Alterations in Mobility or Musculoskeletal Disorders

Bone Health

• Diet strong in vitamin D, calcium, and protein.

  • School-aged children need 1,000 mg of calcium (about 4 cups of milk a day).

  • Adolescents need 1,300 mg of calcium a day.

• Encourage weight-bearing exercises; this increases bone density.

• Avoid carbonated beverages.

  • Educate: Carbonated beverages decrease the bone’s ability to absorb calcium.

Pediatric Bone Anatomy

• Infant skeleton is not fully ossified at birth.

• Thick, strong periosteum—outermost lining of the bone—(better shock absorber!)

  • Pediatric bones can bend up to ~45 degrees before breaking.

  • Due to this, sometimes children can have more of an incomplete fracture than one an adult would have.

• Bone ossification (cartilage to bone) is complete by adolescence.

• The growth plate at the end of long bones is composed of the epiphysis and physis (epiphyseal growth plate).

  • The growth plate is the most vulnerable part of the bone.

  • Bone growth occurs here.

**The growth plate must be protected at all costs! If it is damaged, it can interrupt blood supply and cause growth failure**

Fractures in Children

Fractures are a common injury in children:

• Rare in infants.

  • They aren’t very active or mobile yet; not doing any hazardous behaviors to themselves.

  • When they’re born, they may have a clavicular fracture, if they had some shoulder dystocia coming through the birth canal.

  • Ex: Mom is going down the stairs with her baby in her arms and slips. An infant arm, leg, and skull fracture is possible.

• The clavicle is the most frequently broken bone in childhood, especially in those under 10 years old.

When describing a fracture as a nurse:

• Name the bone affected.

• Note if it is open (bone breaks through skin) or closed (skin is intact, the bone did not break through).

• Note if it is distal or proximal.

• Specify the part of the bone injured: epiphysis, metaphysis, diaphysis, or physis (Salter-Harris Classification)

• Note if it is displaced or nondisplaced.

  • Displaced = ends do not line up; the patient tends to have a pretty significant amount muscle of spasms and their pain is worse.

• Describe the type: transverse, oblique, spiral, or depressed.

Common Pediatric Fractures

• Greenstick

• Buckle

• Compound or Open

• Stress Fracture

• Spiral Fracture

Greenstick Fracture

Incomplete fracture

• That thick periosteum comes into play!

Buckle Fracture

Raised or bulging projection at the site

• Seen in the wrist, typically from a fall on an outstretched hand (FOOSH).

Compound or Open Fracture

Fractured bone protrudes through the skin

• It can be just a little bit or a lot.

• Patient is at a huge risk for infection of the bone and their body.

Stress Fracture

Tiny cracks in a bone

• Seen in athletes.

Spiral Fracture

• Spiral appearance of fracture

  • Always investigate spiral fractures in children when the mechanism of injury does not match the fracture type, especially in a non-ambulatory child!

  • It takes a great force to cause this injury.

Epiphyseal Injuries

• The weakest point of long bones is the cartilage growth plate (epiphyseal plate).

• It is a frequent site of damage during trauma.

• Injury may affect future bone growth.

• Treatment may include open reduction and internal fixation to prevent growth disturbances.

Salter-Harris Fractures

• The Salter-Harris Classification system is used to describe fractures involving the epiphyseal growth plate.

• These injuries have a higher likelihood of healing difficulties.

• The most common concern is:

  • Growth arrest with the potential for deformity and limb length discrepancy.

• Salter-Harris I and II fractures can be treated with closed reduction, casting, or splinting.

• Salter-Harris III, IV and V will require surgery—open reduction.

  • Salter-Harris V fracture diagnosis may be delayed unless there is a high degree of clinical suspicion, and often the diagnosis is not made at the initial presentation.

    • May see in a follow-up examination as the patient starts to have some healing.

Bone Healing and Remodeling

Stages of Bone Healing

• Inflammatory Phase:

  • Duration: hours to days

  • A hematoma forms, then begins forming a primary callus.

• Reparative Phase:

  • Duration: days to weeks

  • A thick mass of callus forms around the bone ends.

  • New bone is formed from bone-forming cells.

• Remodeling Phase:

  • Duration: months to years

  • The callus becomes smoother and is calcified.

Assessment of Musculoskeletal Injuries

• Assess for the 5 Ps to rule out complications of compartment syndrome:

  • Pain (increased and out of proportion)

  • Pulselessness

  • Pallor

  • Paresthesia

  • Paralysis

• Also assess the 5 Ps before and after immobilization, as well as any time the patient reports a change in sensation.

