Transcript Pediatric Chapter 34: Musculoskeletal Alterations

N124IN
Spring 2013
Anatomy and Physiology
 Children’s bones contain large amount of
cartilage
 More flexible and porous

Bones bend rather than break
 Periosteum is thicker, more vascular, stronger,
tougher
 Bones absorb more energy prior to breaking
 Periosteum is more metabolically active
 Quicker healing and remodeling
Anatomy and Physiology, cont.
 Epiphyseal growth plate
 Thin cartilage layer
 Controls bone growth
 Epiphyseal side of growth plate: new cartilage is
laid down
 Metaphyseal side of growth plate: cartilage
converted to bone
 Fracture in this area could result in growth
complications
 Growth hormone: increases bone length
Anatomy and Physiology, cont.
 2nd month of life
 Bone formation begins
 Birth
 Ossification is almost complete
 2-3 months of age
 Posterior fontanel fusing
 16-18 months of age
 Anterior fontanel fusing
 Maturation and bone modeling continues to occur
until 21 years
Sports and Recreation Injuries
 Boys are 6x more likely to be hospitalized
than girls for sports injuries
 Blunt trauma to chest wall is 2nd leading
cause of death in athletes 7-16 years old
Sports and Recreation Injuries,
cont.
 Overuse injury: mictrotraumatic damage to a
bone, muscle, or tendon which has been used
repeatedly without enough time to heal or
repair itself
 1-pain after physical exertion
 2-pain during physical exertion; no performance
restriction
 3-pain during performance; pain restricts
performance
 4-chronic pain, even at rest
 Compartment Syndrome
Sports and Recreation Injuries,
cont.
 Sports injury prevention
 Understanding risk factors
 Proper coaching/supervision
 Protective equipment
 Safe playing conditions
 Adequate conditioning
 Sufficient warm-ups, cool-downs
Sports and Recreation Injuries,
cont.
 Anabolic steroids
 Signs/Symptoms
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Temper tantrums
Personality changes
Decreasing body fat
Increasing acne
Stunted growth
Decreased sperm production
Irreversible breast enlargement in males
LDL increase
HDL decrease
Soft-Tissue Injuries
 Incidence and Etiology
 Sprains: forceful sports activities

Football, wrestling
 Strains: excessive physical activity or effort

High action sports, lifting
 Muscle contusions: contact and collision
type sports

Football
Soft-Tissue Injuries, cont.
 Pathophysiology
 Sprain
 Due to twisting or turning injury to joint
 Ligament stretches or tears
 Strain
 Excessive stretching or tearing of muscle or tendon
 Contusion
 Damage to soft tissues, subcutaneous structures, small
vessels and muscles
 Skin integrity not disrupted
Soft-Tissue Injuries, cont.
 Clinical Manifestations
 Sprain

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Mild sprain: local tenderness, minimal
swelling, no joint instability
Moderate sprain: partial tearing of ligament,
partial joint instability, immediate pain,
swelling, ecchymosis
Severe sprain: less pain than moderate, diffuse
swelling, severe ecchymosis, complete tearing
of ligament, joint instability, loss of function
Soft-Tissue Injuries, cont.
 Clinical Manifestations, cont.
 Strain
 Mild muscle strain: microscopic tear in
muscle, local tenderness, minimal
swelling/ecchymosis
 Moderate strain: more muscle fibers are torn,
“pop” felt, small defect palpated
 Severe strain: popping/snapping sound,
rupture of muscle, severe pain, marked
ecchymosis, loss of function
Soft-Tissue Injuries, cont.
 Clinical Manifestations, cont.
 Contusion
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Soft tissues and small blood vessels tear
Inflammatory response
Ecchymosis
Pain to move injured body part
Soft-Tissue Injuries, cont.
 Diagnosis
 Clinical manifestations
 Radiographic studies
Soft-Tissue Injuries, cont.
 Treatment
 RICE (rest, ice, compression, elevation)
 Pain control
 Bandages, splints
 Casting, bracing
 Surgery
 Strengthening/stretching exercises
 Physical Therapy
Soft-Tissue Injuries, cont.
 Nursing Management
 Monitoring neurovascular status
 Pain management
 Elevate affected limb
 Activity restriction
 Help patient return to previous
functioning levels
Soft-Tissue Injuries, cont.
 Family Teaching
 Rest
 Elevation
 Ice
 Crutch-walking principles
 Activity restrictions
Dislocations
 Incidence and Etiology
 Occurs when force of stress on ligament is
great enough to displace a bone from its
normal articulation within a joint
 Fingers and elbows most common in
children
 Pathophysiology
 Ligament and joint capsule damage
Dislocations, cont.
 Clinical Manifestations
 Pain
 Immobility
 Joint contour change
 Extremity length change
 Diagnosis
 Physical Assessment
 Radiographs
Dislocations, cont.
 Treatment
 Closed manual reduction
 Splint, sling, cast
 Nursing Management and Family Teaching
 Pain management
 Neurovascular status assessments
 Educate family on caring for equipment
and how to prevent reinjury
Fractures
 Incidence and Etiology
 Upper extremity fractures
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Finger/hand
Clavicle
Proximal humerus
Elbow
Supracondylar fractures of humerus
Distal radius fracture
Fractures, cont.
 Incidence and Etiology, cont.
 Lower extremity fractures
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Pelvic and tibial eminence avulsion fractures
Femoral shaft
Metatarsal/phalanx
Tibia fractures
Ankle
Femoral neck
Fractures, cont.
 Pathophysiology
 Simple (closed) vs. compound (open)
 Classified based on type of break
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Transverse
Oblique
Spiral
Greenstick
Buckle (torus)
Fractures, cont.
 Pathophysiology, cont.
 Epiphyseal growth plate injuries
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Epiphyseal growth plate vulnerable to injury
Salter fracture
Can result in growth disruption, arrest,
uneven growth
Fractures, cont.
 Pathophysiology, cont.
 Physiologic process after fracture occurs
Inflammatory
 Reparative
 Bony callus formation or ossification
 Bone remodeling

