altered musculoskeletal system

developmental considerations

• skeletal maturity (ossification) by age of 17 years in boys; 2 years after menarche in girls

• epiphysis/epiphyseal plate

• porous bone

• thicker periosteum

casts

rigid device that immobilizes the affected body part while allowing other body parts to move

• cast materials - plaster, fiberglass, polyester-cotton

• types of casts for various parts of body - arm, leg, brace, body

managing care of patient in a cast: casting materials

• handle with palms of hands if cast wet

  • turn every two hours until dry - no fans, heat or dryers to dry cast

  • plaster 24-48 hours to dry; fiberglass within minutes

managing care of patient in a cast: relieving pain

• depending on reason for casts, child may need range of pain meds (narcotics, nsaids (avoid ibuprofen as it can impede bone healing))

• ice can help with itching and decrease swelling

• elevate extremity

• watch for skin breakdown and deal with itching inside cast

managing care of patient in a cast: improving imobility

• exercise nonaffected side and isometric exercises to affected side

• exercises to prevent foot drop

• keep child moving and active (crutches, etc)

managing care of patient in a cast: promoting healing

good diet and lots of fluid

managing care of patient in a cast: neurovascular function

• 5 p’s

• elevate extremity

• feel for tightness of cast

managing care of patient in a cast: potential complications

• keep heel off mattress

• feel for hot spots, tingling of skin by patient

• notify MD at once of wound drainage

• skin breakdown!! petal edges

nursing care for cast removal

• depending of childs age, they may be quiet fearful that the cast cutter will cut them or that it is loud

• cast cutter works by vibration and will only cut hard surface of cast

• explain procedure, demonstrate on self, provide distraction, provide headphones

• restrain child as necessary, reward child after

traction

application of a pulling force to body to provide reduction, alignment, and rest at that site

types of traction

• skin

• skeletal

• manual

care of traction treatment

• maintain correct balance between traction pull and countertraction force

• care of weights

• skin inspection

• pin care

• assessment of neurovascular status

care of client in traction (TRACTION)

temperature (infection, extremity)

ropes hang freely

alignment

circulation check (5 p’s)

type and location of fracture

increase fluid intake

overhead trapeze

no weights on bed or floor

5 p’s of circulatory checks

pain

paresthesia

paralysis

pulse

pallor

developmental dysplasia of the hip (DDH)

spectrum disorders related to abnormal development of the hip

• more common in females

• caused by lag in development

• risk factors - breech, C/S, twin, swaddled with legs out, +FH

types of DDH

• acetabular dysplasia

• dislocatable

• dislocated

• subluxable

• subluxed

acetabular dysplasia

ball remains in socket, socket is too shallow to keep ball in place

dislocatable

hip rests in either normal or subluxated position (partially out of socket) and ball can be pushed completely out of socket

dislocated

ball is completely out of socket when child is at rest

subluxable

in resting position, ball is located normally in socket, but in certain positions when pushing on hip, ball can be pushed partially out of socket

subluxed

in resting position, ball is not located normally in socket, instead rests partway out of socket

clinical manifestations of DDH

• infant

  • assymetry

  • limited abduction

  • galleazzi sign (short femur)

  • ortolani test (hip click)

• older child (walking)

  • trandelenburg sign

  • waddling gait

  • limp

management/nursing considerations for DDH

• early identification and treatment

• positioning the hip in flexed, abducted position to deepen the hip socket

• 0-6 months

  • pavlik harness (not thick diapering)

• 6-18 months

  • preop skin traction (3 wks) - bucks or russell

  • closed or open reduction under anesthesia

  • hip spica cast (2-4 mo until hip stable)

• older child

  • surgical reduction - steotomy of acetabulum

• always put undershirt on child under chest straps and put knee socks under feet and leg straps

