Musculoskeletal Alterations NUR 264 – Pediatrics Angela Jackson, RN, MSN.
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Transcript of Musculoskeletal Alterations NUR 264 – Pediatrics Angela Jackson, RN, MSN.
Musculoskeletal Alterations
NUR 264 – PediatricsAngela Jackson, RN, MSN
Differences between Children and Adults
Bones contain a large amount of cartilage, making them more flexible and less likely to break
Periosteum is stronger and tougher Bones heal more quickly because the bones are
still growing: The younger the child, the faster the bone heals
Epiphyseal growth plate Bone injury, especially at the growth plate, is more
common than sprains, because soft tissue attachments are stronger in children
Types of Fractures
Closed or Simple fracture: The skin over the broken bone remains intact
Open or Compound fracture: The broken bone protrudes through the skin
Transverse fracture: Occurs at a right angle to the long axis of the bone
Oblique fracture: A slanting or diagonal break across the bone
Spiral fracture: circular and twists around the bone shaft Greenstick fracture: A break through the periosteum and
bone on one side while the other side only bends
Fractures
Salter-Harris Classification of Epiphyseal injuries
Type I: Separation of the epiphysis from the metaphysis. Usually does not affect growth. No fracture of the bone.
Type II: Separation of the epiphyseal growth plate and fracture of the metaphysis. Usually does not affect growth.
Type III: Fracture of the epiphysis extends into the joint. If reduced properly, does not usually affect growth.
Type IV: Fracture of growth plate, epiphysis, and metaphysis. Open reduction and internal fixation usually necessary to prevent growth disturbance
Type V: Crushing injury of the epiphyseal growth plate. Results in premature closure of the plate on one side with growth arrest.
Salter-Harris Classification
Traction
The application of pulling force to a body part against a countertraction pull exerted in the opposite direction
Used to treat a variety of injuries– Spine– Long bones of the upper and lower extremities– pelvis
Traction
Straight traction:– Child’s body weight serves as the countertraction
Balanced Traction: – the body part is suspended by a sling and the
countertraction as well as the primary traction is provided by pulleys and weights. The angle of the involved joint and the angle formed by the placement of the pulleys on the bed determines the direction of the pull or force
Primary Purposes of Traction
Immobilizes the fracture Decreases muscle spasms Realigns and positions bone ends while
healing takes place Prevents further soft tissue damage
Complications of Fractures
malunion compartment
syndrome growth disturbances
Nursing Considerations
Neurovascular status Pain Respiratory status Cardiovascular status Immobilization Skin Integrity Nutrition Elimination
Nursing Management
Monitor for appropriate alignment, and ensure that weights hang freely
Perform Neurovascular checks every hour X 24 hrs, then q4-8hrs Maintain skin integrity Promote pulmonary hygiene Promote adequate fluid and fiber intake to prevent constipation Provide stimulation appropriate for developmental age to promote
growth and development Encourage limited mobility as permitted Encourage parents to hold child as permitted Avoid pressure on the popliteal space to prevent nerve damage Provide adequate pain relief
Infectious Disorders of the Musculoskeletal System
Osteomyelitis
Osteomyelitis
Infection of the bone caused by a microorganism May be bacterial, viral or fungal Bacteria may be introduced through the blood
stream from an infection in another part of the body (endogenous spread) or directly into the bone via a penetrating wound or open fracture (exogenous spread)
More common in children between the ages of 3 and 12
Males are affect 2 to 4 times more often than females
Osteomyelitis: Sources of Infection
Sources of hematogenous spread include
– Acute otitis media– Impetigo– URI’s– Abscessed teeth– Burn infections
Causative Organisms include
– Staphylococci aureus (80 – 90%)
– Haemophilus influenzae– Streptococcus Pneumoniae– Escherichia Coli– Group B streptococci– gram-negative enteric bacilli– Anaerobic bacteria
Osteomyelitis: Pathophysiology
Bacteria travels to the small arteries at the end of the bone
Inflammation with increased blood flow and swelling occurs
The infectious process leads to bone destruction and abscess formation
Increasing pressure as exudate collects and is confined within the bone results in vascular occlusion, ischemia and eventually bone necrosis
Osteomyelitis: Clinical Manifestations
Infants– Irritability– Poor feeding– Failure to move affected
limb– Permanently arrested
bone growth
Children– Constant bone pain– Restricted movement– Swelling– Heat in the affected area– Redness– Fever– Signs and symptoms of
systemic infection
Osteomyelitis: Diagnosis
Lab tests– CBC– C-reactive protein– Sed rate (ESR)– Blood cultures– Wound cultures– Culture of bone aspirate
X-Rays– Routine x-ray of affected
area– Bone scan– X-ray examination of the
affected area will detect bone necrosis ten to fourteen days after appearance of clinical manifestations
Osteomyelitis: Potential Complications
Abscess Joint or bone damage, especially damage to
epiphyseal growth plate Complications affecting the hepatic, renal
and hematological systems (related to high dosages of antibiotics)
Amputation of affected extremity Interference with growth
Osteomyelitis: Treatment
IV broad-spectrum antibiotics for 3 – 6 weeks (may switch to po after adequate response is achieved)
Splinting Surgical drainage and debridement
Osteomyelitis: Nursing Management
Monitor for potential complications– Perform neurovascular checks at least q8hrs– Maintain proper alignment and move the limb cautiously to avoid
