Week 11: Musculoskeletal system alterations

Differences in skeletal system of children

• More cartilage

• More porous

• Heal faster

• Growth plates — epiphyses (separated from main portion of bone by cartilage)

• Sutures on skull

Growth of long bones occurs at the ____

epiphyses

Muscle development pattern

grows top, down, and then out

• heads are larger at younger ages

Physiological effects of immobilization: musculoskeletal (2)

• Bone demineralization

• Muscle atrophy

Physiological effects of immobilization: metabolic

• Decreased metabolic rate — slowing of all systems

• Decreased production of stress hormones

Effect of decreased metabolic rate on food intake and consequences d/t immobilization

Decreased food intake

• decline in nutritional state

• impaired healing

• electrolyte imbalance

Effect of decreased production of stress hormones d/t immobilization

decreased physical and emotional coping capacity

Physiological effects of immobilization: respiratory

• decreased chest and lung expansion

• decreased need of O2

• mechanical/biochemical secretion retention

Results of decreased chest and lung expansion d/t immobilization

• diminished O2 intake

• dyspnea and inadequate O2 saturation

• acidosis

Results of mechanical/biochemical secretion retention r/t immobilization

• pneumonia

• atelectasis

Physiological effects of immobilization: cardiovascular

• decreased efficiency of orthostatic neurovascular reflexes

• venous stasis

Consequences of decreased efficiency of orthostatic neurovascular reflexes d/t immobilization

• inability to adapt readily to upright position — orthostatic intolerance

• pooling of blood in extremities in upright posture

Physiological effects of immobilization: skin

altered tissue integrity

• d/t decreased circulation and pressure leading to injury

• difficulty with personal hygiene

Physiological effects of immobilization: elimination

• abdominal distention d/t poor abdominal muscle tone

• alteration in gravitational force (difficulty voiding in prone position)

• impaired ureteral peristalsis (urine retention, bladder infection, renal calculi)

Consequences/complications of abdominal distention caused by poor abdominal muscle tone d/t immobilization

• Difficulty feeding in prone position

• Interference with respiratory patterns

• Constipation/anorexia

What is the most common fracture site in childhood?

distal forearm

• radial/ulna

Why do kids heal faster than adults when they get a bone fracture?

d/t more blood supply to bones

Fracture healing time for a neonate

2-3 weeks

Fracture healing time in early childhood

4 weeks

Fracture healing time in later childhood

6-8 weeks

Fracture healing time for an adolescent

8-12 weeks

Spiral fracture

a strong twisting force of a long bone that results in a complete fracture

Bend fracture

when a bone bends and cracks on one side without fully breaking

Buckle fracture

a porous bone is compressed and rather that breaking, it bends and buckles, resulting in a raised area

Greenstick fracture

incomplete broken bone d/t bending

Symptoms of fracture

• Swelling

• Pain/point tenderness

• Deformity

• Limited ROM

• Open wound for ecchymosis

• Limp or refusal to use limb

Acute fracture treatment goals (4)

• Regain alignment

• Retain alignment and length

• Restore function of injured parts

• Prevent further damage

Acute treatment of a fracture: heat application purpose (3)

• warm muscles

• vasoodilate

• relieve inflammation and pain

Acute treatment of a fracture: cold application purpose (3)

• vasoconstriction

• prevents swelling, edema, and pain

• decreases O2 needs

Spica cast

cast used to stabilize the hip or femur in infants and children after surgery for hip dysplasia or femur fractures

• never use bar to reposition

6 P’s of a neurovascular assessment

• Pain (not improved w/ pain meds)

• Pulse

• Pallor

• Paresthesia (tingling/burning)

• Paralysis

Cast skin care

line edges with moleskin or plastic line perianal to prevent skin damage

Talipes equinovarus

clubfoot

Clubfoot

congenital birth defect where a baby's foot is twisted inward and downward

Clubfoot deformities of foot (6)

• Forefoot adduction

• Midfoot supination

• Hindfoot varus

• Ankle equinis

• Inversion of heel

• Plantar flexion

Clubfoot signs/symptoms

• Foot turned inward and down

• Tight calf muscle

• Rigid achilles tendon

• Toe walking

Clubfoot treatment

• Ponseti method

• Surgery

• Exercises, splits, and special shoes can be prescribed

Ponseti method for clubfoot

uses gentle, weekly serial casting to gradually correct foot deformity, followed by bracing to maintain proper alignment and prevent relapse

