Musculoskeletal PEDS

Describe a Cast and What It Is Used for

• An immobilizing device that is made up of plaster or fiberglass bandages molded to the body part

  • Immobilizes extremity to hold fragments in reduction

  • Apply compression of tissue

  • Allow for earlier mobilization

  • Correct/Prevent deformities

  • Support and stabilize weak joints

Nursing Interventions For Casts

• Elevate and apply ice for first 24 hours

• avoid using fingers to avoid denting

• Don’t insert items into cast

• Report:

  • Hot spots, drainage, malodor, pain, cool digits, skin color changes

What do we need to watch out for in Hip Spica casts?

• Constipation, increase fiber and fluids

Types of Traction

• Skin traction

• Halo traction

Describe what Skin traction is used for?

• weights are attached to skin to immobilize the area, decrease muscle spasms and realig bones

• Used for Long Bone Fracture

  • Uses screws or pins in the bone

What is Halo Traction used for?

• Metal ring or halo that is attached to skull using pins/screws

Nursing Interventions for Skin tractions

• Weights need to be hanging freely

What is Compartment Syndrome?

• Muscles are organized into compartments separated by fascia

  • Fascia keeps muscle in place

• Swelling or Bleeding increases muscle volume beyond fascia ability to stretch, increasing pressure in the compartment impairs blood flow.

  • Can’t function and die.

• Typically in lower legs.

What are the 6 P’s for Compartment Syndrome?

• Pain (earliest)

  • Intensifies as muscles are stretched

• Pallor

• Paresthesia (tingling, burning, numb sensation)

• Paralysis (Late)

• Poikilothermia (inability of a limb to regulate its temperature, assumes temp of room)

• Pulselessness (latest)

Why do we elevate the cast?

• To decrease swelling (risk of compartment syndrome)

What is traction?

• Method of immobilization, reduction, or alignment of an injured extremity

  • Achieved by

• Reduces pain and decrease muscle spasm

What causes Compartment Syndrome?

• Injuries

• Cast/bandages too tight

• Steroids

• Sudden Return of Blood Flow

• Inflexible Fascia

• Muscle Exertion (Chronic)

What are some types of Casts?

• Casts

• Boots

• Splinting Devices

• Skin traction

• Skeletal traction

• Distraction

What are Hip Spicas For?

Can be used for injuries of the hip or dysplasia

What are all the Neural Tube Defects?

• Spina Bifida Occulta

• Meningocele

• Myelomeningocele

What are Structural Disorders of the Skeleton?

• Pectus Excavatum and Carinatum

• Limb Deficiencies

• Polydactyly (multiple fingers/toes)

• Syndactyly (Webbing of fingers/toes)

• Metatarsus Adductus (front half of the foot turns inward, into "C" shape when viewed from above)

• Congential Club Foot

• Hip Dysplasia (abnorm devel of hip)

• Torticollis (wry neck, neck muscles contract, bending it to one side)

• Tibia Vara

What are Genetic Disorders?

• Osteogenesis Imperfecta

• Spinal Muscular atrophy

What is Myelomeningocele?

• Most Severe Neural Tube Defect

• Fails to close at end of 4th week gestation

• Visible External Sac from spinal area @ birth

  • meninges, spinal fluid, nerves encased in sac

• absent motor/sensory function beyond that point

Describe Myelomeningocele Management

• Prevent infection

• Sterile, saline soaked non-adhesive gauze to keep sac moist

• Prone position

• Keep infant warm

• Keep lesion free from urine/feces

• Maintain latex free area

  • prevent allergic rxn

• Maintain skin integrity

What is Pectus Excavatum

• Funnel shaped chest → depression sinks inwards @ xiphoid process

• Surgical correction b4 puberty

  • Placement of steel bar, 2-4 years after remove

What is Pectus Carinatum

• Protruding of the Chest

What are Limb Deficiencies

• Complete Absence/portion of limb or deformity

• Limb fails to form normally or doesn’t form at all.

• Associated with

  • Craniofacial abnormalities, cardiac, and abdominal wall defects

What is Polydactyly

• Extra digits on hand or foot

• Soft (w/o bone) or full/partial digits w/ bone

• Surgical removal

What is Syndactyly

• webbing of hand or foot

• no treatment or surgical (cosmetic)

What is Metatarsus Adductus?

