Transcript Peds Musculoskeletal

Highlights of Chapter 54 and 55
Musculoskeletal System
Neuromuscular or Muscular
Dysfunction
Index of suspicion on
Child Abuse
Injuries in various stages
Accident description does not fit the injury
Blamed on sibling
Activity NOT age appropriate
Hesitancy to seek medical attention
Bruising in unusual location
Shaken Baby Syndrome
Shaken Baby Syndrome
unable to turn head
extreme irritability
feeding problems or
decreased appetite
inability to suck or
swallow
vomiting
lethargy or poor muscle
tone
inability to follow
movements with eyes
no smiling or
vocalization
rigidity
seizures or convulsions;
pale or bluish skin
coma or loss of
consciousness
difficulty breathing
dilated pupils
blood spots/pooling of
blood in eyes
bruises on shoulders,
neck, ribs, upper arms,
arms, wrists
Shaken Baby Syndrome
SBS occurs when a frustrated caregiver
loses control and shakes a young child,
causing permanent brain damage or
death.
The outcomes for survivors typically
include cerebral palsy like damage,
blindness, deafness, seizures, and
learning/behavioral difficulties.
More Signs and Symptoms of
Child Abuse
A Pediatric Injury Scenario
An eight year old boy is brought to the ER
where you work with a swollen right wrist.
He fell on his outstretched hand when
jumping from the tire swing on the big tree
in the neighborhood. It will be at least 2
hours before the doctor will see him, what
assessments should you perform and what
first aid can you give him?
Scenario Continued
Your eight year old patient’s hand is cool to
touch, the capillary refill is poor and he has
poor sensation to his thumb and index
finger? What would be your best nursing
action?
Scenario Continued
Your patient’s pain reports his pain at a 5 on
a scale of one to ten. His pulsation to the
wrist is good, sensation, color and capillary
refill and movement to the fingers is
normal. What measures would you take
until this patient is able to be seen?
Therapeutic Management
of Soft Tissue Injuries
RICE and ICES
Rest the injured part
Ice Immediately (max 30 min at a time)
Wet elastic bandage for compression
Elevation of the extremity
Immobilization and support (casts or
splints as appropriate to injury)
Fractures
Common injury in children
Rare in infants, except with MVC
Clavicle most frequently broken bone in
childhood, especially in those less than
10 years
School age: bike, sports injuries
Clinical Manifestations of
Fracture
Generalized swelling
Pain or tenderness
Diminished functional use
May have bruising, severe muscular
rigidity, crepitus
Refusal to walk or crawl
Also see emergency care of fx on
1809
Epiphyseal Injuries
Weakest point of long bones is the
cartilage growth plate (epiphyseal plate)
Frequent site of damage during trauma
May affect future bone growth
Treatment may include open reduction
and internal fixation to prevent growth
disturbances
Assessment of Fractures:
The 5 P’s
Pain and point of tenderness
Pulse—distal to the fracture site
Pallor
Paresthesia—sensation distal to the
fracture site
Paralysis—movement distal to the
fracture site
DDH
Clinical Manifestations of DDH
Infant
Shortened limb on affected side
 Restricted abduction of hip on affected side
 Unequal gluteal folds when infant prone
 Positive Ortolani test
 Positive Barlow test

Barlow and Ortalani
Galeazzi
Pavlik Harness and Spica Cast
Therapeutic Management of
DDH
Importance of early intervention
Newborn to 6 months: Pavlik harness for
abduction of hip
Ages 6 to 18 months: dislocation unrecognized
until child begins to stand and walk; use traction
and cast immobilization (spica)
Older child: operative reduction, tenotomy,
osteotomy; very difficult after 4 years
DDH references
http://www.massgeneral.org/ortho/Hip_Dys
plasia.htm
Bryant’s Traction
Modified Bryant’s Traction
Caring for child in modified
Bryant’s Traction
1.Correct positioning and alignment.
2. Neurovascular checks
3. Be sure the weights hang freely.
4. Remove Ace Wraps daily to check skin.
5. Time out for feeding and cuddling. Aim
for 16 to 20 hours a day in traction.******
Maintaining Traction Tips
a.
b.
c.
d.
e.
f.
g.
h.
Traction cords aligned in each pulley;
Cords not stretched and frayed;
Knots tied tightly and secured with tape;
Cords hanging free of bed and floor;
Weights hanging free of bed and floor;
Correct amount of weights hanging;
Spreaders, foot plates, splints not touching end
of bed;
Bed linen not interfering with line of traction
Russell Traction
90/90 Skeletal Traction
Nursing Care of Child in Traction
What are the areas of concern that must be
addressed in the care of a child in traction?
Areas of Nursing Concern
Osteomyelitis
Bone infection; may develop into septic joint
most common organisms Staphylococcus aureus
and Hemophilus influenzae
Common site for infants: hip
Sx: pain decreased range of motion refusal to bear
weight
Dx: Elevated WBC and sed rate; X ray, blood
cultures
Rx: 4-6 week of antibiotics; surgery
Osteomyelitis etiology
Direct inoculation of bone during trauma,
puncture or surgery
Preexisting infection spreads to bone

