Child with Musculoskeletal or Articular Dysfunction Notes

Muscular System

• Decreased muscle size, strength, and endurance

• Muscle atrophy (wasting) occurs due to disuse, leading to a significant loss of muscle mass over time.

• Loss of joint mobility can result in contractures, which are permanent tightening of muscles and tendons that restrict the range of motion.

• Weak abdominal and back muscles lead to decreased core stability, significantly impacting overall balance and posture.

  • Nursing considerations

    • use antiembolism stockings or intermittent compression devices to promote venous return (monitor circulatory and neurovascular status of extremities when such devices are used)

    • plan play activities to use the uninvolved extremities

    • place in upright posture when possible

    • have pt perform ROM, active, passive, and teaching exercises

    • Maintain correct body alignment

    • use joint splints as indicated to prevent further deformity

    • maintain ROM

    • Maintain body alignment

    • see nursing considerations for the respiratory system

Skeletal System

• Bone demineralization can occur, increasing the risk of fractures due to weakened bone structure.

• A negative calcium balance results from immobilization, as insufficient load on bones diminishes calcium retention.

• Patients may experience increased risk of osteoporosis, particularly in individuals with prolonged immobilization, as the lack of mechanical stress on bones fails to stimulate bone remodeling.

  • Nursing consideration

    • with paralysis, use an upright posture on a tilt table

    • handle extremities carefully when turning and positioning

    • Administer calcium-mobilizing drugs (diphosphonates) and normal saline infusions if ordered

    • ensure adequate intake of fluid; monitor output

    • acidify urine

    • Promptly treat urinary tract infections

    • monitor serum calcium levels

    • provide electrolyte replacement as indicated

Metabolism

• Decreased metabolic rate contributes to weight gain and, if energy intake is not adequately monitored, may lead to obesity over time.

• Negative nitrogen balance can occur, indicating that muscle breakdown exceeds muscle synthesis, leading to overall muscle wasting.

• Hypercalcemia, a potentially dangerous condition, may develop as bone resorption releases excess calcium into the bloodstream.

• Decreased production of stress hormones, such as cortisol, may alter metabolic functions and immune responses.

  • nursing consideration

    • Mobilize as soon as possible

    • have pt perform active and passive resistance exercises and deep-breathing exercises

    • ensure adequate food intake

    • provide a high-protein, high-fiber diet

    • Encourage small, frequent feedings with protein and preferred foods

    • prevent pressure areas

    • Implement appropriate interventions to lower physical and psychosocial stresses

Cardiovascular System

• Decreased efficiency of orthostatic neurovascular reflexes can lead to orthostatic hypotension, characterized by faintness or dizziness upon standing.

• Diminished vasopressor mechanisms increase the risk of inadequate blood pressure regulation.

• There is the altered distribution of blood volume, which can lead to reduced perfusion of vital organs.

• Increased risk of venous stasis may ultimately lead to thrombus formation, creating a significant risk of deep vein thrombosis (DVT).

• Dependent edema, a swelling caused by the accumulation of fluid in tissues, can complicate the management of immobilized patients.

  • nursing consideration

    • monitor peripheral pulses and skin temp changes,

    • use antiembolism stockings or intermittent compression devices to decrease pooling when upright

    • provide abdominal support

    • in severe cases, use antigravitational pants

    • position horizontally

    • monitor hydration, blood pressure, and urinary output.

    • elevate extremities without knee flexion

    • monitor for signs of pulmonary embolism-sudden dyspnea, chest pain, respiratory arrest.

    • promptly intervene to maintain adequate oxygenation if S/S of pulmonary emboli are noted

Respiratory System

• Decreased activity levels reduce the overall need for oxygen, which can lead to complications such as hypoxia if not monitored.

• Diminished vital capacity—measured by decreased lung capacity—affects breathing efficiency and can predispose individuals to respiratory infections.

• Poor abdominal tone can hinder respiratory function and lead to complications such as atelectasis, where parts of the lung collapse.

  • Interference with diaphragmatic excursion

• Mechanical or biochemical retention of secretions increases the risk of developing pneumonia, bacterial and viral pneumonia, and atelectasis.

  • hypostatic pneumonia

• Loss of respiratory muscle strength (poor cough)

• nursing consideration

  • Supply torso support to promote chest expansion

  • carry out chest percussion, vibration, drainage (or suctioning) as necessary

  • use an incentive spirometer

  • Support the chest wall by splinting with a pillow when pt coughs

  • administer immunizations as necessary (pneumoccal, meningoccal)

Gastrointestinal System

• Distention of the abdomen may occur due to poor abdominal tone, impacting digestion and potentially leading to discomfort.