• Displaced fractures may require reduction:

  • Open Reduction: requires surgery.

  • Closed Reduction: patient is sedated; performed outpatient.

Casts and Splints

• Immobilizes the fracture to ensure alignment.

• Promotes healing, comfort, and provides protection.

• Splinting:

  • Immobilizes the injury while allowing swelling to decrease.

  • The splint will be worn for approximately 1 week.

  • Like to start off with this.

• Cast:

  • Provides hard immobilization of fractures.

  • Made of fiberglass or plaster.

• Nursing Measures:

  • Assess the injury and determine if an open fracture is present.

    • Splinting or casting material is not placed over open fractures.

    • Open fractures require IV antibiotics and sometimes surgery.

  • Perform peripheral vascular checks during the initial assessment and before and after immobilization and/or reductions.

  • Pain management.

  • Apply the splint and ensure proper placement of splint padding and splint.

  • Educate the patient and family regarding warning signs of compartment syndrome and care of the cast or splint.

Cast Saw

• When removing a cast, a cast saw is used.

  • This cast saw cuts through the cast using vibration.

  • If the cast saw stays against bare skin for more than a couple of seconds, it can cause a burn.

Complications for Splints or Casts

Compartment Syndrome:

• Occurs when there is increased pressure in an enclosed space, such as a cast.

• This results in decreased blood flow.

• The patient will typically report sudden increased pain (this is due to tissue dying).

• Ischemia occurs, followed by necrosis of tissue.

• An emergency fasciotomy must be performed to save the tissue and extremity.

  • These patients will require a skin graft sometime in the future.

Pressure Sore:

• Develops from improper cast or splint application.

• Skin grafts will also be needed for recovery.

Traction

• Uses:

  • Reduce and/or immobilize a fracture

  • Align an injured extremity

  • Allow the extremity to be restored to its normal length

• May also reduce pain by decreasing the incidence of muscle spasms.

• Extension by a pulling force may be used.

• The type of traction used depends on the child’s age, the condition of the soft tissue, and the type and degree of displacement of the fracture:

  • Manual Traction:

    • Applied to the body part by hand, placed distally to the fracture site.

  • Skin Traction:

    • Pulling mechanisms are attached to the skin with adhesive material or elastic bandage.

    • Skin must be intact!

  • Skeletal Traction:

    • Applied directly to the skeletal structure by a pin, wire, or tongs inserted into or through the diameter of bone distal to the fracture.

Skin Traction

Buck’s Traction:

• Reduces femur fractures.

• Also used for contractures of the hip or knee.

• Force is delivered through a traction boot or skin traction in a straight line.

• **Skin must be intact!

Skeletal Traction

90-90 Traction:

• Reduces femur fractures.

• Pins are placed through the distal femur; traction is applied through pins only.

  • Huge risk for infection and pressure sores.

• Nursing Considerations:

  • Regular pin care per policy.

  • Diversional activities

  • Frequent assessment of the peripheral neurovascular system.

  • Encourage patients to use their unaffected extremities.

  • Monitor U/O & BM.

    • Ensure adequate nutrition and hydration.

  • Encourage incentive spirometry use.

Halo Traction:

• Used for fractures or injuries of the cervical spine.

• First step in correcting severe scoliosis, kyphosis, and other spinal deformities.

• A ring surrounds the head, and pins are attached to the outer portion of the skull.

Nursing Care of a Patient in Traction

• Assessment of the 5 Ps

• Maintain traction and alignment

• Monitor weights and ropes:

  • All weights should hang freely; they should not rest on the ground or the bed.

  • Nurses do not adjust the weights.

• Prevent skin breakdown using proper padding

• Prevent complications

• Provide pain management and comfort measures

• Exercise unaffected extremities

• Encourage deep breathing

• Monitor for constipation or urinary stasis

• Provide distraction

• Enlist Child Life Services (CLS)

Child Abuse (Non-Accidental Trauma—NAT) Fractures

• Occurs most often in children under 3 years of age.

• Median age is 7 months.

• Common Fractures in NAT (Non-Accidental Trauma):

  • Femur, humerus, and skull fractures are the most common sites.

  • Clavicular fractures and spiral fractures of long bones in non-ambulatory children.

  • Bucket Handle Fracture:

    • Occurs when an adult grabs, twists, or shakes a child’s limb in frustration.

    • Shaking the child, causing the limbs to move back and forth, can also cause a bucket-handle fracture.

    • It is difficult to sustain this injury from accidental causes, such as a fall.

  • Posterior rib fractures (due to compressive squeezing).

  • Multiple fractures, especially if they are in different stages of healing.