• medidical deviattion of forefoot

• Cause: utero positioning

• Deformity noted @ birth

  • Inward deviation of forefoot w/ hindfoot in normal position

  • ROM normal

Metatarsus Adductus Management

• IF forefoot is

  • Flexible past neutral manipulation passively → observation

  • Flexible only to neutral manipulation → stretching exercises

  • Rigid & flexible to neutral manipulation → serial casting (b4 8 months)

Congenital Club Foot

• rare, seen in identical twins

• Talipes varus, Talipes equinus, cavus, forefoot adduction w/ supination

• Classfications:

  • postural: resolves w/ manipulative casting

  • neurogenic: occurs w/ myelomeningocele

  • syndromic: associated w/ other symptoms (resistant to treatment)

• Inspect foot at rest, and ROM

Describe Talipes Varus

• inversion of the heel

Describe Talipes equinus

• plantarflexion of foot, heel raised -

Describe Cavus

• plantarflexion of forefoot on hindfoot

Describe Forefoot adduction w/ supination

• forefoot inverted and turned slightly upward

Describe Congenital Club Foot Management

• weekly manipulation w/ serial cast changes (q 2 wks)

• Corrective shoes, bracing

• Surgery - release of soft tissue

• Foot immobilized w/ cast 12 wks → ankle-foot orthoses (corrective shoes)

• PROM - Passive Range of Motion

Describe Developmental Dysplasia of HIP (DDH)

• abnormalities of the developing hip that includes dislocation, subluxation, and dysplasia of hip joint

• can cause: necrosis of femoral head, loss of ROM, recurrent unstable hip, femoral nerve palsy, leg-length discrepancy, early osteoarthritis

• Hx of DDH, oligohydramnios, breech birth, native American, eastern European descent

Describe Dislocation (DDH)

• No contact between femoral head and acetabulum

Describe Subluxation (DDH)

• partial dislocation; acetabulum is not fully seated within the hip joint

Describe Dysplasia (DDH)

• acetabulum that is shallow or sloping instead of cup shaped

Describe DDH Management

• Pavlik harness (infants younger than 6 mos)

• Closed Reduction, skin or skeletal traction, spica cast, brace

Describe Torticollis

• painless muscular condition presenting in infants or in children with certain syndromes

• Cause: utero positioning, difficult birth, preferential turning of the head to one side while in supine position after birth

  • tightness of sternocleidomastoid muscle

• hx of head tilt and infant lack of desire to turn the head in opposite direction

• Wryneck = tilting of head to one side; limited movement of neck

Describe Torticollis Management

• Gentle neck-stretching exercises, prevent positional plagiocephaly

Describe Tibia Vara

• Developmental disorder where normal physiologic bowling or genu varum becomes more pronounced

• Causes: unknown

• Risk: African American Females, obesity

• Types:

  • Infantile (1-3 y/o, most common)

  • Juvenile (4-10 y/o)

  • Adolescent (11+ y/o)

• Assessment: age when child first started walking, sig bowling of the legs while child is standing or walking

Describe Tibia Vara management

• Bracing, surgical treatment

Describe Osteogenesis Imperfecta

• Bone disorder

• Range from mild to severe in connective tissue and bone involvement

• Low bone mass, increased fragility of bones, joint hypermobility & instability → inc fractures

• Subtype A: depends on absence of dentinogenesis

• Subtype B: Presence of dentinogenesis imperfecta

• Cause: Defect in collagen type 1 gene

• Complications early hearing loss, acute/chronic pain, scoliosis, resp problems

What is Dentinogenesis imperfecta

• Tooth enamel wearing easily, brittle & discolored teeth

Describe Osteogenesis Imperfecta Assessment and Management

• Family Hx, pattern of freq fracture, eyes with blue/purple/grey tint on sclerae, teeth abnormalities, skin bruising, joint hypermobility

• Management; biphosphate administration, PT, OT, lightweight splints or braces, surgical insertion of rods in long bones

Describe Spinal Muscular Atrophy

• rare neuromuscular disease that affects the motor neurons in the spinal cord, rather than the muscle fibers themselves

• type 0-4 based on age of onset, severity of weakness and clinical course

• Cause: motor neuron protein survival of motor neurons (SMNs) is deficient (faulty gene on chromosome 5)

• Diagnosis: inc creatinine kinase, genetic testing, muscle biopsy, nerve conduction n velocity test, electromyogram

Describe Spinal Muscular Atrophy Assessment and Management

• Developmental milestones/loss of them

• Infant or young child = narrow chest w/ decreased excursion, protuberant abdomen, paradoxical breathing