Hematogenous osteomylelitis
Source may be furuncles, skin infections, URI,
abscessed teeth, pyelonephritis
Any organism can cause osteomyelitis
Infective emboli travel to arteries in bone
metaphysis, causing abscess formation and bone
destruction
Osteomyelitis; manifestations
Page 1829
Fever
Bone pain
Swelling
Erythema
Guarding of extremity
Inability to support
weight
Asymmetric
movement
Movement of
adjoining joint
restricted
Nursing Considerations
Complete bed rest and immobility of limb
Pain management concerns
Long-term IV access (for antibiotic
administration)
Possible open wound care
Nutritional considerations
Long-term hospitalization/therapy
Psychosocial needs
Physical therapy once bone has healed enough to
bare weight
Medical Management
of Osteomyelitis
Prompt, vigorous IV antibiotics for
extended period (4-8 weeks or up to
several months)
Naficillin, vancomycin, clindimycin
 Cefotaxime, ceftriaxone

Monitor hematologic, renal, hepatic
responses to treatment
Rx continues until ESR returns to normal
Septic Arthritis
Also called suppurative, pyogenic, and purulent
arthritis
May result from extension of soft tissue infection
May involve any joint, but most common in hip,
knee, shoulder
Usually involves only one joint
Infants with osteomyelitis are susceptible to
septic arthritis
Therapeutic Management and
Nursing Considerations
Diagnosis made from blood culture,
joint fluid aspirate, and x-rays
Medical treatment is drainage of joint
and at least 3 weeks of antibiotics
until the ESR and CRP normalize
Nursing care is similar to
osteomyelitis
Signs, Symptoms, Manifestations
of Septic Arthritis
Fever, malaise
Joint is warm, tender, painful, swollen
May be comfortable if holding still but has pain
on passive ROM; refuses to move that joint.
Holds joint in position that maximizes
intracapsular volume.
Fever, leukocytosis, increased ESR, CPR
Septic Hip in an infant
http://www.emedicine.com/orthoped/topic438
.htm#target1
Legg-Calve Perthes Disease
Avascular necrosis of the femoral head
Boys 5-15 years of age; ages vary
Tx: keep femoral head deep in socket and
avoid weight bearing; bed rest; traction
Goal: to encourage as near as normal shape
to the femoral head and acetabulum
Legg-Calve Perthes Disease
Pain varies
Limp
Decreased ROM
Internal rotation
 abduction

Atrophy of thigh muscle
Leg length inequality
Legg-Calvé-Perthes Disease
Pathophysiology: cause is unknown but
involves disturbed circulation to the femoral
head with ischemic aseptic necrosis
After resolving may have normal femoral
head or may have severe alteration
Clinical Manifestations
Insidious onset, may have history of limp,
soreness or stiffness, limited ROM, vague
history of trauma
Pain and limp most evident on arising and
at end of activity
Diagnosed by x-ray
Osteosarcoma and
Ewing’s Sarcoma
School age through adolescence
Sx: pain/swelling/mass/pathological
fractures/lymphadenopathy
Rx
Osteosarcoma: radical resection/amputation
followed by chemo
 Ewing’s: chemo and radio therapy and possible
resection amputation

Rhabdomyosarcoma
Malignant neoplasm originating from
undifferentiated mesenchymal cells in
muscle, tendon, bursa, and fascia or in
fibrous, connective, lymphatic, or
vascular tissue
Name reflects tissue of origin
Myosarcoma (myo—muscle)
 Rhabdomyosarcoma (rhabdo—striated)