  • Be suspicious of any injury that does not fit the stated cause of injury.

  • Delay in seeking treatment.**

Osteomyelitis

• Defined as an infectious process in the bone that can occur at any age, but is most commonly seen in children 10 years and younger.

• Causes:

  • Direct inoculation (break in the skin → pathogen enters)

  • Abscess

  • Dead bone

• Clinical Symptoms:

  • Malaise, low-grade fever

  • Irritability (especially in infants and non-verbal children)

  • Edema

  • Erythema

  • Joint tenderness

  • Decreased use

  • Limp

  • Refusal to walk (woke up not wanting to walk)

  • Fever

  • Children may c/o their knee hurting when its actually their hip and vice versa.

• Diagnosis:

  • Bloodwork:

    • For acute: Elevated ESR and CRP

    • WBC count may be non-specific (acute = elevated; chronic = may be normal)

  • Imaging:

    • Deep tissue swelling, periosteal elevation, lytic sclerosis.

    • Bone biopsy may be necessary.

• Nursing Management:

  • Administer IV antibiotics. (for a long time)

  • Provide pain medications as needed.

  • Enforce activity restrictions and immobilization.

  • Provide post-op care after surgical debridement. (5 Ps)

Radial Head Subluxation “Nursemaid’s Elbow”

• Cause:

  • Caused by a pulling motion on the arm that stretches or tears the annular ligament surrounding the radial head, displacing the radial head.

• Typically occurs in children under 5 years of age.

• Injury Reduction Technique:

  • The elbow is flexed to 90 degrees, and then the forearm is fully and firmly supinated.

• Clinical Manifestations:

  • Holds the affected arm close to the body.

  • Pain with forearm supination is always present.

  • No obvious deformity, PNV (peripheral neurovascular) compromise, bony tenderness, or swelling.

  • History of the arm being pulled.

• The ligament becomes entrapped within the joint, preventing spontaneous reduction.

• Nursing Measures:

  • Provide education and reassurance for the child and parents.

  • May need to assist with the reduction.

  • Administer pain medication as needed.

Osteogenesis Imperfecta

• Genetic bone disorder with an autosomal dominant inheritance pattern that affects collagen type I production:

  • Low bone mass

  • Increased bone fragility

  • Connective tissue problems; unstable joints.

• The estimated incidence is approximately 1 in every 12,000 to 15,000 births.

• Occurs equally among males and females, and across races and ethnic groups.

• Fractures may persist into adulthood.

• Physical Characteristics:

  • **Blue sclera:

    • The most common ocular sign.

    • Caused by thin scleral collagen, allowing the underlying darker choroid vasculature to be seen.

    • Patients with OI show reduced thickness of corneal and scleral collagen fibers, resulting in low ocular rigidity.

  • Hearing loss

  • Frequent fractures

  • Short stature

  • Fragile dentition

• Treatment:

  • Goal is to decrease fracture incidence and maintain mobility.

  • Bisphosphonate administration to promote bone growth.

    • Zebra lines are evidence of bisphosphonate treatment.

  • Physical therapy/occupational therapy to prevent contractures and maximize mobility.

  • Standing with bracing is encouraged.

  • Severe cases may require surgical insertion of rods into the long bones.

  • Lightweight splints or braces may allow the child to bear weight earlier.

Developmental Dysplasia of the Hip (DDH)

• Formerly called congenital hip dysplasia or congenital dislocation of the hip

• Femoral head is displaced from the acetabulum

• Risk Factors:

  • Firstborn

  • Breech presentation

  • Female

  • Family history of DDH

• Diagnosis:

  • Physical examination shows asymmetric thigh or gluteal folds

  • Barlow Test, Ortolani Test, Galeazzi Test

  • Ultrasound if < 6 months old

  • X-ray if > 6 months old

• Therapeutic Management:

  • Goal: maintain hip joint in reduction so the femoral head and acetabulum can develop properly

  • Pavlik Harness (< 6 months):

    • Used full-time, do not remove!!

    • Worn for approximately 3 months if started at a young age

  • Closed Reduction (> 6 months):

    • Used for older infants/toddlers

    • Followed by a spica cast after reduction

• Nursing Management:

  • Educate parents on Pavlik harness care and assess the skin

  • Provide education and care for surgical reduction

Pavlik Harness Education

• Do not adjust the harness without checking with the physician or nurse practitioner first.

• Until your physician or nurse practitioner instructs you to remove the harness for periods during the day, it must be worn continuously (for the first week or sometimes longer).

• Change your baby’s diaper while they are in the harness.