  • monitor bowel sounds

• Difficulty feeding in a prone position may hinder nutrition intake, leading to further health complications.

  • encourage small, frequent feedings

• Anorexia and constipation become common due to immobility, necessitating dietary modifications to encourage regular bowel movements.

  • have pt sit upright position in the bedside chair if possible,

  • carry out bowel training program with hydration, stool softeners, increased fiber intake, mild laxatives if necessary

  • stimulate appetite with favored foods

Urinary System

• Altered gravitational force can cause urinary retention, increasing the risk of urinary tract infections (UTIs).

  • position as upright as possible to void

• Difficulty voiding while supine may lead to an over-distended bladder in immobilized patients.

  • Catheterize only for severe urinary retention,

  • stimulate bladder emptying with warm running water as necessary

• Impaired ureteral peristalsis can complicate the urinary drainage pathway, resulting in urinary stasis.

  • Administer antibiotics as indicated

Integumentary System

• Decreased circulation and pressure in skin areas due to immobility lead to reduced healing capacity and a heightened risk of skin breakdown and pressure sores, particularly in bony prominences.

  • turn and reposition at least every 2-4 h

  • Frequently inspect the total skin surface

  • eliminate mechanical factors causing pressure, friction, moisture, or irritation

  • place on a pressure-reduction mattress

  • Assess the ability to perform self-care and assist with bathing, grooming, and toileting as needed

  • encourage self-care to potential ability

  • ensure adequate intake of proteins, vitamins, and minerals

Psychological Effects of Immobilization

• Decreased environmental stimuli can lead to altered perception of self and the environment, affecting mental health.

• Increased feelings of frustration, helplessness, and anxiety may arise as natural routines are disrupted.

• Risk of developing depression, anger, and aggressive behaviors becomes significant, particularly in children and adolescents.

• Possible developmental regression in skills can occur due to loss of mobility and social interaction.

Effects on Family

• Disruption in family function is common due to the child's immobilization, leading to emotional strain among family members.

• Extended periods of immobilization complicate logistics, necessitating adjustments in daily routines for family management.

• Family support systems and home care assistance become essential to provide adequate care and relief for affected children.

• Development of coping skills through individual counseling and support groups can aid families in managing stress and emotional needs.

Nursing Care during Immobilization

• Implement interventions to minimize complications associated with prolonged immobility:

  • Use antiembolism stockings or intermittent compression devices to enhance blood circulation and prevent venous stasis.

  • Position the patient upright to promote better airway clearance and lung function.

  • Encourage range of motion (ROM) exercises and maintain proper body alignment to prevent musculoskeletal complications.

  • Monitor intake/output (I&O), recommending a high-protein, high-fiber diet to support nutritional needs and gastrointestinal health.

  • Regularly change position every 2 hours to prevent the development of pressure ulcers.

Soft Tissue Injuries

• Common causes of soft tissue injuries include mishaps during play and sports, highlighting the importance of precautionary measures.

• Types of Soft Tissue Injuries:

  • Contusion:(bruise)

    • Results from direct impact, causing larger, painful, swollen areas.

    • Immediate ice application is recommended to reduce swelling.

    • ecchymosis, black and blue discoloration

  • Dislocation:

    • Stress on joint ligaments leads to excessive pain and abnormal joint positioning.

      • A common injury in young kids is subluxation or partial dislocation( pulled elbow or nursemaid’s elbow)

      • Treatment is determined by the severity of the injury

      • Usually, no anesthetic is required

  • Sprain:

    • Characterized by a snap, tear, or pop sensation, often accompanied by rapid swelling and bruising.

      • Guarding the joint

      • pain joint is too loose

      • Common sprain sites include ankles and knees

  • Strain:

    • Slow injury tendency is typically followed by overloading or excessive exertion on muscles or tendons.

  • Management includes Rest, Ice, Compression, Elevation (RICE) techniques.

    • 1st 12 to 24 hrs are the most critical period

    • Soft-tissue injuries should be iced immediately ( ice should never be applied for more than 30 min at a time)

    • point of injury should be kept several inches above the level of the heart for therapy to be effective

Fractures in Children

• Common injury in children

• methods of treatment are different in kids than in adults

  • Because childhood is a time of rapid bone growth, treatment doesn’t require a long period of immobilization

• Rare in infants, warrants investigation

  • Injuries need to be investigated if they are at various stages of healing.

• distal forearm: the most frequently broken bone in childhood

• school age: bike-related, sports injuries

fracture lines

• transverse

  • crosswise at right angles to the long axis of the bone

• Oblique

  • slanting but straight between a horizontal and a perpendicular direction

• spiral

  • slanting and circular, twisting around the bone shaft

Growth Plate Injuries

• weakest point of long bones: the cartilage growth plate (epiphyseal plate)

• These are frequent injury sites in children that can affect future bone growth and development.

