musculoskeletal peds

Shurrell’s Notes on the Musculoskeletal System in Pediatrics

Differences Between Child and Adult Muscle Systems

  • Bone Development in Children:

    • Children’s bones are not completely ossified.

    • Presence of epiphyses (end portion of long bones).

    • Thicker periosteum in children, aiding in faster callus production during healing.

    • Common occurrence of bone overgrowth during fracture healing.

Normal Development and Gait

  • Gait Definition:

    • Refers to how a person walks.

Developmental Milestones in Toddler Gait:

  • Initial Walking Phase:

    • Walk initiation occurs with a wide and unstable gait.

  • Gait Stabilization:

    • By 18 months, the gait becomes stable.

  • Advanced Gait Functions:

    • By 4 years, toddlers can hop on one foot and arm swinging is observed.

    • By 6 years, gait resembles that of a normal adult.

  • Toe Walking:

    • Persistence of toe walking after age 3 may indicate a muscle problem.

    • Toe walking typically resolves by age 4.

  • Common Gait Abnormalities:

    • Bow-leggedness: Known as genu verum.

    • Knock-knees: Known as genu valgum.

    • Flat Feet: Referral for follow-up examination if painful; many minor alignment issues resolve spontaneously without intervention.

Soft Tissue Injuries

  • Contusion:

    • Defined as a tearing of the subcutaneous tissue leading to hemorrhage, edema, and pain.

    • Blood escape results in a hematoma, commonly referred to as a “black and blue” mark or bruise.

Other Soft Tissue Injuries:

  • Sprain:

    • Involves the ligament being torn or stretched from the bone, resulting in blood vessel, muscle, and nerve damage.

    • Major signs include swelling, disability, and pain.

  • Strain:

    • Represents a microscopic tear to the muscle or tendon, often occurring over time, leading to edema and pain.

Treatment for Soft Tissue Injuries:

  • Immediate Care:

    • Treat immediately to limit damage from edema and bleeding.

    • Use cold pack and elastic wrap to minimize edema and relieve pain.

    • Apply cold for 30-minute intervals for the first 24-48 hours; switch to heat after this period.

    • Cold application reduces edema; heat enhances circulation for healing localized to the injury site and aids in swelling absorption.

    • Elevation above heart level assists in edema reduction.

    • Elastic bandage applied for compression helps manage swelling.

Nursing Priorities:

  • Frequent Neuro Checks:

    • Essential to ensure tissue perfusion.

    • First sign of poor perfusion may be confusion.

  • RICE Protocol:

    • Rest, Ice, Compression, Elevation.

  • Compartment Syndrome:

    • Can occur if injuries are not managed correctly, leading to loss of tissue perfusion.

Traumatic Fractures

  • Classification of Fractures:

    • Simple Fracture:

    • Bone is broken but skin over the area remains intact.

    • Compound Fracture:

    • Accompanied by a wound in the skin, which increases the risk of infection.

    • Greenstick Fracture:

    • An incomplete fracture where one side of the bone is broken, and the other side is bent, common in children due to their soft and flexible bones.

Specific Fracture Characteristics:

  • Open Fracture:

    • Increased concern for infection.

  • Serious Breaks:

    • Femur commonly affected due to its prevalence in childhood fractures.

    • Suspicion of non-accidental injury or child abuse if fractures occur in infants' lower extremities.

  • Spiral Fracture:

    • Result of forceful twisting motion of the femur.

    • Child may complain of tenderness or pain when the leg is moved and may be unable to bear weight.

Nursing Actions for Fractures:

  • Assessment Procedures:

    • Gently remove clothing, beginning with the uninjured side.

    • X-ray needed for diagnosis.

  • Traction Types:

    • Skin Traction:

    • Used to reduce fractures and keep bones aligned.

    • Buck’s Extension:

    • Traction that pulls the hip and leg into extension, important for femur fractures and hip/knee contractures.

    • Patient must not slip down in bed or be placed in high Fowler's position.

    • Russell’s Traction:

    • Uses a sling positioned under the knee to suspend the distal thigh above the bed.

    • Skeletal Traction:

    • Involves inserting a Steinman pin or Kirschner wire in the bone for traction application.

Checklist for Traction Apparatus:

  • Weights must hang freely and kept out of children's reach.

  • Ensure ropes are correctly aligned in the pulley grooves and not resting against them.

  • Confirm countertraction is in place, and the apparatus does not touch the foot of the bed.

Nursing Responsibilities for Traction:

  • Ensure ropes are intact and the wheeled pulleys function correctly.

  • For Bryant’s traction, confirm legs are positioned at correct angles to allow elevation.

  • Elastic bandages must be carefully applied to avoid being too loose or tight.

  • Use of a jacket restraint to prevent rotation by the child may be necessary.

  • Weights should be left undisturbed after application, and no blankets should be placed over cords.

Neuro Checks:

  • Assess peripheral pulses, color, capillary refill, warmth, movement, and sensation.

  • Capillary Refill Check:

    • Squeeze toes or fingers; color response