N3 musculoskeletal.docx

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Pediatric Musculoskeletal disorders

Terms to Know

  • Trendelenburg Gait

  • Osteotomy- cutting of and removal of bone to improve bone function.

  • Arthrotomy- cutting into a joint to expose its interior

  • Hematogenously- involving, spread by, or arising in the blood.

Variations in Pediatrics

  • Immature musculoskeletal system

  • Rapid muscle growth (clumsiness)

  • Bones are more flexible and more porous

  • Males- testosterone release causes growth spurts and bulkier muscles

  • Females- laxer ligaments from female hormones

  • Shape of spine develops over time

  • Epiphyseal region is vulnerable and weak. Fusing and maturing occurs in adolescence.

  • Quicker bone healing

    • Rich nutrient and blood supply

  • Increased remodeling- breaking down and forming new bone

  • Legs have a bowed appearance- in utero positioning. Resolves in 2-3 years with weight bearing.

  • Feet- in-toeing and flat. Also resolves with walking.

Fractures

  • When a bone is subjected to more energy than it can absorb

  • Forearm & wrist most common

  • Greenstick & buckle account for half

  • Childhood fractures are most frequently from accidental trauma.

  • Child < 2 yo with fractures & any child with spiral, rib, or humerus fractures should be evaluated for child abuse &/or underlying disorder.

  • Growth plate is most vulnerable portion of bone

  • Majority will heal with splinting alone

  • Casting is performed more for comfort and increased activity

  • Reduction (realigning) before casting will be needed with displaced fractures

  • More severe fractures may require traction, surgical reduction, &/or fixation

  • Swelling may occur initially after splinting. Delay casting until swelling subsides.

  • Do not attempt to straighten or manipulate

  • Inspect for bruising, erythema, swelling, deformity, limp, inability to bear weight. Palpate for point tenderness. Assess neurovascular status.

  • Immobilize injured limb above & below injury in most comfortable position with splint

  • Cold therapy to reduce swelling for first 48 hrs

  • Elevate injured extremity above level of heart

  • Frequent neurovascular checks

  • Assess pain using appropriate pain scale

  • Crutch walking teaching as needed

  • Encourage age appropriate protective equipment, such as wrist guards & shin guards

Casting

  • Immobilizes a bone that has been injured or a diseased joint, holds a bone in reduction when a fracture has occurred, and prevents/corrects deformities.

  • Plaster or fiberglass- drying time varies. Be careful to not make indentions during drying time!!

  • Gore-Tex lining available to make waterproof

  • FREQUENT neurovascular checks

    • Compartment syndrome- pressure builds up causing decreased blood flow, preventing nourishment and oxygen from reaching nerves and muscles causing tissue death.

Compartment Syndrome “5 P’s”

  • Monitor for

    • Increased pain

    • Decreased or absence of pulse/prolonged capillary refill (>3 seconds)

    • Cyanosis or pale color/coolness of the skin

    • Numbness or tingling (paresthesia)

    • Decreased or no movement (paralysis)

    • Increased edema

Home Cast Care

  • Ice/elevation for pain or swelling in first 24-48 hrs

  • Wiggle fingers or toes hourly

  • For itching

    • NEVER insert anything into the cast

    • Blow COOL air on hair dryer’s lowest setting

    • NO lotions or powders

  • Cover with plastic to protect from wetness

  • Assess skin integrity

  • Contact HCP if foul smell or drainage, T > 101.5°F (38.5°C), skin irritation or breakdown, “burning” under cast, if cast gets wet, split, cracked, or softened, or for s/sx of compartment syndrome.

After Cast Care

  • May be frightened by loudness of cast saw

  • New skin may be tender—avoid scratching & excessive rubbing

  • Soak in warm water & wash daily with soap

  • Apply moisturizing lotion

  • Encourage gradual increase of ROM

Sprains & Strains

  • Twisting or turning motion of affected body part

  • Tendons & ligaments stretch excessively & may tear

  • Any joint (most common ankle & knee)

  • RICE (rest, ice, compression, elevation)

  • Inspect for edema, bruising, inability to bear weight.

  • Assess neurovascular status.

  • May need crutches

Traction

  • Application of weights and pulleys to provide pulling force on an extremity or body part for:

    • reducing dislocations

    • realigning injured extremities

    • immobilizing fractures

    • correcting deformities

  • Not used as often in practice

  • Ensure ropes move freely & weights do not touch floor. Constant and even traction should be maintained.

