. Duchenne’s characteristics
Gower manuver
Signs and symptoms include- muscle weakness particularly waddling, side-based gate, weak calf muscles, progressing to hip and knee contractures, foot deformities, scoliosis, and lordosis

31. Prognosis Ability to walk lost by age 9-12
Death occurs 9-10 years after diagnosis
1:3500 children effected
Death- usually of respiratory or cardiac complications R/T muscle wasting
May have moderate obesity, decreased IQ, shortened life span.

32. Diagnosis/Treatment Muscle biopsy **Serum enzyme CK Electromyogram ECG
Rehab
Corticosteroid therapy
Muscle biopsy- reveals fatty fibrous tissue gradually replaces muscle
Serum enzyme Serum creatine kinase (CK) elevated in early stages as muscles deteriorate
Electromyogram- graphic record of the contractions of a muscle as a result of electrical stimulation
ECG- Electroencephlogram- abnormalities reflective of cardiomyopathy
Clinical manifestations:
Muscle wasting of upper arms, legs & trunks muscles first
Calves enlarge-fatty infiltrates
Child has difficulty rising (Gower Maneuver)
Waddling gait-**advanced stages
Hip & knee contractures**
Foot deformities**
Mental retardation- increase in kinase**
Corticossteroids may significantly halt the disease progression for up to 3 years. The goal of treatment is to preseve mobility and independence through exercise, physical therapy, and orthopedic appliances.

33. Nursing Care Promote optimal health Goal: keep child ambulatory
Assess muscle weakness
Respiratory function
Nutritional status
OT, PT
Goal- keep ambulatory to prevent contractures and maintain normal as long as possible
Assess respiratory function- need RT to assist with clearance of secretions
Nutritional status- increase fluids to avoid dehydrations- at high risk for aspiration Why?? Inability to swallow excessive secretions- need nutritional consult

34. Scoliosis Curve greater than 25 degrees Functional Structural Postural
Compensatory
Structural
Idiopathic (70-80% of all cases)
Congenital
Neuromuscular
Poliomyelitis
Cerebral palsy
Muscular dystrophy
Incidence is 1.5/1000 persons
Curves of less than 20 degrees are considered slight- curves of >40 degrees require surgery. Curves of 80 degrees are severe and compromise respiratory function.
Functional-postural as a result of habitual positioning
Compensatory- a result of unequal leg length
Idiopathic- with females more frequent 7:1; usually in families with history of scoliosis and often un-detected
Congenital- present at birth- most common with additional neuromuscular disorders
Neuromuscular- occure as a result of other disease processes or disorders.

35. ????
The school nurse would screen an adolescent for scoliosis by instructing him/her to:
Bend forward at the waist and allow upper extremities to dangle
Lie prone on an examination table
Stand with shoulders placed against the wall to check evenness
Sit on a chair and raise shoulders

36. Manifestations Progression- 1 degree per month Observation of curves
Texas response to funding issues
6th & 8th grades
60% of curvatures in rapidly growing prepubetal children will progress. Screening in 4th and 5 th grades identifies baseline and significant early changes.
Texas has changed the age of screening to 6th and 8th grades in response to funding issues in school districts. Progressive curves may increase 1 degree per month- givent he rapid progression…what implications do you recognize for all nurses? Not just school nurses? Assess for scoliosis with every assessment opportunity and teach parents what to observe for. Share experience with dancer…

37. Bracing Used for skeletally immature http://milwaukee.brace.nu/
Used for skeletally immature (11-13 years) to stop progression of the curve- Compliance is very difficult (Not always successful) Brace is worn hours daily and can remove for swimming, showering, and selected activities

38. ????
An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen?
Discourage participation in ADL’s.
Teach appropriate application, removal and care of skin and brace.
Discourage sports like golf and tennis encourage sedentary activities.
Teach non-weight bearing techniques.

39. Rods: Recommended for curves >40 degrees
Goal: fuse spine to prevent progression
Why is surgery the recommended treatment for progressive curvature?
The deformity may become disfiguring and result in cardiopulmonary compromise.
This is a side view of the Harrington Rod- named for and orthopedic surgeon in Houston – in the 1960’s – talk aobut sister and progression of treatmetn- cast for 3 months in bed, no walking, now our ot fed with just splint and back to school within 2 weeks.
What is appropriate pre-op for these pateints
Photos- ex-rays of repairs
Expected equipment for before/during/after (chest tube potential)
Expected proceedures a & p
Written information at least 1 week prior and tour

40. Post-op Care Pain management Monitor Neurovascular status Monitor H&H
Log Roll, sit, ambulate
Dressing changes
Report vomiting WHY???
Pain- usually have epidural or PCA
H&H- significant loss of blood- may need transfusions
Log roll- may have to unplug bed to keep flat- sit and ambulate after 48 hours
Dressing changes- Always verify with physician- assess for signs of cerebral spinal fluid leak on dressing
What might vomiting indicate? IICP- suspect what? Bacterial meningitus
May have a chest tube immediately post-op if lungs manipulated during surgery

41. What would you teach a child to expect in the immediate post-op period?
Frequent neurovascular assessments
Need to CT&DB every 2 hours (IS)
Possibility of IV, chest tubes
Use of post-op analgesia
Neurovascular assessment to include- pulses for all extremities/reflexes/warmth/circulation/movement/ sensation
Chest-tubes if the anterior thoracic approach is utilized.

42. Discharge As sited in text
No contact jarring activities for 6-12 months
X-rays q 1-2 years until bone solidly fused
Once fused may resume normal activity levels, skiing, sports, etc…