Musculoskeletal Disorders

Musculoskeletal Functions

Bones, muscles, tendons, ligaments, cartilage, and joints provide a structural support and protection network. Bones help store minerals. Bone marrow is the source of hematopoiesis.

The average adult has 206 bones, whereas a newborn has up to

300 bones.

In infants, the plates of the skull are not fused together until

1-2 years of age.

Growth plates, which allow for bones in children to expand, fuse by the age of

14-18 years.

Differences in Infants & Children’s Musculoskeletal System

Infant Musculoskeletal System

Newborns should have full ROM. Healthy infants should demonstrate normal muscle tone. Brisk deep tendon reflexes are present at birth. An infant’s skeleton is not fully ossified at birth. Infants’ and young children’s bones are more flexible and porous.

The ends of the bones in young children comprise the physis

(area between the epiphysis and metaphysis), which is the growth plate. Damage close to the growth plate can stop the growth of bone.

Bone age

should match child’s age, is determined by X ray of non dominate hand and wrist

Bone and muscle development is influenced by use.

Certain sports and extreme activities increase risk of injury. Discourage heavy backpacks & weightlifting. Encourage a balanced diet with enough protein, calcium, and vitamin D.

Fractures in children less than 1 are

uncommon.

Because of an abundance in blood supply to the bones, bone healing occurs

more rapidly in children than adults.

(Club Foot) Talipes Equinovarus

A congenital condition that occurs in 1/1000 live births.

Talipes varus

inversion of the foot

Talipes valgus

eversion of the foot

Talipes equinovarus

toes are pointing inward and lower than the heel.

Talipes Equinovarus Risk factors

males, poor position/intrauterine crowding

Talipes Equinovarus Can occur

with one or both feet, as an isolated defect, or with other disorders (CP/ spina bifida). The affected feet/foot is shorter and smaller with an empty heal pad and visible plantar crease at midfoot.

Talipes Equinovarus Treatment options

Serial casting and stretching of the foot muscles (ex. Ponseti method). Abduction Bracing (Denis Browne Bar) worn after casting process., Surgery, Promote normal developmental needs. , Start treatment as soon as possible.

Teaching

Cast care, neurovascular checks

cast care and assessment/plan of care for long term casting and bracing

encougurage parents to continue meeting developmental needs, NV checks (the ps), check cap refill, teach parents to check,

Torticollis

The infant’s neck is twisted. Excessive rotation of the cervical spine. Caused by a shortened sternocleidomastoid muscle.

Congenital Torticollis

Can be caused by birth trauma or a difficult birth.

Acquired Torticollis

Caused by trauma or poor positioning as a baby/infant. (Dislocation of C1/C2)

Torticollis Treatment options

Physical Therapy, Surgery is severe, Tubular orthosis collar

Torticollis With treatment, resolves in

6 months

Untreated Torticollis affect the developmental milestones

reduce feeding, plagiocephaly (flat head), facial asymmetry, muscle imbalances, affects tummy time, rolling over, gross and fine motor skills, sensory - tracing and depth perception

Scoliosis

A deformity of the spine that also causes rib asymmetry 10% or greater lateral curvature of the spine

Scoliosis Screening at age

10 and 12 for females and for males at age 13 and 14. may typically occur during sports physicals.

Scoliosis Diagnostic options

Cobb Method, X-ray

Scoliosis S/S

Asymmetry of the trunk, prominent scapula, un-even shoulders, One leg shorter than the other, Asymmetry in ribs, flanks & hips also

Scoliosis Treatment

Will be based upon the degree of curvature.

Scoliosis Less than 45 degrees

bracing (ex. TLSO or Milwaukee)

Scoliosis Greater than 45 degrees

spinal fusion with rod placement. Halo traction may be used for severe scoliosis.

Scoliosis Bracing

Requires proper fit, Regular skin assessments, Promote child’s positive self-image, Wear for 23 hrs/day – only remove for hygiene/showering, Education!

complications to anticipate & prevent for bracing

skin breakdown, fitted cotton under brace, ensure proper lung expansion, constipation and reduced food intake, psychosocial support,

Post op spinal fusion/rod placement management

PICU immediately post operative, PCA pump, Anticipate blood transfusion, NG Tube, Chest Tube, Indwelling Urinary Cath (Strict I/O)

Post op spinal fusion/rod placement management

Monitor Bowel sounds – paralytic ileus!, N/V control , Frequent NV checks, Log rolling, Skin & wound care – reduce risk of infection, Activity restrictions, Ambulation by 2nd or 3rd day with PT and OT.