Fractures, cont.
 Clinical Manifestations
 Pain/tenderness
 Edema
 Decreased range of motion
 Extremity deformity
 Bruising
 Muscle spasms
 Crepitus
Fractures, cont.
 Diagnosis
 Signs/Symptoms
 History
 Physical examination
 Radiographs
 Ultrasound
 CT
 MRI
Fractures, cont.
 Treatment
 Closed reduction
 Open reduction
 Slings/braces/splints
 Casts
 External Fixation
 Internal Fixation
Fractures, cont.
 Treatment, cont.
 Traction

Skin traction
 Buck extension
 Short-term continuous immobilization, treat contractures
and muscle spasms before surgery
 Bryant traction
 Developmental hip dysplasia, femur fractures
 Russell traction
 Reduce and immobilize hip fractures, tibial plateau
fractures, femur fractures
 Cervical skin traction
 Mild cervical trauma without spinal cord injury, cervical
strains and sprains, whiplash, spastic neck contractions,
degenerative spine and disc disorders, arthritis, subluxations
Fractures, cont.
 Treatment, cont.
 Traction, cont.

Skeletal Traction
 Skeletal (Crutchfield or Garner-Wells) tong
 Stabilize fractures or displaced vertebrae in cervical or high
thoracic spinal areas
 Balanced suspension
 Femur, hip, tibia fractures
 90/90 Femoral traction
 Complicated femur fractures
 Dunlap or sidearm traction
 Fractured elbow or dislocations of elbow, humerus, shoulder
Fractures, cont.
 Complications
 Malunion
 Compartment syndrome
 Growth disturbances
Fractures, cont.
 Nursing Management
 Immobilization
 Neurovascular status assessments
 Assess and manage pain
 Be aware of psychological responses
 Continue schoolwork
 Promote mobility when able to do so
 Encourage visits from family and friends
Fractures, cont.
 Family Teaching
 Initially: hospital routine, casts, traction devices,
mobility restrictions
 Before discharge: cast care, mobility restrictions
 Identify any modifications for home or school
environment
 Referral to social services and physical therapy
 Safety equipment
Osteomyelitis
 Incidence and Etiology
 Routes
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Hematogenous: infection starts elsewhere in
body and spreads to bone via bloodstream
Exogenous: bone is infected from external
factor
 Penetrating wounds, open fractures,
contamination in surgery, trauma
Osteomyelitis, cont.
 Pathophysiology
 Organisms travel to arteries in bone
metaphysis
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Inflammation, hyperemia, edema
Pus increases pressure
 Elevation/bump of periosteum
Osteomyelitis, cont.
 Clinical Manifestations
 Infant: irritability; diarrhea; poor feeding
 Toddlers: pseudoparalysis; pain with passive
movement; limping
 Older children: Pain that is constant,
localized, and increases with
movement/palpation; restricted movement;
swelling; heat; red skin; fever; night sweats;
weight loss; anorexia; systemic fever
Osteomyelitis, cont.
 Diagnosis
 History and physical
 Radiographs
 Lab tests (CBC w/ differential, ESR, C-
reactive protein, blood cultures)
 Ultrasound
 Bone scanning
 CT
 MRI
Osteomyelitis, cont.
 Diagnosis, cont.
 Osteomyelitis diagnosis requires at least 2 of
the following:
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Aspiration of pus from site
Positive bone or blood culture
Classic signs (localized pain, swelling, increased
skin temperature, limited joint mobility)
Positive imaging study (radiography, bone scan,
CT, MRI)
Osteomyelitis, cont.
 Treatment
 Antibiotics
 Splint limb
 Surgery
Osteomyelitis, cont.
 Nursing Management
 Pain control
 Splint/traction care
 Proper alignment; move limb cautiously
 Neurovascular/skin assessments
 Administer antibiotics
 Family Teaching
 Antibiotics
Septic Arthritis
 Incidence and Etiology
 Haemophilus influenzae type b
 Staphylococcus aureus
 Pathophysiology
 Inflammation in synovial membrane

Pus forms, causing the synovial fluid to
thicken
 Articular cartilage destroyed
 Scar tissue replaces cartilage

Joint mobility affected
Septic Arthritis, cont.
 Clinical Manifestations
 Nonweight bearing on affected side
 Painful, limited range-of-motion
 Warmth or redness over area
 Fever
 Toxic (sickly) appearance
 Joint swelling
 Increased WBC count
Septic Arthritis, cont.
 Diagnosis
 Lab tests: CBC w/ differential, ESR, CRP
 Joint fluid aspiration/culture
 Radiography, ultrasound, bone scan
 Treatment
 Needle aspiration/open surgical drainage
 Antibiotics
 Immobilize joint
 Pain relief
Septic Arthritis, cont.
 Nursing Management
 Maintain comfort
 Administer antibiotics
 Avoid complications related to impaired
mobility
 Family Teaching
 Antibiotic therapy
 Enforcing bedrest