Musculoskeletal/Articular Dysfunction in Children

MUSCULOSKELETAL/ARTICULAR DYSFUNCTION IN CHILDREN

Instructors

  • Megan Anibas, DNP, MS, RN

OBJECTIVES

  • Explain the physiologic and psychologic effects immobilization has on a child.

  • Differentiate between the different types of soft tissue injuries.

  • Differentiate between the different types of fractures.

  • Describe nursing interventions for a child in traction.

  • Identify clinical manifestations of compartment syndrome.

  • Describe each of the musculoskeletal congenital disorders, including:

    • Clubfoot

    • Legg-Calve-Perthes

    • Developmental dysplasia of the hip

    • Osteogenesis imperfecta

    • Scoliosis

  • Describe clinical manifestations, treatment, and care of the child affected by each.

IMMOBILIZATION IN CHILDREN

  • Children have a natural tendency to be active.

  • Disuse due to illness, injury, or sedentary lifestyle can limit function and potentially delay age-appropriate milestones.

  • Responses to restricted movement are noted in most body systems.

Physiologic Effects

  • Most pathologic changes arise from:

    • Decreased muscle strength and mass

    • Decreased metabolism

    • Bone demineralization

  • Key phenomena include:

    • Muscle disuse leading to atrophy and decreased strength and endurance.

    • Contractures and loss of joint mobility.

Impact on Body Systems

  1. Muscular System

    • Decreased muscle strength and endurance

    • Atrophy

    • Contractures

    • Loss of joint mobility

  2. Skeletal System

    • Bone demineralization

  3. Cardiovascular System

    • Altered distribution of blood volume

    • Venous stasis

    • Dependent edema

  4. Respiratory System

    • Decreased need for oxygen

    • Loss of respiratory muscle strength

  5. Gastrointestinal System

    • Distention due to poor abdominal muscle tone

    • Difficulty feeding in prone position

    • Constipation

    • Anorexia

  6. Metabolism

    • Decreased metabolic rate

    • Negative nitrogen balance

    • Hypercalcemia

  7. Integumentary System

    • Decreased circulation and pressure leading to decreased healing capacity

  8. Urinary System

    • Alteration of gravitational force

    • Difficulty voiding in the supine position

    • Urinary retention

PSYCHOLOGIC EFFECTS

  • Physical activity is instrumental for communication and expression.

  • Physical interference can lead to varied responses at different developmental stages:

    • Infants: Feelings of helplessness

    • Toddlers: Exploration essential for sense of autonomy

    • Preschoolers: Vigorous physical activity vital for initiative

    • School-Age: Development influenced by physical achievement and competition

    • Adolescents: Rely on mobility to achieve independence

Other Effects of Immobilization

  • Sluggish intellectual and psychomotor responses

  • Decreased communication skills

  • Increased fantasizing

  • Hallucinations and disorientation

  • Regression

  • Signs of protest, anger, or aggressive behavior

  • Quiet, passive, or submissive behavior

  • Behavioral issues may be interpreted as punishment

SOFT TISSUE INJURIES

  • Soft tissue injuries include:

    • Contusion (bruise): Damage to soft tissue, subcutaneous structures, and muscle.

    • Dislocation: A bone end displaced from its socket.

    • Sprain: A ligament partially or completely torn or stretched.

    • Strain: A microscopic tear to the musculotendinous unit.

  • RICE Treatment (Rest, Ice, Compression, Elevation) should be applied within 12-24 hours after injury.

FRACTURES

  • Fractures are a common injury in children.

  • Diagnosis and treatment methods differ in pediatric populations versus older adults.

  • Rarity in infants: Fractures usually occur due to motor vehicle crashes or falls.

  • Frequent sites of fractures: Radius, ulna, and clavicle — particularly in children under 10 years old.

  • In school-age children: Bicycle and sports injuries are prevalent; it is essential to ensure the injury matches the mechanism of injury.

Bone Healing

  • Bone healing is typically rapid in children:

    1. Neonatal period: 2 to 3 weeks

    2. Early childhood: 4 weeks

    3. Later childhood: 6 to 8 weeks

    4. Adolescence: 8 to 12 weeks

Types of Fractures

  1. Plastic Deformation (bend):

    • Bone is bent but not broken, no more than 45 degrees.

  2. Buckle (torus):

    • Compression of the bone; it appears as a raised or bulging projection of the bone.

  3. Greenstick:

    • Incomplete fracture of the bone, one side is bent, and the other side is broken.

  4. Transverse:

    • Break straight across the bone.

  5. Oblique:

    • Break diagonal across the bone.

  6. Spiral:

    • Break spirals around the bone.

  7. Stress:

    • Tiny cracks in the bone, often associated with the growth plate.

    • Weakest point of long bones is the cartilage growth plate (epiphyseal plate); thus, it is a frequent site of damage, which may affect future bone growth.