Post op spinal fusion potential complications

Spinal cord injury, Pneumothorax (decreased mobility), Hypotension (Blood loss), Atelectasis (decreased mobility), Ileus (decreased mobility), Infection (surgical incision)

Kyphosis

Hunchback/ Exaggerated forward rounding of the upper back

Kyphosis S/S

Uneven shoulder height, thoracic pain.

Kyphosis Treatment

May require surgical treatment or bracing or PT. Halo traction may be used in severe cases.

Developmental Dysplasia of the Hip (DDH)

Abnormal development of the acetabulum (hip socket) in utero, infancy, or childhood with or without dislocation of the hip. It can occur in one or both hips. Early diagnosis helps prevent long-term complications.

Dysplasia of the Hip DX

Bartlow and Ortolani assessment, Ultrasound, X-ray.

Dysplasia of the Hip

mildest form- femoral head remains in the acetabulum

Subluxation of the Hip

Partial displacement of the femoral head

Dislocation of the Hip

The femoral head is displaced and loses contact with the acetabulum

DDH Risk factors

Family history, Female, Breech birth, Limited room for movement in utero (Twins) or oligohydramnios.

DDH Common S/S infant

Asymmetrical gluteal/thigh folds, Clunking or clicking sound, Limited hip abduction, Shortening of the femur on the affected side, Positive Bartlow or Ortolani

Positive Barlow Test

The hip is dislocatable. adducts the leg (brings the thighs together) and applies downward/posterior pressure to the knee. positive is a palpable "clunk" as the femoral head slips out of the acetabulum (socket).

Positive Ortolani Test

The hip is dislocated, but reducible. flexes the hips and knees to gently abducts the leg (moves the thigh outward) while applying upward pressure. A positive sign is a palpable "clunk" as the dislocated femoral head slides back into place in the socket.

DDH Common S/S older child

Leg length asymmetrical, Waddling appearance, Positive Trendelenburg gait, walking on toes or one foot, hip drops when leg is raised.

DDH Treatment

Pavlik Harness and Spica cast

Pavlik Harness Mechanism of Action

Prevents hip flexion & adduction

Pavlik Harness Nursing Care

Worn 23 hrs/day until hip stabilized, Straps readjusted by provider every week, Check straps twice daily, NV and skin integrity checks

Pavlik Harness Age of use

Newborn to 6 months

Pavlik Harness Family Education

Do not adjust straps, Instruct how to remove harness, Skin care – undershirt, knee socks, massage skin under straps, Avoid lotions/powders, place diaper under straps

Pavlik Harness Potential Complications

Osteonecrosis Impaired skin integrity

Spica Cast Mechanism of Action

Indicated when abduction splinting is unsuccessful. Cast changed frequently by provider to accommodate growth.

Spica Cast Nursing Care

Pre op teaching, NV checks, Manage post op painm Frequent Skin care – diaper area, Cast care, Evaluate hydration and elimination status daily!

Spica Cast Age of use

6 months to 2 years

Spica Cast Family Education

Neurovascular checks – how to, Proper positioning, turning, Care of cast, Sponge baths, Waterproof barrier around genital opening of cast, Appropriate equipment for travel and mobility

Spica Cast Potential Complications

Atelectasis, ileus, infection, Decreased muscle strength, Skin breakdown

Legg-Calve-Perthes Disease

Impaired circulation to the femoral head that results in aseptic necrosis Slow onset with varying stages

Legg-Calve-Perthes Disease stages

Synovitis, Necrotic fragmentation, Reconstruction

Legg-Calve-Perthes Disease risk

boys aged 2-12 (not deteched until walking age)

Legg-Calve-Perthes Disease Signs & Symptoms

Intermittent painless limp, Hip stiffness, limited ROM, Hip, thigh, knee pain, Shortening of the affected leg

Legg-Calve-Perthes Disease Treatment

Supportive care, Administer NSAIDS, Rest and limited weight bearing, Abduction brace or cast, Physical Therapy, Traction, Advance to active range of motion as prescribed, Surgical - osteotomy of hip

promote healthy development in a school age child with Legg-Calve-Perthes Disease

low impact activities like swimming

Fractures in children Risk Factors

soft bones, not fully ossified , high risk activies, (tibial most complications)

Fractures Signs & Symptoms

Pain, Crepitus, Deformity, Edema, Ecchymosis, Decreased use of affected area

Fractures Treatment

Splinting, casting, immobilization, PT, surgery

Fractures Young children may convey pain differently.