• Place your baby on their back to sleep.

• Check skin folds, especially behind the knees and in the diaper area, for redness, irritation, or breakdown; keep these areas dry and clean.

• Once your baby is permitted to be out of the harness for short periods, you may bathe your baby while the harness is off.

• Long knee socks and an undershirt are recommended to prevent skin irritation from the brace.

• Note the strap markings to ensure proper harness placement.

• Wash the harness by hand with mild detergent and air dry. If using a dryer, use the air fluff setting only (no heat).

Call the doctor if:

• Your baby’s feet are swollen or bluish.

• The harness appears too small.

• Skin is raw or there is a severe rash.

• Your baby is unable to actively kick their legs.

Congenital Clubfoot—Congenital Talipes Equinovarus

• Structural foot deformity present at birth.

• Etiology is unknown, but may be associated with certain syndromes or neurogenic disorders.

• A congenital anomaly occurring in approximately 1 out of 1,000 live births.

• The foot is excessively plantar-flexed, with the forefoot swinging medially and the sole facing inward. It cannot be moved into the normal midline position.

• The deformity resembles a golf club head.

Complications:

• Rocker-bottom deformity

• Awkward gait

• Epiphyseal disturbance

Nursing Management:

• Cast care for serial casting (in stages)

• Post-operative care if surgery is needed

• Education and support for the family

Pectus Excavatum

Funnel-shaped chest:

• Depression that sinks inward at the xiphoid process.

• Worsens as the child grows.

Cardiac and pulmonary compression can occur in severe cases:

• Shortness of breath (SOB)

• Exercise intolerance

Surgery may be required if the condition is severe.

Nursing Management:

• Perform respiratory assessments.

• Provide wound care postoperatively if surgery is done.

• Manage pain effectively.

Kyphosis

• Lateral convex angulation of the thoracic spine.

• Treatment options:

  • Exercises

  • Bracing

  • Physical therapy

  • Surgical spinal fusion, if indicated

Lordosis

• Lateral inward curve of the cervical or lumbar spine.

• Treatment options:

  • Weight loss

  • Correction of underlying deformity

  • Targeted exercises

Scoliosis

• Lateral curvature of the spine > 10 degrees.

• If > 70 degrees, it may cause cardiopulmonary dysfunction due to alterations in the thoracic cage.

Causes:

• Idiopathic (infantile, juvenile, adolescent)

• Congenital (results from anomalous vertebral development)

• Neuromuscular (associated with neuromuscular or muscular diseases such as cerebral palsy, myelomeningocele, spinal cord tumors, spinal muscular atrophy, and muscular dystrophies)

Screening:

• Adam’s Forward Bend Test

Diagnosis:

• Physical examination and full spine X-rays

• Determine underlying cause (idiopathic, congenital, or neuromuscular)

Treatment:

• Bracing or Spinal Fusion

• Treatment depends on the degree of curvature and skeletal maturity:

  • If the curve is < 25 degrees, the doctor may observe the curve and repeat X-rays to monitor progression.

  • If the curve is between 25 and 45 degrees and the child still has growth remaining, bracing may be considered to prevent progression.

  • If the curve is > 50 degrees, surgery may be recommended.

Post-Operative Care (for spinal fusion > 50 degrees):

• Monitor hemodynamic status

• Pain management

• Early ambulation

• Physical therapy

• Logrolling

• Neurovascular checks

• Monitor for infection of surgical hardware

Duchenne Muscular Dystrophy

• Inherited progressive myopathic disorder resulting from a defective gene located on the X chromosome that is responsible for the production of dystrophin.

• X-linked Recessive

Symptoms:

• Muscle Weakness:

  • Typically occurs at 2 to 3 years of age

  • Progresses from proximal to distal limb muscles

  • Affects lower extremities before upper extremities

  • Children are typically wheelchair-bound by approximately 12 years of age

• Decreased endurance; unable to keep up with peers

• Toe walking, calf hypertrophy

• Muscle cramping

• Heart failure and arrhythmias occur late in the disease

• Scoliosis—leads to poor pulmonary function

• Developmental delays are common

• May also present with ADHD, OCD, anxiety, and autism

Diagnosis:

• Elevated creatine kinase (CK) levels

• Muscle biopsy for definitive diagnosis (shows absence of dystrophin)

• **Gower’s Sign (as shown in picture—uses hands to "walk up" the legs when standing from a sitting or lying position)

Treatment:

• Administer corticosteroids and calcium/vitamin D supplements

• Promote mobility

• Assess and maintain cardiopulmonary function

• Provide support (chronic, progressive disease)