  • Serial x-rays to monitor progress

  • Skin Traction (short periods of time)

    • Noninvasive

    • Apply weights via ropes to bandage or foam boot

    • Apply traction over intact skin only

  • Skeletal Traction (long periods of time)

    • Invasive/when more pulling force is needed

    • Apply weights via ropes attached to skeletal pins

    • Protect exposed ends of pins to avoid injury

Types of Skin Traction

  • Bryant—used for femur fractures, DDH in child < 3 yrs, or a shortened limb. Supine with buttocks slightly elevated & clear of bed. Assess bandages & skin every shift. Ensure ankles and heels are free from pressure.

  • Russell—femur fracture, hip or knee injuries/contractures. Ensure heel is free of bed & use foot support to prevent foot drop, assess for skin breakdown from sling

Types of Skeletal Traction

  • Dunlop—humerus fracture. Provide pin site care, neurovascular checks, wiggle fingers periodically.

  • 90-90—femur fracture reduction when skin traction inadequate, pin in distal femur. Provide pin site care, may need restraints, neurovascular checks.

  • Crutchfield tongs— management of cervical or thoracic fractures. Assess tongs q. 8 hours, log roll, pin site care, neurovascular checks.

Fixation

  • Surgical reduction (open reduction) of complicated fracture or skeletal deformity with an internal or external pin(s) or device used to immobilize bone while it heals

  • Routine neurovascular & skin assessment essential

  • Pins inserted into bone & place child at risk for infection

  • External—Pin Site Care daily as prescribed

    • National Association of Orthopedic Nurses (NAON) published minimal guidelines

      • Perform pin care weekly or prn after first 48-72 hrs

      • Chlorhexidine 2 mg/mL is solution of choice.

      • Teach child and family pin site care & s/s of infection to report

  • Internal—no additional care

Bryant Russell Dunlop 90-90 Crutchfield

Congenital & Developmental Disorders

Pectus Excavatum/Carinatum

  • Pectus excavatum—funnel shaped chest, sinks inward at the xiphoid process

    • Progresses with growth

    • May require surgery if cardiac or pulmonary compression occurs- SOB, exercise intolerance, chest pain in older children

  • Pectus carinatum—protuberance of chest wall, pigeon chest

  • Extent for both can be determined by xray, CT, MRI

Limb Deficiencies

  • Absence of a limb or portion of it, or the deformity of a limb

  • Occurs during fetal development

  • Mostly attributed to amniotic bands

  • Provide activities EARLY to improve child’s function & activities that the child can participate in

  • PT/OT- early intervention to meet developmental milestones

  • May need prosthesis

Polydactyly/Syndactyly

  • Polydactyly—extra digits

    • Assess for presence of bone

    • May require surgery to remove the extra digit or simply tying off with suture (necrosis)

  • Syndactyly—webbed digits

    • No treatment necessary

    • May have surgery (more complex) for cosmetic reasons

  • Both can be inherited & associated with other genetic disorders

Metatarsus Adductus -curve foot

  • Medial deviation of forefoot

  • One of most common foot deformities of childhood

  • Degree of flexibility is important & determines treatment

    • If flexible past neutral position, then observe

    • If flexible only to neutral position, stretching exercises may be beneficial

    • If rigid, serial casting (before 8 months of age)

    • Surgery in severe cases (rare)

Congenital Clubfoot

  • Complex deformity of the ankle and foot in which the hindfoot and forefoot are rotated inward with and arched midfoot while the foot is pointed downward

  • Rigid and cannot be manipulated into a neutral position

  • Etiology unknown-

    • genetic/environmental factors

TX

  • Goal of treatment is functional foot

  • Treatment starts as soon after birth as possible

  • Weekly manipulation with serial casting initially, then q2wk

  • May require corrective shoes or bracing

  • Severe may require surgery—foot immobilized with cast for up to 12 wks post-op, then ankle-foot splints or corrective shoes for years

  • Teach cast care as previously discussed & use of braces or splints as necessary

Osteogenesis Imperfecta (OI)

  • Inherited connective tissue disorder that results in fragile bone (fractures), small, weak muscles, & joint hypermobility causing instability of joints (lax joints).

  • Lacks bruising/swelling

  • “brittle bone disease”

  • Multiple classifications ranging mild to severe

    • DX: Collagen biopsy (skin punch), genetic testing to determine severity (50% Type 1-mildest), xray

  • Handle child carefully!

  • Common findings

    • Blue sclera (purple, blue, or gray tint that does not resolve after first few weeks of life.)