Potential Sites of
Rhabdomyosarcoma
Orbit
Nasopharynx
Paranasal sinuses
Middle ear
Retroperitoneal area
Perineum
Diagnostic Evaluation of Tumor
Signs/symptoms depend on site of tumor and
compression of adjacent tissues
Tumor in orbit—symptomatic early in course of
disease leads to rapid diagnosis and improved
prognosis
Tumor in retroperitoneal area—minimal
symptoms until tumor large and invasive
Many symptoms vague and common to childhood
maladies (e.g., earache)
Juvenile Rheumatoid Arthritis
Systemic
Polyarticular, rheumatoid factor positive
Polyarticular, rheumatoid factor negative
Pauciarticular
Systemic Onset JRA
spiking fevers, several times day
Red rash on the trunk and extremities.
Arthralgia
myalgia.
May be complicated with pericarditis,
anemia, hepatosplenomegaly.
Polyarticular
Affects at least 5 joints.
Both large and small joints can be involved,
often in symmetric bilateral distribution.
Severe limitations in motion are usually
accompanied by weakness and decreased
physical function.
Anemia, fatigue, malaise
Low grade intermittent fever
Pauciarticular JRA
4 or fewer joints.
Larger joints (eg, knees, ankles, wrists) are
affected.
Painless joint swelling
Low grade fever
Malaise, anemia
Uvetitis, iridocyclitis (may develop glaucoma)
May develop


hepatosplenomegaly
Ankylosing spondylitis
JRA medical Rx
NSAIDs
Gold Salt injections
Methotrexate
Methoprednisolone
Entanercept (Enbrel)
Nursing Care for JRA Patient
Focus on education
Medications and SE
Pain management
NSAIDs
 Warm compresses and baths
 Physical therapy

Joint mobility and muscle strength
Splints to prevent contractures
Scoliosis
S shaped curvature of the spine
More frequently in girls
Functional (poor posture)
Structural (fixed)
Below 20 degree, no treatment
20-40degree, Milwaukee brace
40 degree and up, spinal fusion with
Harrington Rods
Scoliosis Screening
Scoliosis; Post Surgical Care
Monitoring for bleeding
Monitoring neurovascular
compromise
Monitoring for edema
Fluid needs, IV
Log rolling
Pain management (PCA)
Possible gastric
decompression with
NG tube
Catheter care
Pulmonary care
PT
May need blood
transfusion
Congenital Clubfoot
Talipes varus: inversion or bending
inward
Talipes valgus: eversion or bending out
Talipes equinus: plantar flexion with toes
lower than the heel
Talipes calcaneus: dorsiflexion with toes
higher than the heel
Club foot happens at the ankle
Club foot care
Serial casting every few days to 1-2 weeks
Surgery needed if failure to align by 3
months
Casts and then braces needed after surgery
Metatarsus Adductus
Also called metatarsus varus
Most common congenital foot deformity
Often result from abnormal position in uterus,
usually evident at birth
Angulation at tarsometatarsal joint
“Pigeon-toed” gait
Treatment: PT, orthotics
Serial casting if PT and orthotics not effective
At the tarsometatarsal joint
Assessment of alignment
Internal Tibial Torsion
Internal tibial torsion refers to an
inward or medial torque of the
tibial shaft producing an inward
rotation of the ankle joint relative
to the knee joint.
Tibial Torsion and Femoral
Anteversion
Muscular Dystrophies (MDs)
Largest group of muscular diseases in
children
All have genetic origin with gradual
degeneration of muscle fibers,
progressive weakness, and wasting of
skeletal muscles
All have increasing disability and
deformity with loss of strength
Muscular Dystrophy
Duchenne’s or Becker
Delayed motor development
Initial hypertrophy of calf muscles
Progressive weakness
Clumsiness, falling, waddling gait
Contractures of hip and ankles
Gower’s maneuver
Lordosis
Sex linked disorder only in boys
Gower’s Maneuver
Characteristics of DMD
Onset between ages 3 and 5 years
Progressive muscle weakness, wasting, and
contractures
Calf muscles hypertrophy in most patients
Progressive generalized weakness in
adolescence
Death from respiratory or cardiac failure
Diagnostic Evaluation of DMD
Suspected based on clinical appearance
Confirmation by EMG, muscle biopsy, and
serum enzyme measurement
Serum CPK and AST levels high in first 2
years of life, before onset of weakness;
levels diminish as muscle deterioration
continues
Clinical Manifestations of DMD
Waddling gait, frequent falls, Gower sign
Lordosis
Enlarged muscles, especially thighs and
upper arms
Profound muscular atrophy in later stages
Mental deficiency common
Therapeutic Management of DMD
No effective treatment established
Primary goal: maintain function in
unaffected muscles as long as possible
Keep child as active as possible
ROM, bracing, performance of ADLs,
surgical release of contractures prn
Genetic counseling for family
Nursing Considerations of DMD
Helping child and family cope with chronic,
progressive, debilitating disease
Design program to foster independence and
activity as long as possible
Teach child self-help skills
Appropriate health care assistance as child’s
needs intensify (home health, skilled nursing
facility, respite care for family, etc.)
Cerebral Palsy
Non progressive motor disorder that affect
the motor centers of the brain
Frequently accompanied with mental
retardation
Four types: spastic, athetoid, ataxic, mixed
Types of Cerebral Palsy
Spastic, relates to spasm with movement
very “tight” muscle tone
Athetoid, relates to involuntary movements”
Ataxic, relates to uncoordinated movements
Mixed, usually a combination of spastic and
athetoid
Symptoms of Cerebral Palsy
Poor head control
Irritability
Floppy, limp baby
Arching or pushing away
Hypertonicity, spasticity
Feeding difficulties
Persistent infantile
reflexes
Delayed developments
Early hand preference
Drooling
Speech difficulty
Involuntary purposeless
movements
Lack of muscle
coordination
Using only one side of
body
Gait changes
Scissoring or extension of
legs
Possible Motor Signs of CP
Poor head control after age 3 months
Stiff or rigid limbs
Arching back/pushing away
Floppy tone
Unable to sit without support at age 8
months
Clenched fists after age 3 months
Possible Behavioral Signs of CP
Excessive irritability
No smiling by age 3 months
Feeding difficulties
Persistent tongue thrusting
 Frequent gagging or choking with feeds

