Pediatric Musculoskeletal Disorders

1
Pediatric Musculoskeletal Disorders
2
Musculoskeletal Development

• Infant bones are only 65 ossified
• Long bones are porous and less dense and can
  bend, buckle or break easily
• Growth takes place in Epiphyseal plates, and if
  these are injured, can cause abnormal growth
• Growing bones heal quickly and decrease need for
  treatment

3
Clubfoot

• A congenital abnormality in which the foot is
  twisted out of its normal position.

4
Talipes Equinovarus (Clubfoot)

• How are muscles, tendons, and bones involved in
  this abnormality?

1. ______________
2. _______
3. ____________________
5
Goal of Care
What is the priority goal of care for the
child with a clubfoot?
6
Treatment for Clubfoot

• Serial manipulation
• Corrective casting
• Splints
• Surgical correction

7
Serial Casting

• Cast applied to hold foot in desired position.
• Changed every 1-2 weeks until maximum correction
  is achieved.
• Nursing Care
• Cast care
• Skin Care
• Education of parents

8
What is included in a Neurovascular Assessment?
9
Cast Care Assessment

• Unusual odor beneath the cast
• Tingling, burning, numbness of toes
• Drainage through cast
• Swelling or inability to move toes
• Toes that are cold, blue or white
• Sudden unexplained fever
• Pain that is not relieved by comfort measures

10
Cast Care Teaching

• Petaling the edges of the cast
• Drying of the cast
• Prevention of swelling
• Protecting the cast
• When to call the doctor

11
Try this

• A infant has a cast applied for treatment of club
  foot. Which of the following symptoms requires
  immediate attention and should be reported to the
  health care provider?
• A. Capillary refill of 4 seconds in the affected
  toes.
• B. Edema in the affected toes that improves with
• elevation.
• C. Numbness of the toes on the affected foot.
• D. Skin distal to the cast is warm

12
Dennis Brown Splint
Splinting is used after casts are removed to
maintain the correction.
13
Care of a child in a splint

• Braces should fit snugly but should not interfere
  with neurovascular function.
•  Before wearing the brace, check the skin for any
  areas of redness or breakdown.
• Give parents guidelines for braces.
• If redness develops, arrange to have the fit of
  the brace evaluated and modified.
• Bar between legs is not a handle.
• Teach appropriate positioning for safety to
  prevent falls, and allow mobility and
  "tummy-time

14
Parent Support

• Parents are trained and become active
  participants in the physical therapy treatments
  and childs stretching program
• Nurses need to help the parents understand the
  time commitment involved
• Assess the parents ability to monitor the child
  adequately for complications and confirm they
  understand the signs and symptoms of the
• complications

15
Question

• The parents of an infant with clubfoot ask how
  it is treated. Which of the following treatments
  should the nurse discuss with the parents?
• Weekly cast changes with manipulation
• Probably surgery on the affected
• Abduction device to keep the extremity in
  alignment
• Use of a Dennis-Browne splint to achieve
  correction.

16
Hip Dysplasia
The head of the femur is improperly seated in the
acetabulum of the pelvis
17
Developmental Dysplasia of HipClinical
Manifestations

• Limited abduction of the affected hip during
  Ortolani maneuver. May hear a click upon
  movement.
• Asymmetry of gluteal and thigh fat folds when
  lying with legs extended.
• Telescoping of thigh
• Limp and abnormal gait in older
• child

Ortolani maneuver
Asymmetry of gluteal folds
18
Treatment and Nursing care of a child with
Dysplasia of the Hip

• Pavlik harness
• What is the purpose?
• How does it achieve this?

19
Nursing Care

• Teach parents/caregivers to remove and apply
  harness appropriately only remove for bathing
  and skin checks.
• Teach skin assessment
• Encourage cuddling infant to promote cognitive
  development and infant/caregiver bonding

20
Ask Yourself ?

• A parent asks why the infant must wear a
  Pavlik harness. What is the nurse's best
  response? This treatment is to
• provide comfort and support.
• shorten the limb on the affected side.
• maintain the femur within the acetabulum.
• provide outward displacement of the femoral head.

