Transcript Birth Trauma

Musculoskeletal Stressors and
Adaptation
Common MS disorders in Children
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Congenital hip dysplasia
Clubfoot
Fractures
Scoliosis
Osteogenesis Imperfecta
Osgood-Schlatter Disease
Osteomylitis
Muscular Dystrophy
JRA
Congenital hip dysplasia
• Hereditary disorder, more common
in girls, unilateral
• Improper formation and function
of hip socket
• Head of femur is dislocated
• Flat acetabulum of pelvis (prevents
femur from remaining in the
acetabulum and rotating
adequately)
Diagnosis
 Early
detection is key
 Affected leg may appear
shorter
 Asymmetry of gluteal and thigh
folds
 Limited hip abduction
 “Ortolani click”
 Uneven gait in older child
Management for infants
under 3 months of age
Pavlik harness:
keeps hips and knees flexed, the
hips abducted, and the femoral
head in the acetabulum
worn continuously for 3 to 6 months
effective 90% of time
Management
for infants >3 months age
Hip spica cast:
maintains abduction (frog-like position)
3-18 months age
Worn for 1 year
Must be changed as child grows
ORIF (surgical insertion of pin)
For child >18mos
Successful reduction is difficult after age
4
Clubfoot
Congenital deformity
Can affect one or both feet
Portions of foot and ankle are
twisted out of normal position
Pseudo-deformity vs True-defect
Varying degrees of severity &
combinations of abnormal positions
Assessment:
Early detection
Part of newborn assessment
• Treatment:
Begins soon after birth, before
discharge
Manipulation with serial casting for
8-12 weeks (due to rapid growth)
Cast extends above infant’s knee to
ensure correction
• If ineffective: surgical correction btw 412 mos, realignment of bones, pin
insertion, cast for 6-12 weeks
• Denis Browne Splints: shoes attached to
metal bar to maintain correction
Nursing care
Neurovascular assessment
Pain assessment
Frequent diaper changes
Infection
Skin integrity
Activity
Follow-up
Fractures
• Break in bone from stress
• Frequent in children- bones are not as dense
and more porous
• Usually occur from
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Falls
Sports
MVA
Bone disease
Fractures
• Symptoms:
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Pain
Abnormal limb positioning
Decreased ROM
Edema
Ecchymosis
Crepitus
Refusal to play with extremity, guarding
Common Fractures in Children
• Complete- break across
entire bone
• Spiral- twisting
• Greenstick- compression
• Comminuted- fragments
• Open- through skin
• Closed- not through skin
Management
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Cast
Surgery
Pins and external devices
Traction- used to align bone
– Skin
• Pull is applied to the skin and muscle
– Skeletal
• Pull is applied to the bone pins
Management
• Prevention of complications
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Infection
Neurovascular injury
Compartment Syndrome
Immobility
Malignment
Growth and Development issues
Cast Care in Children
observe for swelling, pain, discoloration,
movement, loss of pulses
keep extremity elevated for 1st day
keep cast free of foreign objects
cast becomes part of body, fear removal
relate it to a haircut, doesn’t hurt
“tickly” sensation, extremity may become
hot from vibrating cast cutter
Scoliosis
• Most common type of spinal deformity,
girls 5:1 ratio
• Lateral curvature of spine
• Can be congenital or develop in infancy
or childhood
Dx: by observation
• All children screened in 5th grade
• Ill fitting clothes
• Uneven shoulders, scapulae, hips
• Scoliometer: degree of curvature
Treatment
• Mild
– Life Long monitoring
• Moderate
– Bracing
– Exercises to improve posture and flexibility
– Electrical Stimulation to back muscles
Treatment for Severe
• Milwaukee brace worn 16-23 hours/day
• Surgical correction: spinal realignment &
straightening (Harrington Rod)
• Nursing Care
– Log Roll
– Skin Care
– Circulation and Neuro status
Osteogenesis Imperfecta
• Connective tissue disorder, leads to fragile
bone formation
• Causes recurrent pathological fxs
• Will not have normal growth in height
2 types:
Severe autosomal dominant form
• Infant born with fxs from birth
Autosomal recessive
• Occurs later in life, associated deafness and
dental deformities
Goal: protect from trauma
• Reduce the number of fractures
• Early intervention
– Splints, Braces, Surgical Rods
– Handle child gently
– Childproof home
Osgood-Schlatter Disease
• Thickening &
enlargement of tibial
tuberosity, results
from microtrauma
(sports-related)
• Bilateral knee pain
exacerbated by
running, jumping,
climbing stairs
Treatment:
• Self-limiting
