1. MUSCULOSKELETAL DISORDERS By Marlene Meador RN, MSN Fall 2006

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)

3. Clinical Manifestations Focus on early detection Rocker bottom foot Fixed position Diagnostic tests Ultrasound CT MRI

4. Treatment Corrective casting every 3-14 days Dennis Browne splints- horizontal bar attached to foot plates

5. Nursing Care Care of Casts CMS assessment Keep dry/clean Assess placement

6. Evaluation: Regular check-ups Prognosis ROM after removal of casts

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

8. Congenital Dislocation of Hip Malrotation of the hip at birth Improper formation or function of acetabulum

9. Clinical Manifestations Gluteal folds Ortolanis sign Shorter femur Prominence of femur

10. Clinical Manifestations cont… Limited abduction Barlow Maneuver Signs and Symptoms in older child

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

12. Surgical Treatment: Release muscles and tendons Application of body- spica cast

13. Treatment Splinting of hip- Pavlick harness Hip maintained in flexion and abduction Deepen acetabulum from pressure of femur head

14. ????? A parent asks why her infant must wear a Pavlik harness. The nurse responds that he 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.

15. Treatment with Spica Cast For complex cases and older children Dislocated -some closed and open reductions

16. Nursing Management Case finding and referral Teach parent application of harness Protect skin Bring environment to child Safety

17. Spica Cast Care Use palms to handle cast Bar between the legs is not a handle! Use pillows for positioning Keep cast clean & dry

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

19. Pathophysiology Epiphyseal plate Pliable and porous

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

21. Healing Rapid in children 1 week for every year of life up to 10 years of age

22. Assessment Pain (PROM) Tenderness Edema Limited movement Distortion of limb

23. Nursing Care Casting Traction Compartment syndrome Surgical intervention

24. Muscular Dystrophy Duchennes- 13 types Onset of symptoms

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

26. Diagnosis Muscle biopsy Serum enzyme CK Electromyogram EEG (75% are abnormal)

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

28. Scoliosis Curve greater than 25 degrees Functional Postural Compensatory Structural Idiopathic (70-80% of all cases) Congenital Neuromuscular –Poliomyelitis –Cerebral palsy –Muscular dystrophy

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

30. Manifestations Progression- 1 degree per month Observation of curves Texas response to funding issues 6 th & 8 th grades

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

32. ???? 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.

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

34. Post-op Care Pain management Monitor Neurovascular status Monitor H&H Log Roll, sit, ambulate Dressing changes Report vomiting WHY???

35. 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

36. 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…

37. Osteosarcoma Most common primary malignancy of the bone Etiology: Genetic Radiation therapy

38. Pathophysiology Originate in bone-producing cells that invade the medullary canal of the bone Incidence is higher in most rapidly growing bones in adolescents Distal femur Proximal tibia Proximal humerus

39. Assessment Progressive insidious or intermittent pain Palpable mass Progressive limping Pathologic fractures at tumor (late sign)

40. Diagnosis X-ray CT MRI Biopsy of tumor Lab tests CBC ALP LDH

41. Therapeutic Management Surgery Chemotherapy Radiation Amputation

42. Nursing Care Site of tumor History of injuries Current activity level Psychosocial history Body image

43. Nursing Interventions Preoperative teaching Infection Pain Risk for hemorrhage Risk for pneumonia Post operative

44. Ewing’s Sarcoma Second most common bone tumor Mimics infection Etiology No know cause or genetic link

45. Pathophysiology No defining characteristics Invades midshaft of long bones Metastasis

46. Diagnosis Biopsy to differentiate from other neoplastic processes

47. Therapeutic Management Chemotherapy Surgery Radiation

48. Rabdomyosarcoma Malignancy of muscle, or striated tissue Etiology associated with familial cancer syndromes

49. Pathophysiology Subtypes Embryonal Alveolar Pleomorphic Prognosis depends on excision of tumor, rate of metastasis

50. Diagnosis Soft to hard, non-tender, immobile mass Limited range of motion in effected extremity In pelvic tumors organ function disrupted CT, bone marrow aspiration and biopsy

51. Treatment Chemotherapy Surgery Radiation

52. Nursing Considerations Palpation of tumor Family support Facilitate education Postoperative Infection Hemorrhage Edema NG tube/drains

53. If you have further questions Contact me via email mmeador@austincc.edu Marlene Meador RN, MSN