    • Short stature

    • Early hearing loss

    • Discolored teeth

    • Joint hypermobility

    • Acute & chronic pain

    • Scoliosis

    • Respiratory complications(from immobility)

    • Gross motor developmental delays

  • OI Treatment

  • Biphosphonate (increases bone mineral density)

  • Increased calcium and Vitamin D in their diet

  • PT/OT

  • Splints/braces

  • Surgical insertion of rods into long bones

  • Exercise- walking, swimming, water therapy

Developmental Dysplasia of the Hip (DDH)

  • Abnormalities of the hip joint including dislocation and subluxation

  • Femoral head has abnormal relationship with acetabulum

  • Unilateral or bilateral

  • May cause avascular necrosis of femoral head, loss of ROM, recurrent instability, femoral nerve palsy, leg length discrepancy, early osteoarthritis.

  • Goal is to maintain hip joint in proper place so that femoral head & acetabulum can develop properly

  • Treatment varies based on age & severity

  • Diagnosing DDH

    • Asymmetrical gluteal &/or thigh folds lying prone

    • Limb-length discrepancy- shortening of affected femur

    • Trendelenburg gait in older child

    • Limited hip abduction with passive ROM

    • Positive Barlow and Ortolani test- palpable “clunk”

    • Galeazzi sign- discrepancy of knee height when both knees

TX For DDH:

  • Pavlik Harness for DDH

  • Up to 6 mo of age may be treated with Pavlik harness—maintains hip flexion & abduction

  • Must be worn continuously at first & applied properly, then off for short periods (23 of 24 hours/day)

  • Parents are instructed to not adjust the harness

  • Assess for skin breakdown (long socks & undershirt recommended to prevent rubbing)

  • Usually worn for 3 months

  • Hand wash, air dry

  • Other options for DDH

  • For children 6 mo old or those who do not improve with Pavlik harness- traction may be used (Bryant)

  • Surgical reduction & casting followed by bracing or orthotic use may also be necessary

  • Spica cast for 12 wk

    • Abduction brace

    • Physical Therapy-

    • Strength and flexibility

Tibia Vara (Blount Disease)

  • An exaggerated “bowing” of the legs

  • Etiology unknown

  • Occurs more frequently in child who walks early

  • Obesity is risk factor

  • Bracing & surgery should start before age 4 yrs

    • Compliance is most significant barrier to successful tx

    • Brace must be continued for months to years & worn 23 hrs/day

    • Long-leg bent knee or spica cast after surgery

Torticollis- “twisted neck”

  • Painless muscular condition in infants or children

  • Observe for wryneck (tilting head to one side)

  • Congenital form may be related to in utero positioning

  • Preferential turning of head to one side when supine or prone can lead to tightness of sternocleidomastoid muscle

TX

  • Passive stretching exercises and tummy time

  • PT & a tubular orthosis collar may be used

  • Pharmacological treatment-

    • Baclofen (muscle relaxant)

    • Injection of botulinum toxin (Botox) can provide temporary relief—need to be repeated q3mo

Plagiocephaly

  • Flat spot on baby’s head/asymmetrical head shape

  • Management- wearing a helmet for 23 hours a day for 3-6 months, encouraging tummy time

Acquired Disorders

Rickets

  • Softening or weakening of bones as result of nutritional deficiency from inadequate Ca or vitamin D consumption or limited exposure to sunlight (preventable)

  • Can also occur if body cannot regulate Ca and Phos (such as in chronic renal dz and malabsorption GI disorders—CF, Chrons, & prematurity)

  • Look for: dental deformities, bowlegs, bone pain, hx of fractures, low serum Ca, Vitamin D, and Phos levels

  • Treatment is Ca, Phos, & possibly vitamin D supplements

Slipped Capital Femoral Epiphysis (SCFE)

  • Femoral head dislocates (slips) through the epiphyseal (growth) plate

  • Etiology unknown

  • Promptly refer to orthopedic surgeon

  • Can result in chondrolysis (cartilage necrosis), avascular necrosis of femoral head, shortening of the affected leg, thigh atrophy, and osteoarthritis.

  • May present with

    • (acute or chronic) groin, thigh, or knee pain,

    • inability to bear weight

    • a limp or Trendelenburg gait

    • decreased ROM

    • affected leg may be shorter

  • X-ray for diagnosis

  • Once diagnosed, strict bed rest & activity restriction (No ROM movements)

  • May need Russell traction before surgery (pins or screws to hold the femoral head in place)

  • Monitor neurovascular status

  • Teach crutche walking (PT), weight bearing after 1 week, pin removal later.

  • Severe cases may need osteotomy

Legg-Calve-Perthes Disease

  • Self-limiting condition involving avascular necrosis (cutting off blood supply) of femoral head

  • MRI for diagnosis

  • Interruption of blood supply to femoral head results in bone death, loss of spherical shape, and swelling of the soft tissues.