Nursing considerations; CP
Skin care
Prevention of deformities
Nutritional
Respiratory
Developmental/Educational
Communication
Menigomyelocele
Comparison with Meningocele
Midline Defects in General
Refer to page 1849 Figure 55-5
Pictures on page 1850
Myelomeningocele problems
Infection
Possible hydrocephalus
Decreased sensation and mobility to LE
Orthopedic
Neuropathic bladder dysfunction
Bowel control
Myelomeningocele problems
Infection
Possible
hydrocephalus
Orthopedic
Neuropathic bladder
dysfunction
Bowel control
Prevention
.4 mg folic acid daily in women of
childbearing age
4 mg in women who have had a history of
neural tube defect one month before a
planned pregancy and through the first
trimester
Immediate nursing care
Efforts to keep the membranous cyst intact
until surgical intervention
Infant is usually in an incubator or warmer
Frequent moistening of dressings to keep
membrane moist.
Careful cleansing of membranes if soiled
No rectal temps
Prone position with hips slightly flexed
Immediate care continued
Observe for infection
Observe for urinary retention, may need
CIC
Keep skin and cyst clean of bowel
movements
General skin care and gentle range of
motion to lower extremities
Latex free products
Post op care
Observe for signs of leaking from surgical
area
Prone position. May use side lying unless
there are concerns on hip dysplasia
May have splints for contractures
Feeding is begun as soon as possible
Head circumference monitoring
Latex free products
Long term care
Assessment of neurological/musculoskeletal
deficits and targeted care
Prevention of contractures and
developmental dysplasia of the hip
Continued observation for hydrocephalus
Management of urinary dysfunction and
bowel dysfunction
Neurogenic Bladders
90% of infants with myelomeningocele have
normal renal function but 50% of them have
deterioration of renal function over time.
Problems and extent of problems vary
Goals of care:



Store urine at a low safe pressure to protect kidneys
Empty bladder completely to prevent urinary stasis and
infection
Prevent leaking and incontinence
Neurogenic bowels
Poor or weak bowel peristalsis and motility
Most patients are managed with stool
softeners, high fiber, laxatives and enemas
Some patients are opting for undergoing the
Malone Antegrade Continence Enema
procedure
MACE
References
http://www.pediatricurologyinformation.co
m/meningomyelocele/topic.html
http://www.ich.ucl.ac.uk/factsheets/families
/F050008/index.html
http://www.emedicine.com/orthoped/topic5
57.htm