Week 4 (pt. 1): Musculoskeletal Dysfunction

Effects of Immobilization in Children

• Physiologic: muscle atrophy, bone demineralization, decreased joint mobility, venous stasis (risk of DVT), and skin breakdown

• Psychological: regression, anxiety, and depression

• Nurs Care: focuses on maintaining circulation, nutrition, respiratory function, skin integrity, providing diversional activities for coping, repositioning, passive ROM exercises

Nursing Care for the Immobilized Child

• Maintaining circulation → repositioning, passive ROM exercises

• Maintain skin integrity → assessing for pressure injuries, repositioning

• Ensure proper nutrition → protein, calcium intake

• Address family anxiety by explaining treatment and involving them in care.

• Provide diversional activities for coping

Soft Tissue Injury

Injury to muscles, ligaments, or tendons

• types: contusions (bruises), dislocations, sprains, and strains

• management: RICE (Rest, Ice, Compression, Elevation)

Dislocation

Displacement of bone ends from their normal articulation. Often causes severe pain, joint deformity, and limited movement

Sprain

Partial or complete tear of a ligament, usually from twisting. Presents with swelling, instability, and pain.

Strain

Microscopic tear to a muscle or tendon

Fractures

resistant of bone against stress exerted yields to stress force

• types: compound (open), complicated, comminuted, greenstick

Types of Fractures → Compound (open)

Bone breaks through skin (aka open wound); risk of infection

Types of Fractures → Complicated

Bone fragments damage other organs or tissues

Types of Fractures → Comminuted

Bone shatters into several pieces and lie in the surrounding tissue

Types of Fractures → Greenstick

Incomplete fracture common in children; bone bends and partially breaks on one side

Pediatric Bone Healing

Children’s bones heal faster than adults due to rich blood supply and thick periosteum. Immobilization and alignment are crucial to prevent deformity.

Compartment Syndrome + 5 P’s

limb-threatening condition where swelling increases pressure within muscle compartments, impairing circulation and nerve function

• 5 P’s: Pain, Pallor, Pulselessness, Paresthesia, Paralysis.

• Management: immediate involving remove cast/splint, surgical fasciotomy

How is a cast constructed?

using gauze strips and bandages impregnated with plaster of Paris or synthetic; molded to body part

Cast Care

• Keep the cast dry

• Check for skin irritation

• Monitor circulation and sensation (compartment syndrome) → instruct families to report pain, swelling, or color changes

• Elevate the limb

• Avoid inserting objects inside

Pediatric Cast Types

long leg cast, short leg cast, bilateral leg cast, full spica cast, single spica cast, short arm cast, long arm cast

Traction

application of a pulling force to a body part (usually a limb or the spine) to achieve therapeutic goals such as:

• bone alignment → position distal and proximal bone ends

• reduction of muscle spasms

• immobilization of a fracture before casting or splinting

• help prevent or improve contracture deformity

Traction → Types

• Skin Traction: force applied to the skin surface using adhesive materials, foam boots, or wraps; used for short-term treatment

• Skeletal Traction: pins, wires, or tongs are surgically inserted into bone; used for long-term treatment & stronger

Traction → Nursing Care

Check ropes and pulleys for function, assess neurovascular status, prevent pressure injuries, and encourage movement of unaffected limbs. Provide emotional support and maintain hygiene.

Amputation in Children + Nursing Care

surgical removal or repair of a limb

• nurs care: pain control (phantom limb pain), stump shaping for prosthetic fit, infection prevention, and emotional support to aid body image adjustment

Overuse Syndromes + Management

Repetitive microtrauma from sports or improper biomechanics leading to stress fractures or tendonitis

• risks: training errors, muscle/tendon imbalance, anatomic malalignment, incorrect footwear, associated disease state, growth

• management: includes rest, physical therapy, and correcting technique or footwear

Developmental Dysplasia of the Hip (DDH)

formerly known as congenital hip dysplasia; abnormal development of the hip joint where the femoral head dislocates from the joint; commonly seen in newborns

• type: idiopathic, teratologic, dysplasia, subluxation, dislocation

• symptoms: hip click, uneven thigh folds, or limb shortening

• diagnosis: Barlow, Ortolani test

• management: depends on age

Barlow Test

exam used to test for developmental dysplasia of the hip in newborns by trying to dislocate the hip by bringing them together toward the midline

• positive sign indicates hip instability

Ortolani Test

exam used to test for developmental dysplasia of the hip in newborns by trying to put hip back into place by moving them apart, away from midline

• positive sign indicates hip dislocation

Pavlik Harness

soft, dynamic splint commonly used to treat DDH in infants under 6 months; worn 23 hours/day; holds the hips in a stable, flexed, and abducted position, to allow for proper hip joint development

Developmental Dysplasia of the Hip (DDH) → Dysplasia

mildest form of DDH; femoral head remains in place, but the socket is too shallow or oblique

Developmental Dysplasia of the Hip (DDH) → Subluxation

partial or incomplete dislocation of the hip joint; most common; femoral head is partially displaced remaining in contact with the acetabulum but not fully seated within it; causes joint capsule and ligaments to be stretched

Developmental Dysplasia of the Hip (DDH) → Dislocation

most severe form of DDH; femoral head is completely displaced; no contact between the femoral head and the socket