• check skin for redness 2-3 times a day

• gently massage skin understraps daily to increase circulation

• avoid lotions and powders

• teach how to hold child with harness on

congenital clubfoot

complex deformity of ankle and foot that involves bone deformity and malposition with soft tissue contracture

etiology of clubfoot

• strong family tendency

• abnormal position/arrested development

types of clubfoot

• positional clubfoot

• syndromic clubfoot

• congenital clubfoot

positional clubfoot

occurs primarily from intrauterine crowding and responds to simple stretching and casting

syndromic clubfoot

associated with other congenital abnormalities such as congenital joint contractures (arthrogryposis)

congenital clubfoot

referred to as idiopathic or true clubfoot and usually requires surgical intervention

therapeutic management of congenital clubfoot

• serial casting (gradual manipulation, new cast every 1-1.5 weeks for total treatment time of 8-12 weeks)

• surgery (if serial casting has not been effective) to place pins and severe tendons followed by casting for 2-3 months

• after serial casting or surgery the child will wear a splint or brace to maintain correction

nursing considerations for congenital clubfoot

• potential for injury r/t cast (N/V impairment)

• 5 P’s; apply ice to decrease swelling, elevate cast

• altered family process r/t child with physical defect

osteogenesis imperfecta

group of inherited disorders of connective tissue

• aka brittle bone disease

• most common genetic disorder of bone

• some infants born with fractures

• characterized by connective tissue and bone defects

clinical manifestations of osteogenesis imperfecta

• bone fragility and deformity

• poor growth (short stature, bone length discrepancies)

• bruising and recurrent epistaxis

• blue sclerae

• pre-senile hearing loss (@ 20-30 years of age)

• thin skin (due to thin collagen)

• excessive diaphoresis and teeth discoloration

• mild hyperpyrexia

• decreased incidence of fractures in adolescence

supportive goals of osteogenesis imperfecta

• prevent contractures and deformities

• prevent muscle weakness and osteoporosis

• prevent mal-alignment of lower extremity joints

treatment of osteogenesis imperfecta

• lightweight braces and splints

• simple exercise and or PT

• surgery to correct deformity or rod to stabilize bone

• pamidronate disodium (IV) - aids bone healing and slows bone resorption (calcium regulator); calcitonin; biphosphates

nursing considerations for osteogenesis imperfecta

• careful handling to prevent fractures

• teaching r/t limitations and activity for optimal growth and development

• family support

  • OI foundation

  • OT

  • genetic counseling

legg-calve-perthes disease

idiopathic, self limiting aseptic necrosis of femoral head (usually unilateral)

• boys affected more between ages 3-12

pathophysiology of legg-calve-perthes disease

• disturbance in circulation to proximal femoral epiphysis causing 4 stage necrosis

• flattening of femoral head

• new bone growth

• deformity

clinical manifestations of legg-calve-perthes disease

• insidious onset (slow/quiet, with slight pain or limp)

• symptoms most evident upon arising and end of day

  • hip, knee, or thigh pain

  • intermittent limp on affected side (+ trandelenburg sign)

  • decreased joint ROM

  • history of trauma

diagnosis of legg-calve-perthes disease

radiography

therapeutic management of legg-calve-perthes disease

• objective - keep head of femur (abduction) contained in acetabulum to preserve spherical shape and prevent flattening

• initial non-weight bearing period to reduce inflammation and restore motion (deformity occurs early in disease)

• containment devices (head of femur in acetabulum)

• weight bearing and non-weight bearing devices

• surgical reconstruction and containment

• ROM, PT

nursing considerations for legg-calve-perthes disease

• parent/child teaching - most care at home

• diversional activities

• encourage return to school

• patient adherence to treatment

  • conservative treatment for 2-4 years

  • if surgical correction - nl activity 3-4 months

scoliosis

complex spinal deformity

• most common spinal deformity

• lateral curvature (s-shape)

• spinal rotation

• thoracic kyphosis

types of scoliosis

• functional

• structural

clinical manifestation of scoliosis

• nonpainful lateral curvature of spine

• asymmetry of hips and shoulders

• unequal scapula prominences

• asymmetry of abdominal skinfolds

screening for scoliosis

mass screening controversial

diagnosis of scoliosis

scoliometer, spinal xrays

mild scoliosis

<20 degree curve

• observation, eval every 3-12 months

moderate scoliosis

20-40 degree curve

• bracing (milwaukee brace, boston brace)

