1. MUSCULOSKELETAL DISORDERS By Ann Hearn RNC, MSN 2010

2. Newborn Musculoskeletal System Resiliency – prevent injury Birth process Walking Long bones – porous Injury – bend, buckle, or break Epiphyseal plates

3. Talipes Equinovarus (Clubfoot) Adduction and supination of forefoot with an inversion (varus) of the heel and fixed plantar flexion and the midfoot directs downward (equinus).

4. Clinical Manifestations Focus on early detection Assessment Diagnostic tests

5. Treatment Serial manipulation with corrective casting Dennis Browne splints - horizontal bar attached to foot plates Dennis Browne splints Surgical correction

6. Nursing Care & Evaluation Provide Emotional Support Promote bonding Cast Care Referrals Regular check-ups Prognosis ROM after removal of casts

7. Developmental Dysplasia of the Hip Malrotation of the hip at birth Improper formation or function of acetabulum

8. Clinical Manifestations Limited abduction Gluteal folds Ortolani’ s & Barlow’s Maneuver Shorter femur Prominence of femur S&S in older children

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

10. Treatment: Splinting of hip - Pavlik harness Hip maintained in flexion and abduction Deepens acetabulum from pressure of femur head

11. Treatment cont’d. Skin Traction Relocates femoral head while stretching restrictive soft tissue

12. Surgical Treatment & Spica Cast: Release muscles and tendons Application of body spica cast

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

14. Cast Care & Assessment Use palms to handle wet cast Bar between the legs is not a handle! Use pillows for positioning Keep cast clean & dry Pedal cast Assess CMS (circulation, movement, sensory)

15. Complications Associated with Casts Compromised circulation Cast displacement from therapeutic position Immobility Compartment Syndrome Parathesia Pain Pressure Pallor ** Paralysis ** Pulselessness **

16. Nursing Management for the Casted Child Encourage cuddling Teach parent application of harness Developmental needs Bring environment to child Protect skin Diet Safety

17. ????? 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

18. Fractures Occur as a result of direct force Greenstick fracture MVA Repeated stress on the bone Pathologic conditions

19. Patho-physiology Epiphyseal plate Pliable and porous Healing is Rapid in children 1 week for every year of life up to 10 years of age

20. Assessment Pain Tenderness Edema Limited movement Distortion of limb

21. Treatment Casting Traction Surgical intervention

22. Scoliosis Lateral “S” or “C” curvature of the spine > 10° Structural Idiopathic (70-80% of all cases) Congenital Neuromuscular –Poliomyelitis –Cerebral palsy –Muscular dystrophy

23. Scoliosis

24. Manifestations Classic Signs: Truncal asymmetry Uneven shoulders and hips A one-sided rib bump Prominent scapula Screening 5 th & 7 th grades

25. ???? The school nurse would screen an adolescent for scoliosis by instructing him/her to: A. Bend forward at the waist, holding hands together B. Lie prone on an examination table C. Stand with shoulders placed against the wall D. Sit on a chair and raise shoulders

26. Treatment of Scoliosis Mild 10-20° Exercises improve posture Moderate 20-40° Bracing maintains existing curvature Severe 40° or > Spinal fusion Goal: limit or stop progression of curvature

27. Bracing Used for skeletally immature http://milwaukee.brace.nu/

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

29. Rods: Recommended for curves > 40 degrees Goal: fuse spine to prevent progression Why is surgery the recommended treatment for progressive curvature?

30. Surgical Care Pre-op Mentally prepare Demonstrate incentive spirometer, TCDB, log roll PCA pump Post – op Pain management Monitor neurovascular status Monitor H&H Log Roll, sit, ambulate ROM Dressing changes

31. What would you teach a child to expect in the immediate post-op period? a. Frequent neurovascular assessments b. Need to CT&DB every 2 hours (IS) c. Possibility of IV, chest tubes d. Use of post-op analgesia

32. Discharge No heavy lifting, bending or twisting at the waist. Follow-up X-rays Once fused may resume normal activity levels, skiing, sports, etc…

33. Muscular Dystrophy Muscle fiber degeneration and muscle wasting. Duchennes Onset of symptoms 3-4 years of life Terminal disorder

34. Clinical Manifestations & Diagnosis S/S Delayed walking, frequent falls, tire easily, toe walking, hypertrophied calves, waddling gait, lardosis, + Gower’s maneuver, mental retardation Dx: Muscle biopsy (↓ distrophin) ↑ Serum enzyme CK Electromyogram EEG (75% are abnormal)

35. Prognosis 1:3500 children effected Ability to walk lost by age 9-12 Death occurs 9-10 years after diagnosis

36. Nursing Care Promote optimal health Goal: keep child ambulatory Assess muscle weakness Respiratory function Nutritional status OT, PT, RT

37. Psychological Impact What are some psychological issues that may affect a family caring for a child with muscular dystrophy?

38. Musculoskeletal Cancers of Childhood Osteosarcoma Rare Adolescent boys During rapid bone growth Location: metaphysis of distal femur, proximal tibia or humerus. Bone issue does not mature into compact bone **related to radiation exposure Ewing’s sarcoma 2:million Whites & Hispanics Ages 10-20 Location:diaphyseal (shaft) of long bones- femur, pelvis, tibia fibula, ribs, humerus, scapula, clavicle. Small, round cell tumor **chromosome translocation

39. Clinical Manifestations Pain Edema Palpable mass Progressive limping Pathologic fractures at tumor (late sign) Metastasis 20% pulmonary

40. Diagnosis Radiography Lab tests Biopsy

41. Therapeutic Management Chemotherapy Pre & post-op Surgery: Tumor – limb salvation Limb amputation

42. Nursing Assessment: Pre op History of injuries Site of tumor Pain, mobility, gait Vital signs Current activity level Psychosocial history Body image

43. Nursing Assessment: Post op Post operative Circulation above & below operative site S/S infection Pain Edema Hemorrhage

44. Nursing Interventions: Post op Amputation Inspect surgical site using sterile technique Turn at least q 2 hr. Pain management (phantom pain) Medication Reposition and support the limb Distraction and deep breathing. Post op teaching Self care Physical therapy Out-patient chemotherapy

45. Rabdomyosarcoma Malignancy of muscle, or striated tissue Most commonly: around the eyes & neck Less commonly: abdomen, genitourinary tract, extremities Prevalence: < 5 years of age

46. Diagnosis Assessment Radiography Biopsy

47. Treatment Surgery Radiation – wide field Chemotherapy

48. Chemotherapeutic Agents VAC Therapy Vincristine Actinomycin Cyclophosphamide

49. Pre-Op Nursing Goals Disturbed sensory perception (visual) Anticipatory grieving Knowledge deficit Risk for infection

50. Post-op Nursing Diagnosis Risk for infection Impaired skin integrity Impaired physical mobility Impaired adjustment Disturbed body image Pain

51. Chemotherapy & Radiation Preoperative use: Tumor size Prevent seeding Teaching Suppressed immune system Isolate from public areas where illness can be transmitted. Lab monitoring RBC & WBC

52. Psycho-social Considerations Psychological stressors Financial stressors Social stressors