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. TalipesEquinovarus (Clubfoot) • Muscles, tendons, and bones are involved in the abnormality. • Adduction and supination of forefoot • Inversion of the heel • Fixed plantar flexion

5. Goal of Care • Stretch tightened ligaments and • tendons gently to • Return the foot to a maximal anatomic position

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. 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 child’s 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 • Ensures hip flexion and abduction and does not allow hip extension or adduction. • It maintains correct position of the femoral head in the acetabulum.

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 • Repositioning of the bone fragments into normal alignment • Application of a device or mechanism that maintains alignment until healing occurs Reduction Retention

26. Retention Pull or force exerted on one part of the body Application of Cast Traction

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 Gower’s maneuver to rise from floor Unable to walk independently by age 9 – 12.

33. Diagnostic findings: Muscle biopsy – reveal fatty fibrous tissue that gradually replaces muscles (the protein dystrophin is low in the muscles of these patients) Elevated serum enzyme CK (creatine kinase)

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. Scoliosis • Assessment findings: • Lateral curvature of spine • Truncal asymmetry • Uneven shoulders • Prominent scapula – uneven height • Rib-hump • uneven hips

39. Braces used in Treatment of Scoliosis

40. Quick Question: What is the priority psychosocial nursing diagnosis for the adolescent diagnosed with scoliosis?

41. Treatment and Nursing Care for Scoliosis Spinal Fusion • Pre-operative teaching • Demonstrate incentive spirometer and C&DB • 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.

42. Nursing Care for spinal fusion • Post-operative Care • Maintain airway • Neurovascular Assessment of lower extremities • Teach passive and active ROM exercises • Encourage independence in ADL’s • Provide with resources / information on scoliosis support groups

43. 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

44. The End