• brace is worn until cessation of bone growth

severe scoliosis

>40 degree curve

• surgical spinal fusion with instrumentation (harrington or luque rod; dwyer cable)

surgical management of scoliosis

• spinal fusion with instrumentation

  • harrington rod

  • dwyer cables

  • luque rod

preop nursing care of scoliosis

• may be hospitalized for weeks for halo traction prior to surgery

• will have lots of xrays before surgery, lab work, IV insertion, teaching before surgery of how to log roll, work PCA pump is helpful

postop nursing care of scoliosis

• monitor VS (especially hypotension), wound assessment, circulation, NVS (5 p’s)

• IS every 2 hours

• keep flat, log roll every 2 hours

• pain relief (PCA)

• PT started as soon as possible

• encourage independence

• encourage family to be involved

common postop complications of scoliosis surgery

• neurological or spinal cord injury

• SIADH

• atelectasis

• pneumothroax

• ileus

• implanted hardware complications

• superior mesenteric artery syndrome

  • involves duodenal compression by aorta and super mesenteric artery and may result in acute duodenal obstruction

  • s/s include vomiting, epigastric pain, nausea, and symptoms aggravated when patient is on back, better when on side or belly

juvenile idiopathic arthritis (JIA)

chronic inflammatory joint disease

• most common rheumatic disease in children

• more common in females

pathophysiology of idiopathic arthritis

chronic inflammation of synovium

types of juvenile idiopathic arthritis

• systemic

• pauciarticular

• polyarticular

systemic JIA

fever, rash, pericarditis/other organs

pauciarticular JIA

<5 joints, can lead to blindness

polyarticular JIA

5 or more joine; spinal and hip involvement (crippling)

juvenile idiopathic arthritis clinical manifestations

• spiking fever

• pain

• skin rash

• malaise

• pericarditis

• anorexia

• morning stiffness

• swelling of joint

• joint warm to touch

• joint pain

• weight loss

• loss of movement

• eye problems

therapeutic management of juvenile idiopathic arthritis

• goals - get inflammation under control and the. ROM

  • preserve joint function - heat and exercise

• swim, play (need to wiggle, lie prone watching TV)

• prevent deformity - PT/OT, ROM

• relieve symptoms (pain) - NSAIDs

  • severe - methotrexate

  • corticosteroids short term

  • ATC pain meds

nursing care for juvenile idiopathic arthritis

• medication teaching

• encourage heat and exercise to relieve pain and stiffness (as adjunct therapy, does not replace pain meds)

• promote general overall health/nutrition/rest/exercise

pauciarticular JIA

requires regular eye screening

• uveitis - inflammation of part or all of uveal tract, layer under white part of eye

  • made of 3 parts:

    • iris (colored part of eye)

    • ciliary body

    • choroid

osteomyelitis

infectious process of bone caused by any organism

• older children - staphylococcus aureus

• younger children - hemophilus influenzae

• more common in boys, 5-14 years of age

• bones most often involved - femur and tibia

• painful disorder

etiology of osteomyelitis

hematogenous (endogenous) or exogenous

pathopysiology of osteomyelitis

• bacterial infection carried to bone (spreads laterally)

• abscess formation and local bone destruction

• dead bone forms sequestrum (necrotic)

• bone may become honeycombed with sinuses that retain infective material

• chronic site for exacerbations

clinical manifestations of osteomyelitis

• child appears very ill

• abrupt bone pain (tenderness, edema, erythema)

• unwilling to move limb or bear weight

• fever

• irritability

• malaise - will not feel like participating in age appropriate activities

• poor appetite

diagnostic tests for osteomyelitis

• ESR

• WBC

• blood culture

• x-ray?

therapeutic management of osteomyelitis

• IV antibiotics x 3-4 weeks; then oral antibiotics

  • penicillin G; methicillin; oxacillin

• heat

• bedrest

• surgical drainage of abscess (sequestrectomy)

complications of osteomyelitis

pathological fractures and chronic osteomyelitis

nursing considerations for osteomyelitis

• supportive (high risk for injury r/t NV impairment)

• pain management

• maintenance of IV access (PICC line)

• cast care (sometimes used for immobilization)

• nutrition - high calorie drinks and protein for tissue repair and to prevent negative N balance

• diversional activity - quiet play on bedrest