21
Treatment and Nursing care of a child with
Dysplasia of the Hip

• Spica cast
• Covers lower half of
• body except perineal area
• Nursing Care
• Elimination/ protection of cast
• Positioning
• Neurovascular assessment
• Skin care
• Hygiene

22
Fractures
23
Causes of Fractures

• Increased mobility and immature motor skills
• Trauma
• Bone diseases

24
Manifestations of Fracture

• Pain or tenderness at site
• Immobility or decreased ROM
• Deformity of extremity
• Edema
• Other signs crepitus, ecchymosis, muscle spasm
  and inability to bear weight

25
Treatment

• Reduction

• Repositioning of the bone fragments into normal
  alignment

• Application of a device or mechanism that
  maintains alignment until healing occurs

• Retention

26
Retention

• Application of Cast
• Traction

Pull or force exerted on one part of the body
27
Question

• Which of the following nursing interventions
  takes highest priority when caring for a child in
  skeletal traction?
• Assessing bowel sounds every shift
• Providing adequate nutrition
• Assessing temperature every 4 hours
• Providing age-appropriate activities

28
Complications associated with Orthopedic Trauma/
Fractures

• Fat Embolism
• Particles of fat are carried through circulation
  and lodge in lung capillaries causing
• Pulmonary edema
• Respiratory distress with hypoxemia and
  respiratory acidosis
• Treatment
• Increase in IV fluids
• Respiratory support and adequate oxygenation

29
Orthopedic Trauma / Fracture Complications

• Compartment syndrome (very serious)

30
Legal Ethical implications when caring for a
child with a fracture?

• All fractures entering the hospital via ER
  require social service consult for documentation
  of suspected abuse or neglect.
• The nurse must report all suspected abuse to the
  appropriate authority.
• Do not discuss the possibility of abuse with the
  parents or guardians!! Do not attempt to prove or
  disprove abuse.

31
Muscular Dystrophy
Progressive degeneration of
Muscle fibers
32
Manifestations of Muscular Dystrophy

• Delayed walking (first sign)
• Progressive, symmetric muscle wasting
• Frequent falls
• Easily tired when walking, running, or climbing
  stairs
• Hypertrophied calves muscle
• Waddling wide-based gait
• Uses Gowers maneuver to rise from floor
• Unable to walk independently by
• age 9 12.

33
Diagnostic findings

• What diagnostic tests are used in confirming the
  diagnosis?

34
Goal of Care
Maintain ambulation and independence for as long
as possible.
35
Nursing Care

• Coordinate a variety of health care services
• Maintain activity and self-care functions
• Skin care
• Maintain bladder and bowel functioning
• Protect from respiratory infections
• Teach dietary modifications to decrease obesity

36
Question

• Which of the following interventions is
• INAPPROPRIATE to incorporate in the care for a
• child with muscular dystrophy hospitalized with a
  
• respiratory infection?
• Physical therapy
• Aggressive antibiotic therapy
• Passive range of motion exercises
• Complete Bedrest

37
Scoliosis

• Lateral S curvature of the spine

38
What are the manifestations of Scoliosis
Rib Prominence or hump
Prominent scapula
lateral
Uneven shoulders
With uneven hips
39
Diagnosis

• When does screening for this disorder occur?

40
Braces used in Treatment of Scoliosis
Why would lead to non-compliance in
wearing the brace?
41
Quick Question

• What is the priority psychosocial nursing
  diagnosis for the adolescent diagnosed with
  scoliosis?

42
Treatment and Nursing Care for Scoliosis Spinal
Fusion

• Pre-operative teaching
• Demonstrate incentive spirometer and CDB
• Discuss all potential equipment (chest tubes, IV,
  O2 masks nasal canula, Foley catheter)
• Teach use of pumps for PCA or epidural block.
• Demonstrate log rolling and assist out of bed.

43
Nursing Care for spinal fusion

• Post-operative Care
• Maintain airway
• Neurovascular Assessment of lower extremities
• Teach passive and active ROM exercises
• Encourage independence in ADLs
• Provide with resources / information on scoliosis
  support groups

44

• Post operative care of an adolescent following a
• spinal fusion for scoliosis includes (select
  ALL
• that apply)
• Oral analgesics for pain
• Logrolling every 2 hours
• Nasogastric intubation
• Bilateral Neurovascular checks of lower
  extremities
• Use of incentive spirometer q 2 hours
• Assess skin on bony prominences

45
The End