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Chapter 20 Care of the Child with Musculoskeletal Disorders
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Anatomy and Physiology of the Muscles
3 Types of body muscles Skeletal muscles are striated Assists in movement, maintains posture Tendons Attach bones to muscles
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Anatomy and Physiology of the Skeleton
Ossification almost complete at birth 3 sections of bone Epiphyseal plate (growth plates) Hematopoiesis
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A and P of the Bone Diagram
Figure The three sections of the long bone are the epiphysis, metaphysis, and diaphysis. Note the growth plate or epiphyseal plate near the top of the illustration.
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Postural Changes with Growth
Cervical and lumbar areas become concave Bowed legs (genu varum) in infant Knock knees (genu valgum) in preschool child Resolve with growth
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Postural Changes Figure (A) Genu valgum, or knock-knees.Note that the ankles are far apart while the knees are together. (B) Genu varum, or bowlegs. The legs are bowed so the knees are far apart as the child stands. This second condition is often associated with vitamin D deficiency (rickets) or Blount’s disease if the genu varum persists beyond 2 years of age.
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Assessment of the Musculoskeletal System History
Review history of birth in infants Obtain information about injuries in children Inquire about deformities Determine activity level, developmental delays
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Assessment of the Musculoskeletal System History
Inspect posture and gait Note symmetry of shoulders, hips, an any unusual curvature of spine Assess for full ROM of joints Assess muscle strength
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Congenital Skeletal Defects
Range from minor and easy to correct to major malformations requiring long-term therapy Rarely life threatening Two common defects Developmental dysplasia of the hip Clubfoot
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Developmental Dysplasia of the Hip
Developmental hip abnormality Involves femoral head, acetabulum, or both
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Developmental Dysplasia of Hip Manifestations
Partial or complete dislocation of hip joint Shortening of femur Uneven thigh and gluteal folds Limited abduction on the affected side
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Developmental Dysplasia of Hip Diagnosis
Physical examination of hip Allis sign Flex knees and hips with heels close to buttocks and feet flat on exam table Dislocation of hip demonstrated by lower position of knee on affected side Ortolani-Barlow maneuver See figure
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Ortolani-Barlow Maneuver
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Developmental Dysplasia of Hip Treatment
Medical Management Small abnormality – apply three diapers Apply Pavlik harness for 3 – 4 months Place in skin traction for older children Perform surgery followed by hip spica cast
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Developmental Dysplasia of Hip
Figure Steps for Pavlik harness application. (1) Position the chest halter at nipple line and fasten with Velcro. (2) Position the legs and feet in the stirrups, being sure the hips are flexed and abducted. Fasten with Velcro. (3) Connect the chest halter and leg straps in front. (4) Connect the chest halter and leg straps in back. All straps are marked at the first fitting with indelible ink so they can be reattached easily after the harness is rinsed and dried.
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Developmental Dysplasia of Hip Nursing Care
Maintain traction Provide cast care Assess lung sounds, neurovascular symptoms, skin Reposition with cast every 2 hours Encourage diet high in fiber, adequate fluids
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Talipes Talipes or Clubfoot Congenital twisting of the foot
Unilateral or bilateral Usually inward twisting
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Talipes Manifestations
Equines or midfoot directed downward Varus or hindfoot turns inward Forefoot curls toward heel and upward Smaller foot, shortened Achilles tendon Atrophies muscles of lower leg
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Talipes Diagnosis and Treatment
Observation of symptoms X-ray Treatment Apply cast to correct foot position Change cast every 1-2 weeks for 3 months Perform surgical correction if casting fails
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Talipes Nursing Considerations
Nursing interventions Assist with cast application Teach parents cast care Administer pain medications Observe for drainage and bleeding
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Musculoskeletal Disorders
Most common disorders affecting older child Partially due to changes in bone structure during rapid growth or accidents Common disorders Muscular dystrophy Legg-Calve-Perthes Disease Scoliosis Juvenile rheumatoid arthritis
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Scoliosis Lateral S-or-C shaped curve of spine
Rotation of spine and ribs Right-sided thoracic curve Left-sided lumbar curve More common in girls
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Scoliosis Manifestations
Shoulders and hips different heights Rotation of vertebrae and ribs One-sided rib hump, prominent scapula Asymmetrical posterior chest Figure Scoliosis, showing deviation of the spine to the left. (Phototake NYC).