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

• Salter-Harris classification system

Healing Process

• Healing occurs at different rates depending on age group:

  • Neonatal period: 2-3 weeks for rapid recovery.

  • Early childhood: Approximately 4 weeks as growth factors are significant.

  • Later childhood: Healing takes about 6-8 weeks due to increased bone density.

  • Adolescence: Healing averages 8-12 weeks as bone maturation advances.

Diagnosis and Management of Fractures

• Tools for diagnosis include radiographs and comprehensive history-taking to evaluate injury extent.

  • Suspicion of fractures in a young child who refuses to walk or bear weight

• Nursing care

  • assesses the neurovascular status of injured extremities

  • position the kids in supine position for injuries to the distal arms, pelvis, lower extremities

  • position the child in a sitting position for injuries to the shoulder or upper arm

  • provide splinting at the joint above and below the injured area

  • elevate the affected extremity and apply ice packs

  Goals of fracture management involve:

  • Proper reduction and immobilization to ensure alignment and healing.

  • Restoration of function through rehabilitation strategies.

  • Prevention of deformity through monitoring and timely interventions.

Symptoms of Fractures (The Six P’s):

• Pain and point tenderness: Sharp localized pain experienced at the fracture site.

• Pallor: Skin color changes indicating possible reduced blood flow.

• Pulselessness: Observed in severe cases, signifying compromised circulation.

• Paresthesia: Unusual sensations in distal areas, potentially indicating nerve involvement.

• Paralysis: Loss of movement or control distal to the fracture suggests critical injury.

• Pressure: Swelling around the fracture site can suggest local inflammation.

Casting and Care

• Cast application typically involves Plaster of Paris or synthetic materials, ensuring an appropriate fit for immobilization.

  • Plaster of Paris casts are heavy, not water-resistant, and can take 10 to 72 hr to dry

  • Synthetic fiberglass casts are light, water-resistant ,and dry quickly (5 to 20)

• Home care management is crucial and includes:

  • Monitor cast tightness for signs of swelling or decreased blood flow.

  • Providing skin care assistance to prevent irritation or breakdown during cast wear.

  • elevate the casted area by using pillows during the 1st 24 to 48 hrs to prevent swelling

  • turn and position every 2hr so that dry air circulates around and under the cast

  • notify provider immediately of any soft spots on the cast, changes in sensation or increased pain

Types of Casts

• Long leg cast: Provides extensive immobilization for fractures in the leg.

• Short leg cast: Used for lower leg and ankle injuries in pediatric patients.

• Spica cast: Special cast for hip immobilization, requiring specific handling.

• Arm casts: Fractures in the upper extremities require careful assessment and monitoring.

Traction in Children

• Used primarily for: (the most fractured bone is the femur in children)

  • Providing physiologic stability to affected regions.

  • Assisting in the alignment and evaluation of injuries.

  • Relieving muscle fatigue and immobilizing the site effectively for healing.

  • position of distal and proximal bone ends

  • prevent deformity

  • reduce muscle spasms

• skin traction: (Buck, Russell, Bryant traction)

  • uses a pulling force that is applied by weight.

  • Nursing actions

    • Maintain body alignment

    • provides management for muscle spasms

    • Routinely monitor skin integrity and document findings

    • Consult the provider for an overbed trapeze to assist the child to move in bed

Overuse Syndromes

• Common among young athletes who exceed their body's limits, leading to stress fractures.

  • at risk for recurrent upper respiratory infections, sleep and mood disturbances, loss of appetite, decreased interest in training nad competition and inability to concentrate.

• Stress fractures are a consequence of repetitive, excessive stress on the bone that causes microfractures within the bone

  • symptoms:

    • sharp, persistent, progressive pain or deep, persistent dull ache located over the bone

    • pain on impact (heel strike)

    • most clinical sign is pain over the involved bony surface

    • DX: MRI

  • Treatmnets

    • rest is the primary therapy, usually interpreted as reduced activity and the use of alternative exercise

    • physical therapy

      • cryotherapy, cold whirlpool baths

      • taping or bracing

    • Medication

      • NSAIDS

      • give 1 hr before the activity

Developmental Dysplasia of the Hips (DDH)

• describes a spectrum of disorders related to the abnormal development of the hip that may occur.