  • New blood vessels develop and revascularization takes 6-12 months

  • Femoral head reforms over 1-2 years

  • Legg-Calve-Perthes Disease

  • Characterized by:

    • Starts as a painless limp (intermittent over period of months) resulting in…

    • Mild hip pain or referred knee or hip pain

    • Pain aggravated by exercise

    • Trendelenburg gait/joint dysfunction

    • Limited abduction of hip (ROM)

    • Muscle spasms

    • Wasting/atrophy of thigh/buttock muscles

  • Treatment includes anti-inflammatory medications to decrease muscle spasms around hip joint & relieve pain. May take 18 months to 4 years to fully recover. (no preventative measures)

  • Activity limitations may be prescribed (crutch teaching)

  • Bracing, casting, or traction. Serial x-rays.

  • Surgery is rare—osteotomy may be performed

Osteomyelitis

  • Bacterial infection of bone & soft tissue surrounding bone (long bones most common)

  • Staphylococcus aureus is most common infecting organism – bacteria enters the bloodstream and invades the bone. (hematogenously)

  • X-ray/bone scan to confirm diagnosis. Blood cultures to identify organism. Elevated WBC.

  • Pain, refusal to walk/guarding, fever, swelling, warmth, tenderness

  • Bed rest, pain management, antipyretics, 4-6 wk course of antibiotics (IV then po), possible debridement

Septic Arthritis

  • Bacterial invasion of joint space (most often hip or knee)

  • Usually obtained hematogenously through direct puncture from injections, venipuncture, wound infection, surgery, or injury

  • Sepsis of hip joint may cause avascular necrosis of femoral head

  • Considered MEDICAL EMERGENCY because destruction of joint cartilage may occur within few days

  • Joint aspiration (responsible organism) or arthrotomy, IV antibiotics, then possibly PO antibiotics at home

  • Note recent respiratory infection or otitis media, skin or soft tissue infections, traumatic puncture wounds, or femoral venipuncture

  • S/S: Ill appearance, sudden onset of fever, moderate-severe pain, usually maintains joint in flexion & will not allow leg to be straightened. Will not bear weight.

  • Pain management with acetaminophen or ibuprofen usually sufficient, but may need morphine or codeine

  • Crutches, wheelchair, PT

Scoliosis

  • Lateral curvature of spine that exceeds 10 degrees

  • Congenital, associated with disorders, or arises spontaneously (idiopathic)

  • Idiopathic occurs more during adolescence & is the most common type

  • Children are screened at each healthy visit until bones mature

  • With progression & changes of the shape of the thoracic cage, cardiac & pulmonary compromise may occur

  • Treatment based on age, expected future growth, & severity of curvature

    • Commonly will not report back pain- just mild discomfort

    • Asymmetry in hips or shoulders is noted by family or during scoliosis screening.

  • 25-40 degree curvature, bracing may be sufficient

    • Watch closely for skin breakdown

  • > 45 degrees curvature, surgical approach used

    • Rod placement, bone grafting, or spinal fusion

  • Post-op -> ICU

    • use log-roll technique to turn to avoid flexion of back

    • Indwelling urinary catheter, incision care, PCA, IV antibiotics, may need blood transfusion

    • Ambulate slowly when ordered to avoid orthostatic hypotension. Passive ROM exercises.

    • Home Health/PT/OT- can return to school in 4-6 weeks

Overuse Syndromes

  • Group of disorders that result form repeated force applied to normal tissue

  • Develop over weeks to months

  • No identifiable injury

  • Pain associated with an activity & worsens with participation in the activity

  • Initially apply ice when pain is severe.

  • Anti-inflammatory medications (NSAIDs- ibuprofen) may be helpful

  • Encourage to limit exercise & participate in different activity

  • Resolves over few weeks then can resume activity

    • Osgood-Schlatter disease—partial pulling/tearing of the ossification center of the tibial tubercle

      • Most commonly affects adolescent boys during period of rapid growth

      • Often dismissed as “growing pains”

      • May take 12-24 mo to resolve

  • Encourage stretching before activities & conditioning before season begins

  • Resolves on its own once the child’s bones stop growing

Radial Head Subluxation (Nursemaid’s Elbow)

  • Occurs when pulling motion on the arm causes annular ligament surrounding radial head to stretch or tear, therefore displacing the radial head

  • Ligament becomes entrapped within the joint

  • Child will hold arm slightly flexed at side or across abdomen & refuse to move it

  • Neurovascular status is normal, no edema or bruising, & no obvious discomfort if arm is still

  • After reduction, child will experience less pain almost immediately (video)