• Mangement: Promote mobility (ROM exercises, lightweight orthotics, standing frames, wheelchair use

  • Airway clearance: manual or mechanical cough assistance, chest percussion, postural drainage

  • Gastrotomy tube, bracing, skin inspections

Describe Muscular Dystrophy

• Group of inherited types of neuromuscular disorders that affect voluntary muscles

• Sx not at birth, manifest later

• Limits lifespan (compromise to support ventilation)

• Cause: Mutation → absence of decrease of specific muscle protein that prevents normal fn of muscle

• Diagnosis: electromyography, inc serum creatinine kinase, absence of dystrophin, DNA testing

Types of Muscular Dystrophy: Duchenne

• Early childhood, most common, usually fatal

• hallmark finding of Duchenne muscular dystrophy

  • Gower’s sign (can’t rise from floor in standard fashion)

Types of Muscular Dystrophy: Becker

• 2-16 yr old, less severe than Duchenne

Types of Muscular Dystrophy: Emery-Dreifuss

• Childhood to early teens

Types of Muscular Dystrophy: Limb-girdle

• late teens to middle age

Types of Muscular Dystrophy: facioscapulohumeral

• Late childhood to early adulthood

Types of Muscular Dystrophy: Myotonic

• Teens

Describe Muscular Dystrophy Assessment

• Hx, family HX, pregnancy, delivery hx

• Developmental milestone achievement status, ADLs

Describe Medication for Muscular Dystrophy

• Meds = Corticosteroids, calcium supplements, vit D, antidepressants, beta-blockers, ACE inhibitor

Describe Cerebral Palsy

• range of nonspecific clinical sx → Most common motor disorder (lifelong impairment)

• Characterizations: nonprogressive abnormal brain fn → abnormal motor pattern and posture

• preterm have inc incidence

• Cause: abnormal develop or damage to motor areas of brain (neurologic lesions)

• Complications: mental impairments, seizures, growth problems, impaired vision/hearing, abnormal sensation or perception, hydrocephalus

Describe Cerebral Palsy Assessment

• Motor impairment: spasticity, muscle weakness, ataxia (lack of coordination of muscle movements during voluntary movements)

• Abnorm brain fn, not progressive

• Abnorm postures

• Supine → scissor crossing of legs w/ plantar flexion

• Prone → raise head higher than normal due to arching of back or opisthotonic position

• Hypertonicity, increase resistance to dorsiflexion, passive hip abduction, sustained clonus, prolonged standing on toes

Describe Cerebral Palsy Management: Therapy

• Physical - development of gross motor movements (walking, positioning), independent movement and prevent contractures (changes to soft tissue)

• Occupational - orthotics, splints, braces, serial casting, fine motor skills

  • AFOs = most common to help prevent deformity

• Speech - receptive and expressive language, feeding techniques, communication strategies

Describe Cerebral Palsy Management: Pharmacologic

• Baclofen, dantrolene sodium, diazepam = treats spasticity

• Paternal meds = botulinum toxins, baclofen, phenol block

• dyskinetic/athetoid cerebral palsy → anticholinergic → decre abnorm movements

• anticholinergic agents reduce saliva to help w/ drooling

Describe Cerebral Palsy Management: Surgical

• Corrective (ortho/neuro surgery): corrects deformities related to spasticity

• Orthopedic procedure: tendon lengthening, correction of hip and adductor muscle spasticity

What is Spasticity?

• increased muscle tone, exaggerated reflexes, and uncontrolled muscle spasms

Describe Rickets

• Softening/weakening of the bones

• Cause: nutritional deficiencies (inadequate consumption of calcium or Vitamin D)

  • inability to regulate Ca, P

  • GI disorder in which fat absorption is altered

• Diagnosis: decre serum calcium and phosphate, incre alkaline phosphatase levels

Describe Rickets Assessment and Management

• Hx fractures/bone pain

• Dental formities, bowlegs, decreased muscle tone

• Management: Ca/P supplements, vita D supp, diet changes

  • Exposure to moderate sunlight

Describe Slipped Capital Femoral Epiphysis (SCFE)

• femoral head dislocates from neck and shaft of femur at epiphyseal plate

• unknown cause, femoral growth plate weakens → less resistant to stressors during teens

• Diagnosis: radiographs, bone scans, CT

Describe Slipped Capital Femoral Epiphysis (SCFE) Management and Assessment

• Hx: health hx, onset/extent of pain

  • Ambulation, note for trendelenburg gait, hip pain related to groin, inside of thigh, or knee

• Management:

  • Minimize deformity, prevent further slippage, avoid cartilage necrosis, or avascular necrosis of femoral head

  • Orthopedic surgery, osteotomy

Describe Legg-Calve-Perthes Disease

• self-limiting condition involving avascular necrosis of femoral head

• Cause: unknown, interruption of blood supply to femoral head → bone death, lost of spherical shape of head.