condition: rest, ice,
heat, NSAIDs
• Immobilization of
limb may be
necessary
Osteomyelitis
• Bacterial infection of bone
• Can follow open fractures, burns,
skin abscess, foreign body
Signs and Symptoms
• Pain, warmth, tenderness, limited
ROM localized to the area of
infection
• In younger child- more subtle
symptoms, irritability
Osteomyelitis
• Dx: increased WBC’s, sed rate,
positive blood culture, on MRI bone
purulence, edema
Treatment:
• 4-6 weeks of ABX (PICC line)
• Limit weight bearing on extremity
Muscular Dystrophy
• Inherited disease with progressive
deterioration of muscle cells
• Causes progressive muscle weakness
and atrophy
• Several different types
• All differ by age of onset and severity
Duchenne’s Muscular Dystrophy
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Most common type
Sex-linked recessive, boys, s/s by age 3
Will meet motor milestones, but later
Age 3 see waddling gait, difficulty
climbing stairs
Gower’s Sign: press hands against
ankles, knees & thighs to stand up
Duchenne’s Muscular Dystrophy
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Speech & swallowing become impaired
More pronounced muscle weakness (scoliosis)
Wheelchair by junior high
Tachycardia
Pneumonia
Heart failure age 20
Treatment:
• Maintain ambulation & independence
• Muscular Dystrophy Association, mdausa.org
Juvenile Rheumatoid Arthritis
• Chronic inflammation of synovium with eventual erosion
of articular cartilage
• Cause is autoimmune
• + ANA (antinuclear antibodies) and + RF
(rheumatoid factor)
• Peak: 1-3 years or 8-12 years, girls affected
more
• Follows one of three clinical courses
• Systemic:elevated temperature, rash, any
# of joints affected
• Pauciarticular: involves 4 or less joints,
usually large joints
• Polyarticular: involves 5 or more joints,
smaller joints or weight bearing joints
Clinical manifestations
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Increased WBC’s & sed rate
Stiffness in AM
Swelling
Tenderness
Painful to touch
Warm to touch, seldom red
Loss of motion
Juvenile Rheumatoid Arthritis
Goals of care:
1. Maintain joint fx (splints, ROM)
2. Prevent physical deformities
3. Relieve symptoms (pain &
inflammation)
• NSAID’s (aspirin, ibuprofen, naproxen)
• SAARD’s Slower Acting Antirheumatic
Drugs(gold, D-penicllamine)
Nursing Care
• Facilitate medication compliance
• Encourage child to be as independent as
possible
• Moist heat (bath or whirlpool)
especially in morning
Most common complications:
 severe hip involvement with loss of
function
 possible blindness r/t iridocyclitis
(inflammation of iris & ciliary body)
Case Study
• A newborn is found to have Congenital hip
dysplasia prior to discharge. You will be the
nurse caring for this baby and new mother
after discharge from the nursery and will be
admitting the infant to the pediatric unit.
• What assessment findings would you expect
in the newborn?
• How will this condition be treated?
What teaching needs to be completed with the
parents of this newborn?
• The parents ask you about what they can
expect regarding long-term consequences.
How should you respond?
A 3-year-old child is suspected of having Duchenne’s
muscular dystrophy. Which of the following
assessment findings by the nurse would support
this diagnosis?
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A history of delayed crawling
Outward rotation of the hips
Difficulty climbing stairs
Wasted muscle appearance
A child is admitted to the hospital with a
diagnosis of rule out osteomyelitis. Which of
the following serum laboratory values noted
by the nurse supports this diagnosis?
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Decreased WBC
Positive Blood Cultures
Increased HCT
Increased BUN
An adolescent diagnosed with idiopathic
structural scoliosis describes all of the
following symptoms. Which one would the
nurse conclude is not associated with this
diagnosis?
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Back pain
Skirts that hang unevenly
Unequal shoulder heights
Uneven waist angles
A 4-year-old child with osteogenesis imperfecta is
admitted to the hospital unit for an unrelated
condition. The nurse determines that which nursing
diagnosis has the highest priority for this child?
1. Impaired skin integrity related to cast
2. Pain related to fractures
3. Risk for injury related to disease state
4. Disturbed body image related to short stature
• Which item should the nurse remove from the
bedside table of a 4-year-old child who has
just been placed in bilateral long leg casts?
1. Legos
2. Etch-a-sketch
3. Fireman’s hat
4. Coloring book