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Scoliosis Diagnosis Diagnosis Moiré photography Spinal x-ray
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Scoliosis Treatment Treatment Mild scoliosis Moderate scoliosis
Exercise, chiropractic adjustments Moderate scoliosis Boston or Milwaukee brace Severe scoliosis Surgery with rods, wires, halo brace
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Other Spinal Curvatures
Kyphosis Excessive convex curvature of thoracic spine or hunchback Lordosis Excessive concave curvature of lumbar spine, or sway back Torticollis Tilt of head caused by rotation of cervical spine or wry neck
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RICE R - Rest I - Ice C - Compression E - Elevation
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Musculoskeletal Trauma Fracture
Altered continuity of bone Common occurrence in childhood
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Fractures Manifestations & Diagnosis
Pain, abnormal positioning, edema Discoloration, abnormal movement Broken skin, bleeding Diagnosis X-rays of injured area
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Fractures Treatment Treatment Realign by closed reduction
Realign by open reduction Apply traction Immobilize with external fixators or immobilizers Apply plastic or plaster cast
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Fractures Nursing Considerations
Assess neurovascular status using the 5Ps Paresthesias, pain/pressure, pallor, paralysis, pulselessness Prevent skin breakdown Maintain proper alignment Traction weights hang freely Administer pin care
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Compartment Syndrome Occurs when increased pressure in limited space compromises circulation and nerve innervation May lead to necrosis Symptoms Paresthesia, pain/pressure, pallor, paralysis, pulselessness Deep pain unrelieved by analgesia Edema
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Compartment Syndrome Nursing Care
Report immediately Requires removal or alteration of cast
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Fractures Nursing Considerations
Assess for compartment syndrome Administer pain medication Teach cast care, orthopedic appliances Teach proper crutch walking Teach to recognize complications, signs of abuse
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Bucks Traction
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Bryant Traction
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Skeletal Traction 90/90
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Russels Traction
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External Fixator
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Clavical Strap
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Cast Care Figure Cast care. Plastic can be placed over the cast during bathing or toileting to keep materials dry and clean. (A) Nurses can protect children’s skin from the rough edges of the cast by “petaling” it. (B) This is done by securing adhesive tape to the inside of the cast and pulling it over the edge, covering the jagged or broken pieces of plaster, and securing it to the outer surface of the cast. Moleskin may also be used on the cast.
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Spica Cast
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Musculoskeletal Infection Osteomyelitis
Infection of bone May spread to surrounding tissue Caused by bacteria, virus, fungi Follows injury or surgery
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Osteomyelitis Manifestations
Constant pain in affected area Edema Decreased mobility of joint Refusal to use limb, limp Redness at site of injury, fever
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Osteomyelitis Diagnosis
History of trauma Increased white blood cell count Increased erythrocyte sedimentation rate X-rays, bone scans Needle aspiration of fluid for culture
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Osteomyelitis Treatment
Hospitalization Administer intravenous medication
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Osteomyelitis Nursing Considerations
Administer antibiotics Arrange for home health nurse Care of intravenous site
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Stump Care Figure With an above-the-knee amputation, a figure eight bandage is wrapped around the waist, then brought down over the stump and back up around the hip.
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Nursing Care Priorities
Promote independence of the child Promote mobility as allowed Maintain safety Explain resources for support and proper home care
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Nursing Care Assessing
Monitor cardiac, respiratory, urinary, and bowel function Assess ROM, mobility, posture, and muscle strength Note swelling, redness With assistive devices assess correct use and effectiveness For chronic disorders assess family’s ability to provide care
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Nursing Diagnoses Impaired physical mobility related to musculoskeletal impairment Activity intolerance related to weakness Risk for injury related to altered mobility Compromised coping: family related to caring for a child with a chronic condition
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Outcomes Mobility will be restored through the use of assistive devices Tolerance for activity will be demonstrated as evidenced by vital signs within normal limits Family will create a safe environment Family will effectively participate in developing a plan of care
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Nursing Care Interventions
Teach use of assistive devices Provide positive encouragement before, during, and after use of device Assist the family in planning daily activities to include rest Keep frequently used objects within easy reach
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Nursing Care Interventions
Assist parents in assessing home environment for hazards Provide information about correcting identified hazards Discuss common responses to caring for a child with a musculoskeletal disorder Provide family with specific information on home care
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Nursing Care Evaluating
Evaluate for Mobility Tolerance for activity Safety Family coping
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