Clubfoot surgery

May require surgery to release tendons, reposition bones, reconstruct parts if sufficient correction not achieved in 3-6 months

Developmental Dysplasia of the hip

A condition where the hip joint is improperly formed, causing the femoral head to be unstable, partially dislocated, or fully dislocated from the acetabulum

Developmental Dysplasia risk factors (7)

• Maternal hormones

• Oligohydraminos (low amniotic fluid)

• Genetics

• Multifetal birth

• LGA

• Swaddling of hips in extension or adduction

• Female sex

Developmental Dysplasia signs and symptoms (4)

• uneven thigh/buttock skin folds

• one leg appearing shorter

• limited flexibility or inability to spread legs (abduction)

• clicking or popping sound during movement

If the first-born child has DDH, what is the screening recommendation for future siblings?

all siblings born after DDH child will need screening because family hx increases risk 10x

DDH diagnostics

• Ortolani and Barlow maneuvers (feeling/listening for a click/clunk)

• Galeazzi sign

• Trendelenburg sign

• X-ray if >4 months

• Ultrasound

Galeazzi sign

A clinical test for hip dislocation where, with the infant lying supine and knees flexed, one knee appears lower than the other, indicating possible developmental dysplasia of the hip (DDH)

Trendelenburg sign

A clinical finding where the pelvis drops on the unaffected side when standing on one leg, indicating weakness of the hip abductors (gluteus medius/minimus) on the weight-bearing side

DDH treatment

• < 6 months

• > 6 months

• > 24 months

• < 6 months: Pavlik harness

• > 6 months: traction with manual reduction and hip spica cast after

• > 24 months: reduction surgery with casting

Pavlik Harness

A brace that keeps an infant’s hips flexed and abducted to treat DDH and maintain proper hip alignment

Osteogenesis Imperfecta

brittle bone disease d/t less collagen production in the bone, teeth, skin, tendons, and parts of the eye

Osteogenesis Imperfecta signs and symptoms (6)

• Blue sclera

• Poor teeth development

• Short stature

• Progressive skeletal deformity

• Joint laxity

• Deafness

OI type 1

• mildest and most common form

• most fracture occur before puberty

• normal life expectancy

OI type 2

• severe/lethal form that is often fatal

• multiple fractures at birth

• underdeveloped lungs

OI type 3

• severe form with extreme bone deformities

• frequent fractures

• short stature

• shortened life expectancy

OI type 4

Similar to type 1 but is a moderate form d/t:

• Short stature

• Bone deficiencies

OI treatment

• drugs

• supportive care — must be careful handling patient to prevent fractures (even taking BP)

OI drug

Bisphosphonate therapy

Bisphosphonate therapy purpose

• Promote bone density

• Prevent fractures

• Mostly helps spine

Muscular Dystrophy (MD)

genetic disorder causing gradual degeneration of muscle fibers characterized by progressive weakness of skeletal muscles, increased fatting infiltration, and elevated creatinine/kinase

Most common type of MD

Duchenne MD

How is MD inherited?

Sex-linked recessive

• affects only males

MD occurs when a gene on an X chromosome fails to make the protein _____

dystrophin

Dystrophin absence r/t MD

1. absence of dystrophin inhibits muscle cell function

2. degeneration of muscle fibers

3. progressive weakness and wasting of skeletal muscles

MD is more common in people with have _______ _______

neurodevelopmental disorders

• e.g., autism/intellect disability

Muscular Dystrophy signs and symptoms

• Children often late in learning to walk

• Preschooler may seem clumsy and fall often

• Trouble climbing stairs, getting up from floor (uses Gower maneuver)

• By school age has waddling and unsteady gait d/t weak pelvic muscles

• Tries to keep balance by sticking belly out and shoulders back

When do kids with MD lose the ability to walk?