  8. Complete:

    • Bone fragments are separated.

  9. Incomplete:

    • Bone fragments are still attached.

  10. Closed (simple):

    • Fracture occurs without a break in the skin.

  11. Open (compound):

    • Fractured bone protrudes through the skin.

  12. Complicated:

    • Fragments result in injury to other organs and tissues.

Clinical Manifestations of Fracture

  • Generalized swelling

  • Pain or tenderness

  • Deformity

  • Diminished functional use

  • May have bruising or severe muscular rigidity

  • Edema

  • Warmth or redness

Diagnostic Procedures

  • X-ray is a common method for diagnosing fractures.

Nursing Interventions at Time of Injury

  1. Monitor ABC’s (Airway, Breathing, Circulation).

  2. Monitor vital signs (VS), pain levels, and neurological status.

  3. Assess neurovascular status of the injured extremity.

  4. Position the child in a supine position.

  5. Stabilize the injured area.

  6. Elevate the injured area if able.

  7. Administer analgesics as needed.

Nursing Interventions for Neurovascular Assessment

  • Assess the following:

    • Sensation: Evaluate touch or pressure sensation.

    • Temperature: Compare warmth of the injured area to other extremities.

    • Color: Check for pallor or cyanosis.

    • Capillary refill: Measure time for blood to return to the capillaries after pressure is applied.

    • Pulses: Check for the presence and quality of peripheral pulses.

    • Movement: Assess range of motion or ability to move the limb.

Treatment - Types of Casts

  1. Long leg cast (LLC)

  2. Short leg cast (SLC)

  3. Bilateral LLC

  4. Full spica cast

  5. Single spica cast

  6. Short arm cast (SAC)

  7. Long arm cast (LAC)

Treatment - Types of Materials

  • Plaster of Paris:

    • Heavy

    • Non-water resistant

    • Takes 10-72 hours to dry

  • Synthetic Fiberglass:

    • Light

    • Water resistant

    • Dries in approximately 5-20 minutes

Nursing Interventions for Casts

  • Assess neurovascular status regularly.

  • Elevate above the level of the heart for the first 24-48 hours to reduce swelling.

  • Apply ice for the first 24 hours to minimize edema.

  • Turn and reposition every 2 hours to maintain skin integrity.

  • Support the affected extremity.

  • Monitor skin condition around the cast edges.

  • Provide perineal care if applicable.

  • Prepare for mobility issues based on the casted area.

COMPLICATIONS

Compartment Syndrome

  • Definition: Results from compression of nerves, blood vessels, and muscle inside a closed space leading to tissue death.

  • Emergency Attention Needed!

Clinical Manifestations of Compartment Syndrome - Remember the 6 P’s:

  1. Pain

  2. Pulselessness (Late sign)

  3. Pallor (Late sign)

  4. Paresthesia

  5. Paralysis (Late sign)

  6. Pressure

Treatment of Compartment Syndrome

  • Fasciotomy may be performed to relieve pressure.

Osteomyelitis

  • Definition: Infection of the bone which can be caused by exogenous or hematogenous sources.

Types of Sources:

  • Exogenous: Outside source, such as an open fracture.

  • Hematogenous: Bloodborne bacterial source, often leading to infection.

Clinical Manifestations of Osteomyelitis

  • 2-7 day history of pain in the affected area.

  • Warmth and tenderness in the limb.

  • Decreased range of motion in the affected limb.

  • Fever

  • Irritability

  • Lethargy

Treatment of Osteomyelitis

  1. IV antibiotics are prescribed.

  2. If severe cases arise, surgery might be necessary.

MUSCULOSKELETAL CONGENITAL DISORDERS

  • Clubfoot

  • Legg-Calve-Perthes

  • Developmental Dysplasia of the Hip (DDH)

  • Osteogenesis Imperfecta (OI)

  • Scoliosis

Clubfoot

  • Definition: Deformity of the ankle and foot, categorized into three types:

    1. Positional Clubfoot: Caused by intrauterine crowding, responds well to treatment via stretching and casting.

    2. Syndromic Clubfoot: Associated with other anomalies, more severe, and often resistant to treatment.

    3. Congenital Clubfoot: Occurs in an otherwise normal child.

Variations of Clubfoot

  1. Talipes Varus: Inversion or bending inward.

  2. Talipes Valgus: Eversion or bending outward.

  3. Talipes Equinus: Plantar flexion where the toes are lower than the heel.

  4. Talipes Calcaneus: Dorsiflexion where the toes are higher than the heel.

  5. Talipes Equinovarus: Toes facing inward and lower than the heel, seen in 95% of cases.

Treatment of Clubfoot

  • Treatment may involve castings done in series shortly after birth.

  • Surgery is required for syndromic and congenital clubfoot.

