1. Pediatric Musculoskeletal Disorders

2. Musculoskeletal Development
Infant bones are only 65% ossified
Long bones are porous and less dense and can bend, buckle or break easily
Growth takes place in Epiphyseal plates, and if these are injured, can cause abnormal growth
Growing bones heal quickly and decrease need for treatment

3. Clubfoot
A congenital abnormality in which the foot is twisted out of its normal position.

4. Talipes Equinovarus (Clubfoot)
How are muscles, tendons, and bones involved in this abnormality?
1. ______________
2. _______
3. ____________________

5. What is the priority goal
Goal of Care
What is the priority goal of
care for the child
with a
clubfoot?

6. Treatment for Clubfoot
Serial manipulation
Corrective casting
Splints
Surgical correction

7. Serial Casting Cast applied to hold foot in desired position.
Changed every 1-2 weeks until maximum correction is achieved.
Nursing Care:
Cast care
Skin Care
Education of parents

8. What is included in a Neurovascular Assessment?
Circulation S
Sensory M
Motion

9. Cast Care – Assessment Unusual odor beneath the cast
Tingling, burning, numbness of toes
Drainage through cast
Swelling or inability to move toes
Toes that are cold, blue or white
Sudden unexplained fever
Pain that is not relieved by comfort measures

10. Cast Care Teaching “Petaling” the edges of the cast Drying of the cast
Prevention of swelling
Protecting the cast
When to call the doctor

11. Try this
A infant has a cast applied for treatment of club foot. Which of the following symptoms requires immediate attention and should be reported to the health care provider?
A. Capillary refill of 4 seconds in the affected toes.
B. Edema in the affected toes that improves with
elevation.
C. Numbness of the toes on the affected foot.
D. Skin distal to the cast is warm

12. Splinting is used after casts are removed to maintain the correction.
Dennis Brown Splint
Splinting is used after casts are removed to maintain the correction.

13. Care of a child in a splint
Braces should fit snugly but should not interfere with neurovascular function.
 Before wearing the brace, check the skin for any areas of redness or breakdown.
Give parents guidelines for braces.
If redness develops, arrange to have the fit of the brace evaluated and modified.
Bar between legs is not a handle.
Teach appropriate positioning for safety to prevent falls, and allow mobility and "tummy-time“

14. Parent Support
Parents are trained and become active participants in the physical therapy treatments and child’s stretching program
Nurses need to help the parents understand the time commitment involved
Assess the parents’ ability to monitor the child adequately for complications and confirm they understand the signs and symptoms of the
complications

15. Question
The parents of an infant with clubfoot ask how it is treated. Which of the following treatments should the nurse discuss with the parents?
Weekly cast changes with manipulation
Probably surgery on the affected
Abduction device to keep the extremity in alignment
Use of a Dennis-Browne splint to achieve correction.

16. Hip Dysplasia
The head of the femur is improperly seated in the acetabulum of the pelvis

17. Developmental Dysplasia of Hip Clinical Manifestations
Limited abduction of the affected hip during Ortolani maneuver. May hear a click upon movement.
Asymmetry of gluteal and thigh fat folds when lying with legs extended.
Telescoping of thigh
Limp and abnormal gait in older
child
Ortolani maneuver
Asymmetry of gluteal folds

18. Treatment and Nursing care of a child with Dysplasia of the Hip:
Pavlik harness
What is the purpose?
How does it achieve this?

19. Nursing Care
Teach parents/caregivers to remove and apply harness appropriately –only remove for bathing and skin checks.
Teach skin assessment
Encourage cuddling infant to promote cognitive development and infant/caregiver bonding

20. Ask Yourself ?
A parent asks why the infant must wear a Pavlik harness. What is the nurse's best response? This treatment 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.