7-13 y/o

Gower’s Maneuver

A sign of proximal muscle weakness where a child uses their hands to “climb up” their legs to stand from a sitting or lying position

MD complications (7)

• *Mobility

• Hip and knee contractures + foot deformities

• Scoliosis / lordosis

• Nutritional concerns

• Inability to feed self / can’t chew

• Hypoventilation — difficulty coughing / airway clearance

• Cardiac failure

Most common cause of death in MD patients and when it occurs

cardiac failure in late 20s-30s

MD cardiac failure prevention

digoxin

MD nutrition

• will eventually loose ability to chew — risk to aspirate and will need an enteral source

• monitor calories

• as fine motor and gross motor abilities decline, self feeding becomes difficult

MD respiratory interventions

• hypoventilation d/t weakness

• cough assist machines, CPT, or vests may be required

• CPAP/Trach

Slipped Capital Femoral Epiphysis (SCFE)

Gradual displacement / slippage of the femoral head at the growth plate, causing hip pain and limp in adolescents

SCFE age

10-15 y/o

• occurs during/before puberty

SCFE is more common in what groups? (3)

• Obese children

• Adolescents

• Boys

SCFE signs and symptoms (5)

• Pain in hip toward groin, thigh, or knee that is worse with activity

• Limp (progresses)

• External rotation of affected hip

• Loss of hip flexion, abduction, and internal rotation

• Obesity / growth spurt

SCFE diagnostics (2)

• Xray

• MRI

SCFE complications (4)

• Acute necrosis of the hip cartilage

• Femoroacetabular impingement

• Avascular necrosis of the femoral head

• Later concerns of degenerative hip arthritis as an adult

SCFE treatment

Is an emergency once diagnosed, requiring:

• bedrest

• surgical fixation

• immobilization/spica casting/traction to keep hip completely still

SCFE treatment goals

• Prevent avascular necrosis of hip

• Early gait training

• Pin/screw inserted across growth plate to secure femoral head

Legg Calve-Perthes Disease (LCP)

A condition where temporary loss of blood supply to the femoral head causes bone death, leading to hip pain, limp, and limited motion in children

LCP affected ages

2-12 y/o

Avascular necrotic head

Loss of blood supply to the femoral head leading to bone death and collapse

Legg Calve-Perthes Disease: stage 1

Decreased blood supply → early bone death

• avascular necrosis of the femoral head

Legg Calve-Perthes Disease: stage 2

Fragmentation

• Femoral head breaks down and is resorbed

Legg Calve-Perthes Disease: stage 3

Reossification

• New bone begins to form

• on xray it looks like increased bone density in area

Legg Calve-Perthes Disease: stage 4

healing and fuller remodeling

• gradual reforming of head

• occurs until compete recovery

LCPD treatment goals (4)

• eliminate hip irritability/inflammation

• restore and maintain adequate hip ROM

• prevent capital femoral epiphyseal collapse, extrusion, or subluxation

• ensure a well-rounded femoral head at the time of healing

LCPD treatment methods

• Non-surgical (3)

• Surgical

Non-surgical

• NSAIDs

• PT

• Potential casting/abduction bracing

Surgical

• Osteotomy

LCPD vs SCFE: ages

LCPD: 4-8 y/o

SCFE: 10-15 y/o

LCPD vs SCFE: body size

LCPD: typically shorter in stature

SCFE: typically overweight

LCPD vs SCFE: physiology

LCPD: deformity of femoral head

SCFE: displacement of femoral head

LCPD vs SCFE: primary treatment method

LCPD: conservative

SCFE: operative

LCPD vs SCFE: surgery

LCPD: femoral osteotomy (avoided if possible)

SCFE: usually involves internal fixation with a screw

Osgood-Schlatter Disease (OSD)

Overuse injury causing inflammation and pain at the knee in adolescents

• anterior tibial tuberosity

• benign

OSD exacerbations (2)

• *Rapid growth spurts

• Sports

When does OSD typically resolve?

once growth plate ossifies

OSD treatment

• PT to strengthen quad and hamstring

• Ice

• NSAIDs

Scoliosis

lateral curvature of the spine

• causes rib asymmetry

Scoliosis classifications by age

• Congenital = during fetal development

• Infantile = birth to 3 y/o

• Juvenile = 3-10 y/o

• Adolescent >10 y/o

Scoliosis types (3)

• Idiopathic

• Neuromuscular (e.g., NTDs, CP, MD)

• Congenital