• formerly called “congenital hip dysplasia” or “congenital dislocation of the hip”

• girls are more commonly affected, and a positive family history increases a child’s risk of having DDH

• Signs of DDH

  • Asymmetry of gluteal and thigh folds

  • Limited hip abduction is seen in flexion

  • apparent shortening of the femur indicated by the level of knees in flexion (Galeazzi sign)

  • Ortolani maneuver with clunk elicited

    • and barlow tests are most reliable from birth to 4 wks of age. with test, the thigh is abducted and light pressure is applied to see if the femoral head can be felt to slip posteriorly out of the acetabulum.

  • Positive Trendelenburg sign (if child is weight bearing)

Clubfoot Deformities

• Or talipes equinovarus (TEV) is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus.

  • The foot is pointed downward (plantarflexed) and inward in varying degree of severity.

  • Talipes Varus: inversion or bending inward

  • Talipes valgus: eversion or bending out

  • talipes equinus: plantar flexion with toes lower than the heel (horse feet)

  • Talipes calcaneus: dorsiflexion with toes higher than the heel.

• therapeutic management

  • 3 stages

    • Correction of the deformity

      • Start early with serial casting

      • gentle manipulation and stretching

      • cast care

      • rapid growth

    • Maintenance of the correction until normal muscle balance is regained

    • followed-up to avert possible recurrence

  • Ponseti method (serial casting)

    • series of castings applied during the 1st month of life and continuing until max correction is accomplished (5 to 8 wks)

    • weekly manipulation of the foot to stretch the muscles, with subsequent placement of a long-leg cast

    • following casting, a heel cord tenotomy is usually performed, followed by application of long leg cast for 3 wks

    • after casting is complete, a Denis Browne bar and specialized sandals (abduction brace) are applied to maintain alignment and prevent recurrence

    • abduction brace is worn at bedtime for 3 to 5 yrs

Osteogenesis Imperfecta

• An inherited connective tissue condition that results in bone fractures and deformity, along with restricted growth.

  • several types of osteogenesis imperfecta (OI). Type 1 is a mild and common form

• assessment

  • multiple bone fractures (fragile bones and deformities)

  • blue sclera

  • early hearing loss

  • small, discolored teeth

• DX: bone biopsy

• Pt-centred care

  • med: bisphosphonate therapy (pamidronate)

    • increase bone density, prevent fractures

  • occupational therapy and genetic therapy

  • screen small children with fractures for this disorder

Legg-Calvé-Perthes Disease

• impaired circulation to the femoral head that results in aseptic necrosis

  • condition can be unilateral or bilateral, with insidious onset.

  • stages: synovitis, necrotic, fragmentation, reconstruction

• Risk factors

  • age: 2-12 but more common between 4 to 8 yrs

  • trauma, decreased circulation, and inflammation to the femoral head

• finding

  • intermittent painless limp, hip stiffness, limited ROM,

  • hip, thigh, knee pain

  • shortening of the affected leg

• DX: radiograph of the hip and pelvis, MRI

• surgery: osteotomy of the hip or femur

• goal is to keep the head of the femur in the acetabulum

• containment with various appliances and devices

• rest, no weight bearing initially

• NSAIDs

• Home traction in some cases

Scoliosis

• most common spinal deformity

• complex spinal deformity in 3 planes

  • lateral curvature

  • spinal rotation, causing rib asymmetry

  • thoracic hypokyphosis

• may be congenital or develop during childhood

• multiple potential causes; most cases idiopathic

• generally becomes noticeable after preadolescent growth spurt

• clothes: may be ‘ill-fitting’

Diagnostic evaluation of spinal curvatures

• mostly seen in females

• expected findings

  • asymmetry in scapula, ribs, flanks, shoulders, and hips

  • improperly fitting clothing (one leg shorter than the other)

• diagnostic procedures

  • observe the child, who should be wearing only underwear, from the back

  • have the child bend over at the waist with arms hanging down and observe for asymmetry of ribs and flank

  • measure spinal curvature with a scoliometer

  • Radiography

    • use the cobb technique to determine the degree of curvature

    • risser scale to determine the skeletal maturity

    • MRI and CT

    • lung capacity: pulmonary function studies, chest x-ray

  • in addition to primary curve, compensatory curve often present to align head with gluteal cleft

• Therapeutic management of spinal curvature

  • team approach to treatment

  • bracing (Boston and Wilmington)

    • wear brace for 23 hrs per day only remove to shower

  • exercise

  • surgical intervention for severe curvatures (spinal fusion with rod placement)

    • Harrington rods

    • luque rods

• Care mangegemnt of spinal curvatures

  • concerns of body image

  • the therapy program and the nature of the device must be explained thoroughly to both the child and the parent so they will understand the anticipated results, how the appliance corrects the defect.