21. Treatment and Nursing care of a child with Dysplasia of the Hip:
Spica cast
Covers lower half of
body except perineal area
Nursing Care
Elimination/ protection of cast
Positioning
Neurovascular assessment
Skin care
Hygiene

22. Fractures

23. Causes of Fractures Increased mobility and immature motor skills
Trauma
Bone diseases

24. Manifestations of Fracture
Pain or tenderness at site
Immobility or decreased ROM
Deformity of extremity
Edema
Other signs – crepitus, ecchymosis, muscle spasm and inability to bear weight

25. Repositioning of the bone fragments into normal alignment
Treatment
Reduction
Repositioning of the bone fragments into normal alignment
Application of a device or mechanism that maintains alignment until healing occurs
Retention

26. Retention Application of Cast Traction
Pull or force exerted on one part of the body

27. Question
Which of the following nursing interventions takes highest priority when caring for a child in skeletal traction?
Assessing bowel sounds every shift
Providing adequate nutrition
Assessing temperature every 4 hours
Providing age-appropriate activities

28. Complications associated with Orthopedic Trauma/ Fractures
Fat Embolism
Particles of fat are carried through circulation and lodge in lung capillaries causing:
Pulmonary edema
Respiratory distress with hypoxemia and respiratory acidosis
Treatment
Increase in IV fluids
Respiratory support and adequate oxygenation

29. Orthopedic Trauma / Fracture Complications
Compartment syndrome (very serious)
Paresthesia
Pain
Pallor
Paralysis
Pulselessness

30. Legal & Ethical implications when caring for a child with a fracture?
All fractures entering the hospital via ER require social service consult for documentation of suspected abuse or neglect.
The nurse must report all suspected abuse to the appropriate authority.
Do not discuss the possibility of abuse with the parents or guardians!! Do not attempt to prove or disprove abuse.

31. Progressive degeneration of
Muscular Dystrophy
Progressive degeneration of
Muscle fibers

32. Manifestations of Muscular Dystrophy
Delayed walking – (first sign)
Progressive, symmetric muscle wasting
Frequent falls
Easily tired when walking, running, or climbing stairs
Hypertrophied calves muscle
Waddling wide-based gait
Uses Gower’s maneuver to rise from floor
Unable to walk independently by
age 9 – 12.

33. What diagnostic tests are used in confirming the diagnosis?
Diagnostic findings:
What diagnostic tests are used in confirming the diagnosis?

34. Maintain ambulation and independence for as long as possible.
Goal of Care
Maintain ambulation and independence for as long as possible.

35. Nursing Care Coordinate a variety of health care services
Maintain activity and self-care functions
Skin care
Maintain bladder and bowel functioning
Protect from respiratory infections
Teach dietary modifications to decrease obesity

36. Question Which of the following interventions is
INAPPROPRIATE to incorporate in the care for a
child with muscular dystrophy hospitalized with a
respiratory infection?
Physical therapy
Aggressive antibiotic therapy
Passive range of motion exercises
Complete Bedrest

37. Lateral S curvature of the spine
Scoliosis
Lateral S curvature of the spine

38. What are the manifestations of Scoliosis
Rib Prominence or hump
Prominent scapula
lateral
Uneven shoulders
With uneven hips

39. Diagnosis
When does screening for this disorder occur?

40. Braces used in Treatment of Scoliosis
Why would lead to non-compliance
in wearing the brace?

41. Quick Question:
What is the priority psychosocial nursing diagnosis for the adolescent diagnosed with scoliosis?

42. Treatment and Nursing Care for Scoliosis Spinal Fusion
Pre-operative teaching
Demonstrate incentive spirometer and C&DB
Discuss all potential equipment (chest tubes, IV, O2 masks & nasal canula, Foley catheter)
Teach use of pumps for PCA or epidural block.
Demonstrate log rolling and assist out of bed.

43. Nursing Care for spinal fusion
Post-operative Care
Maintain airway
Neurovascular Assessment of lower extremities
Teach passive and active ROM exercises
Encourage independence in ADL’s
Provide with resources / information on scoliosis support groups

44. Post operative care of an adolescent following a
spinal fusion for scoliosis includes: (select ALL
that apply)
Oral analgesics for pain
Logrolling every 2 hours
Nasogastric intubation
Bilateral Neurovascular checks of lower extremities
Use of incentive spirometer q 2 hours
Assess skin on bony prominences

45. The End