Legg-Calvé-Perthes Disease

  • Definition: Disturbance of circulation to the femoral head, leading to aseptic necrosis.

  • Affected demographic: Occurs in children ages 3 to 12 years, more common in males ages 4 to 8 years.

  • Bilateral hip involvement: Seen in 10% to 15% of cases.

  • Etiology: Cause is unknown but can be associated with trauma, inflammation, and coagulation defects.

Clinical Manifestations

  • Subtle onset of symptoms.

  • Intermittent painless limp.

  • Soreness, ache, or stiffness, can be constant or intermittent.

  • Pain.

  • Limited range of motion.

Treatment Goals for Legg-Calvé-Perthes Disease

  • The primary objective is to keep the head of the femur in the acetabulum.

  • Treatment methods may include containment with various appliances/devices, initial rest with no weight-bearing, NSAIDs, and possibly surgery in some cases.

  • Home traction may be used in specific cases.

  • Outcome depends on early and efficient diagnosis and treatment and age of the child at the onset of the disorder.

Developmental Dysplasia of the Hip (DDH)

  • Definition: A spectrum of disorders related to abnormal development of the hip occurring during fetal life, infancy, and/or childhood.

  • Etiology: Cause is unknown.

  • Risk factors include:

    • Gender (girls are more often affected).

    • Family history of the condition.

    • Intrauterine positioning.

    • Delivery type (breech).

    • Postnatal positioning: adduction vs abduction.

Degrees of DDH

  1. Acetabular Dysplasia: Mildest form where the femoral head remains in the acetabulum.

  2. Subluxation: Incomplete dislocation of the hip.

  3. Dislocation: Femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly; the ligaments are elongated and taut.

Clinical Manifestations

  • In Infants:

    • Shortened limb on the affected side.

    • Restricted abduction of the hip on the affected side.

    • Unequal gluteal folds when the infant is prone.

    • Positive Ortolani test.

    • Positive Barlow test (tests for hip dislocation).

  • Older Infants and Children:

    • Affected leg appears shorter than the unaffected leg.

    • Positive Trendelenburg sign.

    • Walking on toes on one foot.

    • Marked lordosis if bilateral dislocations are present.

    • Waddling gait may occur if bilateral dislocations are present.

Diagnosis of DDH

  • Imaging techniques include:

  1. Ultrasound

  2. X-ray

Treatment of DDH

  • Early recognition is crucial!

  • For Newborns to 6 Months:

    • Use of Pavlik harness to maintain reduction for 12 weeks.

    • Bryant traction to stretch the hip to full abduction.

    • Hip spica cast may be applied to maintain reduction.

  • For ages 6-24 months:

    • Surgical closed reduction performed, often followed by spica cast application for 12 weeks.

  • For older children:

    • Surgical reduction which may be preceded/ followed by traction.

    • Femoral osteotomy, reconstruction, and tenotomy may often be required.

Osteogenesis Imperfecta (OI)

  • Definition: Rare osteoporosis syndrome occurring in childhood, marked by varying degrees of bone fragility, deformities, and fractures due to a genetic error causing faulty bone mineralization.

Clinical Manifestations of OI

  • Multiple bone fractures with minimal trauma.

  • Blue sclerae.

  • Early onset hearing loss.

  • Bowed legs and arms.

  • Kyphosis and scoliosis may occur.

  • Severity and manifestations depend on the type of OI.

Treatment of OI

  • Primarily supportive care aimed at preventing complications such as contractures and deformities.

  • Focus on rehabilitation to manage muscle weakness and osteoporosis.

  • Surgical interventions may be indicated if necessary.

  • Medications, such as pamidronate (Aredia), are used to increase bone density.

Scoliosis

  • Definition: A complex spinal deformity characterized by a lateral curvature of the spine, often associated with spinal rotation causing rib asymmetry.

  • Idiopathic Scoliosis: The most common type which may occur alone or in conjunction with other conditions.

  • Screening Recommendations: AAP recommends scoliosis screening to occur in school settings, provider offices, or nurse clinics; specifically screening girls at ages 10 to 12 and boys at ages 13 to 14.

Clinical Manifestations of Scoliosis

  • Asymmetry notable in scapulae, ribs, flanks, shoulders, and hips.

  • Patients may experience improper fitting in clothing.

  • Definitive Diagnosis: Typically made through X-ray examination.

Treatment of Scoliosis

  • A team approach involving various healthcare providers is crucial for treatment.

  • Interventions may include:

    • Bracing to support proper spinal alignment.

    • Exercise programs tailored to strengthen core muscles.

    • Surgical intervention, particularly for severe curvatures greater than 45 degrees, may require instrumentation and spinal fusion.

REFERENCES

  • Hockenberry, M.J., Wilson, D., & Rodgers, C.C. (2022). Wong’s Essentials of Pediatric Nursing (11th ed.). St. Louis, MO: Elsevier Mosby.