  • preopeartive care

    • pt is taught how to manage PCA

    • demonstrate log rolling that will be used after surgery

    • perform extensive preop teaching

  • Post op care

    • complications

      • breathing difficulties

      • lowered self-esteem

      • spinal cord or neurolgic injury

      • pneumothorax (decreased mobility)

      • hypotension (blood loss)

      • atelectasia (decreased mobility)

      • ileus (decreased mobility)

      • infection (wound)

      • SIADH

      • superior mesenteric artery syndrome: compression of the duodenum by the aorta and superior mesenteric artery that leads to an obstruction

    • emphasize the importance of physical therapy and proper positioning of the spine

    • encourage independence following surgery for the adolescent/child

Juvenile Idiopathic Arthritis

• chronic childhood arthritis

• firmly known as “ juvenile rheumatoid arthritis”

• also called “idiopathic arthritis of childhood”

• possible causes

  • immunogenic trigger

  • environmental trigger

• peak onset: 1 to 3 years of age

• often undiagnosed

• actually a heterogeneous group of disease

  • systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy)

  • One to several joints effected

    • oligoarthritic (involves <4 joints)

    • polyarthritic (involves >5 joints)

  • psoriatic

• affected kids: 90% have negative rheumatic factors

• symptoms: may “burn ot” and become inactive

• chronic inflammation of synovium with joint effusion, destruction of cartilage and ankylosis of joints as disease progresses

• severe cases have uveitis

• diagnostic evaluation of JIA

  • no definitive diagnostic tests

  • elevated ESR/CRP in some cases

  • antinuclear antibodies common, but not specific for JIA

  • leukocytosis during excerbations

  • diagnosis based on criteria of American college of rheumatology

• Therapeutic management

  • no specific cure

  • goal of therapy:

    • control pain

    • preserve ROM and function

    • prevent deformities

    • promote normal growth and development

    • primarily outpatient care

      • exercising in pool

      • nighttime splinting

      • physical therapy, occupational therapy

  • Medication

    • NSAIDs (naproxen, ibuprofen, meloxicam, celecoxib)

    • DMARDs ( methotrexate and sulfasalazine)

    • biologic disease-modifying anti-rheumatic drugs

      • used with those who have poor prognosis and failed treatment with methotrexate

      • may cause malignancies

      • hold if febrile

    • Glucocoriticoids

      • life threathinign cases

      • short and taprer off

      • side effects

        • risk for infection, adrenal insufficiency, cushinggoid features, weight gain, mood or sleep changes, hypertension, diabetes and osteoporosis and avascular necrosis

Bone Tumors in Children

• Osteosarcoma and Ewing's sarcoma are among the most common types diagnosed in childhood,

  • they occur more commonly in boys; incidence is highest during accelerated growth rate of adolescence

  • peaks at 15 yrs of age

• Diagnostic evaluation of bone tumors

  • rule out trauma or infection 1st

  • definitive diagnosis is findings on radiologic studies (computed tomography scans, bone scans) bone biopsy

  • MRI helps evaluate neurovascular and soft tissue extension

  • lab tests: alkaline phosphatase levels are elevated with some bone tumors

Osteosarcoma (osteogenic sarcoma)

• most frequent malignant bone tumor type in kids

• peak: in the 2nd decade of life

• most primary tumor sites: in diametaphyseal region of long bones

• most cases: in distal femurs

• other sites: humerus, tibia, pelvis, jaw

• Therapeutic management

  • traditional approach; radical surgical resection or amputation of affected area

  • limb-salvage procedures: resection of bone with prosthetic replacement of affected area

  • chemotherapy accompanying surgical treatment

• care management

  • preoop preparation (crucial)

  • support during adjustment to concept of amputation, surgical resection

  • body image concerns: issues of adolescents

  • pain managemnet

    • phantom limb pain characterized by sensations such as tingling, itching and more frequently, pain felt in the amputated limb.

      • pain and sensation is real and should be treated

Ewing’s Sarcoma

• primitive neuroectodermal turmor

• second most common malignant bone tumor in kids and adolescents, rare after age 30 yrs

• arise in marrow especially in

  • femur, tibia, ulna, humerus

  • vertebrae, pelvis, scapula, ribs, skull

• therapeutic management

  • radiation: most common 1st approach

  • chemotherapy: adjunct to radiation

  • surgical resection in some cases: usually able to preserve affected limb

  • prognosis best if no metastasis at time of diagnosis; distal lesions have best potential for cure

• care management

  • assisting family in dealing with diagnosis of malignancy

  • managing complications of radiation and chemotherapy

  • nutritional concerns throughout treatment regimen

  • protect radiation site from sunlight