  • Complications: joint deformity, early degen joint disease, pain, loss of hip motion or func, gait disturb

• Diag: MRI, bone scan, U/S

Describe Legg-Calve-Perthes Disease Assessment/Management

• Hx: health for short stature, delayed bone maturation, related trauma, family hx

• Painless limp, trendenlenburg gait, muscle spasms

• Management: Anti-inflam meds, limit activity, bracing, casting, traction

  • Labs: serial XR, surgeyr, osteotomy

Describe Transient Synovitis of the Hip

• common cause of hip pain/limping children (3-8 yrs)

• Self-limiting → resolve sin a week or lasts 3-6 wks

• Cause: unk, associated w/ infec, trauma, allergic

  • Risk fact: antecedent trauma, concurrent or recent upper resp tract infection, pharyngitis, otitis media

Describe Transient Synovitis of the Hip Assessment/Management

• Suddent acute onset fo mod/severe pain on one hip

• limp/position of affected hip

• restricted rom for abduction/internal rotation

• Management: non-steroidal anti-inflam, analgesics, bed-rest

Describe Kyphosis

• Hunchback, non-painful curvature of spine on sagittal plane

• occas pain in thoracic region, uneven shoulder height

• management: >70degree + no response to bracing → surgery

Describe Lordosis

• Swayback, spinal curv of sagittal plane + flexion of contractures of hip/scoliosis and obesity

• Assessment: parents notice clothing don’t fit

  • Management: severe → surgery

Describe Scoliosis

• lateral curvature of spina > 10 degrees (C or S curve)

• Common in Females

• Cause: congenital, associated with other disorder or acquires

• Risk: fam hx, recent growth spurt, phys change relate to puberty

• Three Types: Idiopathic, neuromuscular, congenital

Describe Scoliosis Assessment/Management

• Unequal shoulder height, leg length discrepency

• skin - hairy patches, nevi, cafe au lait spots lipomas

• Management:

• Mild (10-15 deg): monitor

• Mode (15-40 deg): brace 18 hrs/day, prevent curve progression

  • promote body image (baggy clothes)

  • Inspect for skin integ, shower when off, wear cotton T under, exercise for back muscles

• Severe (>40 deg): surgery, spinal fusion, rod palcement, bone grafting

Describe Scoliosis Spinal Fusion Management

• Pre-op: Tour ICU, foley cath, teach ROM exercises

• Post-op: ICU for 1-2 days (pain, resp, VS, fluids, renal)

• → acute care (chest tube, circu in extrem, BS)

• Incentive spiro, CPT, Cough/deep breathe

• Log-roll (avoid flexion of back)

What are the Acquired Neuromuscular and Musculoskeletal Disorders?

• Rickets, Slipped capital femoral epiphysis (SCFE), Legg–Calvé–Perthes disease, transient synovitis of the hip, scoliosis

What are Acquired Neuromuscular and Musculoskeletal Disorders Injuries

• Spinal cord injury

• Fractures, strains/sprains, overuse syndromes, and dislocated radial head.

• Trauma or unintentional injury is the leading cause of childhood morbidity and mortality

What are Genetic Disorders?

• Legg-Calve- Perthes Disease

• Slipped Capital Femoral Epiphysis

What are Congenital Disorders

• Neural Tube: Spina bifida occulta, Meningocele, Myelomeningocele

• Structural disorders of the skeleton: Clubfoot, Pectus Excavatum/Carinatum, limb defe, poly/syndactyly, hip dysplasia, torticollis, tibia vara,

Describe Spinal Cord Injury

• dmg to spinal cord → loss of func

• Cause: trauma, car accidentals, falls, diving into shallow water, gunshot, stab wounds, sports, abuse, birth injuries

• Diag: radiographs, CT scans, MRI

Describe Spinal Cord Injury Assessment

• Inability to move/feel extrem

• Numbness, tingling, weakness

• Loss of voluntary movement below level of lesion

  • High cervical injury: paralysis, dmg to phrenic nerve → unable to breathe w/o assistance