Remember to assess non-verbal cues of pain

Fractures in infants are

rare. **Consider osteogenesis imperfecta or abuse.

Fractures potential complications with fractures

compartment syndrome, shock, dvt pe, fat emboli, infection , contractures.

Incomplete fracture

Only one side of the bone is fractured.

Complete fracture

Both sides of the bones are affected.

Bend/plastic deformation

Bone bends without breaking.

Stress fractures

Tiny cracks in bone that occur because of repetitive trauma or overuse.

Greenstick fractures

A bone bends and it causes splintering of the bone without fully breaking the bone. Common in children less than 10 years.

Torus fractures (Buckle fractures)

Commonly occurs around the wrist as the child tries to catch him/herself when falling. This is the most common type of fracture in the pediatric population and is caused by excessive pressure placed on the bone and the bone bulges instead of breaking.

Physeal fractures

Growth plate fractures. Injury occurs on the growth plate which is the weakest area of the bone. (Complication- May affect bone growth later in life) Compression fractures

Nursing Care for fracture

This will depend on the type of fracture and the type of casting. Consider Hygiene, positioning, mobility, risk for infection, safety, Immobilize., Infection Prevention.

Nursing Care for fracture Cast care

Remember nothing goes into the cast.

Nursing Care for fracture Pain control.

Children can typically locate their pain (pointing etc.) by 3 years of age. Neurovascular assessments

Compartment Syndrome

Compression of nerves, blood vessels, and muscle inside a confined space leading to neuromuscular ischemia!

The 7 ps

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia , Pressure (pulsations – skin is hard)

fracture Traction

used to stabilize and re-align the bones preoperatively or postoperatively. Used to treat femur fractures, severe scoliosis/kyphosis, or severe musculoskeletal injuries.

Skeletal traction

direct pressure on the bones through pins or rods or screws. Weight is attached via ropes to pins or rods to provide stabilization. This is surgically placed. Example

Skin traction

Applies pulling force (weights to the skin) via tape, splints, or bandages. Buck’s traction

Bryant’s traction

skin traction used primarily for young children with femur fractures. Both legs are elevated vertically, with the hips flexed at approximately 90 degrees.

Russell’s traction

skin traction used for femur fractures. A sling supports the knee while weights provide longitudinal traction to help align the fracture and reduce muscle spasms.

nurse care for the child in traction

keep weights free hanging, diversional activies, muscle spams, consider Respitory, gi, constipation

Osteogenesis Imperfecta

An inherited connective tissue condition resulting in bone fractures and deformity along with restricted growth. Caused by a defect in the collagen gene leading to insufficient collagen. Type 1 is mild and most common. Type 2 is not compatible with life (1 Year) . Other types not compatiable with life (check abuse)

Osteogenesis Imperfecta Signs & Symptoms

Lax joints, Frequent fractures, Short stature, Blue sclera, Bone deformities, Bowing, Growth pattern disturbances. Hearing loss

Osteogenesis Imperfecta Treatment

Fracture care, Bracing, Surgery, PT, Bisphosphonate therapy (Reclast), Exercise modifications.

Osteogenesis Imperfecta Bisphosphonate

(Reclast) is the pharmacological treatment of choice. It inhibits bone resorption (breakdown) and slows bone loss.

Osteogenesis Imperfecta Nursing implications

Manual blood pressures (more gentle), Oral care, Assist with positioning and safety. monitor for low serum magnesium, hypocalcemia, hypophosphatemia.

Osteogenesis Imperfecta Other comorbidities

Respiratory infections, such as pneumonia, Heart problems such as poor heart valve function, Kidney stones, Joint problems, Hearing loss, Eye conditions and vision loss