Congenital Clubfoot

Foot deformity with ankle inversion and foot pointing inward

• types: positional, congenital, and syndromic

• diagnosis: physical exam or fetal ultrasound

• management: serial casting, bracing, or surgery

• nurs care: skin care and support family through treatment

Congenital Clubfoot → Positional

flexible deformity caused by intrauterine crowding or positioning; bones are normal; can be manually corrected to a neutral position

Congenital Clubfoot → Congenital

true structural deformity present at birth

Congenital Clubfoot → Syndromic (teratologic)

rigid, resistant form of clubfoot that occurs as part of a neuromuscular or genetic syndrome (spina bifida or cerebral palsy); requires surgical correction after initial casting

Metatarsus Adductus

also known as metatarsus varus; inward curvature or medial adduction of toes and forefoot; no change to the ankle

• types: type 1, type 2, type 3

• management: gentle stretching or casting if rigid

Metatarsus Adductus → Type 1

forefoot flexible, corrects with easy manipulation

Metatarsus Adductus → Type 2

forefoot partial flexibility, corrects passively

Metatarsus Adductus → Type 3

forefoot rigid, will not stretch to neutral with manipulation

Skeletal Limb Deficiency

Congenital underdevelopment or absence of limb parts resulting from genetic, vascular, or environmental causes.

• management: prosthetics & therapy, promote mobility and self-esteem

Osteogenesis Imperfecta (OI)

Genetic disorder of collagen production leading to fragile bones, multiple fractures and bone defects; parents have been accused of abuse

• symptoms: hearing loss, blue sclera, multiple fractures

• types: I-IV

• management: supportive

• nurs care: handle gently, prevent fractures, educate parents, encourage safe mobility

Osteogenesis Imperfecta (OI) → Type I

most common and mildest

Osteogenesis Imperfecta (OI) → Type II

most severe, lethal in infancy

Osteogenesis Imperfecta (OI) → Type III

multiple fractures present at birth, short stature, severe bone deformity, disability

Osteogenesis Imperfecta (OI) → Type IV

similar to Type I but more severe, short stature

Legg-Calvé-Perthes Disease

Insidious onset of avascular necrosis of the femoral head causing hip pain and limp in children (ages 4–8)

• management: rest, traction, or surgery

• nurs care: family-centered care, supports adherence, provide education on limited weight-bearing

Slipped Capital Femoral Epiphysis (SCFE)

Spontaneous displacement of the proximal femoral head from the neck at the growth plate; common in obese or adolescent males; similar to hip displacement for newborns

• symptoms: hip or knee pain, limp, decreased ROM

• diagnosis: physical exam, x-ray

• management: surgery

• nurs care: assess for pain and limit weight-bearing pre-surgery

Kyphosis vs Lordosis 

• kyphosis: excessive thoracic curvature (hunchback) resulting from posture or disease; treatment → exercises, bracing, or surgery

• lordosis: excessive inward lumbar curvature (“swayback”); linked to obesity or hip flexion contractures; treatment → weight management, posture correction

Idiopathic Scoliosis

most common spinal deformity characterized by lateral curvature, spinal rotation causing rib asymmetry and thoracic hypokyphosis; often seen in preadolescent girls

• types: thoracic scoliosis, lumbar scoliosis, thoraco-lumbar scoliosis, combined scoliosis (defined according to location)

• diagnosis: clinical evaluation, radiographs (x-ray)

• management: bracing or spinal fusion if severe

• nurs care: pre/post op care, monitor for respiratory compromise, provide emotional support

Osteomyelitis

Infection of the bone usually caused by bacteria (Staph aureus)

• symptoms: localized pain, fever, and limited mobility

• treatment: IV antibiotics, maybe surgery

• nurs care: monitor IV therapy, pain control, maintain mobility

Septic Arthritis

Bacterial infection of the joint space, often the hip, knee or shoulder

• symptoms: acute pain, fever, limited motion

• treatment: IV antibiotics, pain meds, ROM exercises post-treatment, mobility

Skeletal Tuberculosis

Bone or joint infection due to hematogenous spread of pulmonary TB

• diagnosis: clinical eval, tb test, imaging tests (x-ray)

• symptoms: spinal deformity, swelling, pain, decreased movement, can progress to Pott’s disease (late)

• treatment: long-term TB therapy, isolation, sometimes surgery

Juvenile Idiopathic Arthritis (JIA)

chronic childhood arthritis causing inflammation in joint synovium and surrounding tissues

• types: systemic, oligoarticular, and polyarticular

• symptoms: joint swelling, pain, stiffness, and loss of motion

• management: NSAIDs, corticosteroids, DMARDs, physical therapy

• nurs role: relieve pain, promote comfort, prevent deformity, encourage activity/adherence, support child/family

Systemic Lupus Erythematosus (SLE)

Severe multisystem progressive autoimmune disease of connective tissue and blood vessels causing inflammation in connective tissues and multiorgan damage; cause unknown

• symptoms: cutaneous lesions, generalized weakness, CNS symptoms, proteinuria, pericarditis, nausea, diaherra 

• treatment: corticosteroids, immunosuppressants

• nurs care: monitor for infection, support coping, and prevent triggers (sun exposure, stress)

Juvenile Idiopathic Arthritis (JIA) → Oligoarthritis

1-4 joints for the first 6 months

Juvenile Idiopathic Arthritis (JIA) → Polyarthritis rheumatoid factor negative

5+ joints in the first 6 months w/ negative rheumatoid factor

Juvenile Idiopathic Arthritis (JIA) → polyarthritis rheumatoid factor positive

5+ joints in the first 6 months with positive rheumatoid factor