Describe Spinal Cord Injury Management

• Immobilization of spine untill full eval

• promote mobility, bladder/bowel management, nutrition

• prevent complications (contractures, muscle atrophy)

  • long term hospitalization/rehab

Describe Spinal Cord Injury Prevention

• Vehic, Bike, Sport, Recreation Safety

• Fall/Violence prevention

• Water safety (risk of diving)

Describe Sport Injuries + Management

• ½ boys, ¼ girls (8-16 years old) participate in comp sports

• RICE

  • Rest - prevents further injury, allows ligament bone/tendon to heal

  • Ice - (48 hrs) keep in place for 15 min intervals

  • Compression - apply ace wrap to apply pressure to joint to reduce swelling

  • Elevation and Early motion to affected joint - reduce swelling and keep full ROM

Describe ACL Tear

• instability, pain, & tenderness in knee, loss of full extension

• Manage: Mild - ice + rest

• Severe: takes up 8 weeks to heal

Describe Osgood-Schlatter Disease

• Overuse in older school children/adolescents

• Common in boys (12-15) and girls (10-12)

• Assessment:

  • Pain below kneecap → aggravated w/ activity, squating, extending knee against resistance/relieved with rest

• Manage: NSAIDS, ice, ace wrap

Describe Fractures

• Causes: accidental trauma, nonaccid trauma (disease), abuse

• Classification based on nature, location, and amt of injury (Type I-IV)

  • Epiphyseal, proximal, distal, midshaft

• Risk: rickets, renal osteodystrophy, osteogenesis imperfecta, playing sports, lack of use of protective equipment in sports

• Comp: mal-union, non-union, refracture, joint stiffness, reflex sympathetic delayed union, pseudoarthrosis

Describe Fracture Assessment/Manage

• Pain, diff weight bearing, refusal to use extremity

• Manage:

  • Monitor for shock, fat emboli, DVT, pul embo, infect

  • Neurovascualr check (pain/numb/tingle)

  • Prevent limping, decre ROM, nerve deficit, elevate extreme, avoid indenting cast, assess for swell, discolor, sens/movement, abnormal

  • Rest, nutri, movement of joint (above+below)

  • Open reduct (internal fixation), use to stab bones until heal (done with pins, screws, plate, rod, removed after bone heal)

  • Care for infection potential.

Describe Plastic/Bowling Deformity Fracture

• significant bending w/o breaking of the bone

Describe Buckle Fracture

• compression injury, bones buckle rather than break

Describe Greenstick Fracture

• incomplete fracture of the bone

Describe Complete Fracture

• bone breaks into two pieces

Describe Sprains

• twisting/turning motion of affected body part → tendons/ligaments stretch excessively + tear

  • Uncommon in young children (weak growth plates → more prone to fractures)

Describe Sprain Assessment/Management

• Edema, brusing, inability to bear weight, Don’t attempt to perform passive ROM

• Remove Ace Wrap if finger/toe swollen or discolored

• Manage:

  • RICE, Activity restrict, splint/cast

Describe Overuse Syndromes

• group of disorders that result from repeated force applied to norm tissue

• Repetitive stress (wks/months) → connective tissue fails and breaks down

Describe Overuse Syndromes Assess/Management

• No identifiable injury

• Pain w/ activity, worsens with continuation

• Manage:

  • Severe - apply ice

  • Anti inflam (ibuprofen)

  • Limit exercise, participate in diff activity

  • Osgood-Schlatter Disease: require 6-18 months to resolve

    • pads, brace, slings, heel cups in athletic shoes (sever disease)

  • Prevent: stretch 20-30 min before activity, weeks of conditioning before season begins

What is a Splint?

• temporary stiff support of injured area

  • for temporary fracture reduction, immobilization, support of sprains

What is Fixation?

• surgical reduction of fracture/skeletal deformity w/ internal/external pin, fixation devices

  • for fractures/skeletal deformities

What is Cold Therapy?

• ice bags, commerical cold packs, cold compress

  • acute injureis, causes vasoconstriction to decrease pain

What is Crutches?

• assistive ambulation device, transfers body weight from lower to upper extremities

• when weight bearing is contraindicated

What is Skeletal/Cervical traction?

• pulling force on extremity or body part

  • prevents trauma to spinal cord, fracture reduction, dislocations, correction of deformities