further injury to the bone Administer antibiotics as scheduled Assess the site of infection; monitor for edema, redness,
warmth or drainage every 4 hours Monitor white blood cell count and therapeutic medication
levels Maintain splinting if present Use sterile technique for dressing changes Assess for pain, and administer analgesics as prescribed
Muscular Disorders
Muscular Dystrophy
Muscular Dystrophy
A group of inherited diseases affecting the muscle, leading to progressive muscular wasting and degeneration of muscle fibers
It is the largest group of muscle diseases affecting children, and it is genetically acquired
Duchenne’s Muscular Dystrophy is the most common childhood form (x-linked recessive)
– Affects all races and ethnic groups– Affects males almost exclusively– Females may be carriers and pass the defect to their male
children
Muscular Dystrophy: Pathophysiology
Absence of the muscle protein dystrophin, which plays a role in supporting the structure of muscle fibers
Results in degeneration of skeletal muscles that control movement
Fat and connective tissue replace the degenerated muscle fibers
Muscular Dystrophy: Clinical Manifestations
Generalized muscular weakness and muscle wasting – usually appears during the third year of life
Difficulty running and climbing stairs
Tires easily when walking Waddling gait
(Trendelenburg gait)
Lordosis Frequent falls Gower’s sign As disease progresses,
calves, thighs, and upper arms become larger as a result of fatty infiltration (pseudohypertrophy)
Mental retardation is common
Gower’s Sign
Muscular Dystrophy: Diagnosis
Muscle biopsy (identifies presence of fatty tissue)
DNA testing Electromyography (detects decreased
electrical impulses) Elevated serum creatine kinase (enzymes
leak from deteriorating muscles) History and physical findings
Muscular Dystrophy: Treatment
There is no cure for muscular dystrophy. Treatment is supportive and includes:– PT/OT– Braces, wheelchairs– Surgery
Muscular Dystrophy: Potential Complications
Atrophy may develop as a result of immobility Contracture deformities may develop as a result of
immobility and disease Obesity may result from bed rest and immobility Cardiac complications occur lat in disease and may
require a pacemaker Infections, especially respiratory, secondary to weak
muscles of respiration, occur. Even minor infections require prompt treatment to avoid complications or death.
Muscular Dystrophy: Nursing Management
Participation with the interdisciplinary team Respiratory care: teach deep breathing and coughing exercises Maintenance of optimal nutrition Prevention of skin breakdown Maintenance of optimal bowel and bladder function Teach signs and symptoms of infection Encourage independence as long as child is capable. Powered
wheelchairs, special eating utensils, and other assistive equipment is available
Encourage genetic counseling Assist family and child in coping with a fatal disease Teach proper body mechanics and range-of-motion exercises
Musculoskeletal Disorders
Legg-Calve PerthesOsteogenesis Imperfecta
Legg-Calve-Perthes: Pathophysiology
Temporary loss of blood supply to the femoral capital epiphysis, results in avascular necrosis of the femoral head
Unknown cause Occurs in four stages:
– Incipient stage– Necrotic stage– Regenerative stage– Residual stage
Legg-Calve-Perthes: Clinical Manifestations
Intermittent appearance of limp on affected side Mild pain in hip exacerbated by increased activity and relieved
by rest Joint dysfunction and limited range of motion, especially
abduction and internal rotation Stiffness varying from intermittent to constant Limb-length inequality Pain, soreness, and aching; usually worse on rising or at the
end of the day; may be in groin, hip or knee area Tenderness over hip capsule External hip rotation (late sign) Deterioration of the femoral head on x-ray
Legg-Calve-Perthes: Nursing Management
Monitor neurovascular status Encourage meticulous skin care Teach signs of muscle atrophy Teach crutch Walking Encourage non-weight bearing activities Teach safety measures
Legg-Calve-Perthes: Treatment
The main goals of treatment are to keep the head of the femur contained in the acetabulum, to promote healing, and to prevent deformity. This may be achieved through:
– Traction– Braces– Leg casts– Surgery
Legg-Calve-Perthes: Diagnosis
Diagnosed and classified by X-ray Bone scan
Osteogenesis Imperfecta (OI)
Known as brittle bone disease Connective tissue disorder. Occurs in several forms
with variable degree of severity Fractures may result form trauma, but also from
simple walking or pressure of birth Affects boys and girls equally A child with this diagnosis should not be
confused with the child with fractures because of abuse
OI: Pathophysiology
Characterized by disturbed formation of periosteal bone, resulting in formation of pathologic fractures
Normal calcium and phosphorus levels, and abnormal precollagen type I, which prevents the formation of collagen, the major component of connective tissue
Bones consist of large areas of osseous tissue and increased numbers of osteoblasts
OI: Clinical Manifestations
Multiple and frequent fractures, some of which may be present at birth
Limb and spinal column deformities related to multiple breaks
Blue sclera Thin, soft skin with easy
bruising Increased joint flexibility
Weak muscles Short stature Conductive hearing loss May have dentinogenesis
imperfecta: hypoplastic teeth with opalescent blue or brown discoloration
OI: Diagnosis
Collagen studies Prenatally, may be detected by level II ultrasound if
disease is severe
OI: Treatment
Early intervention of fractures Prevention of deformities using splints,
braces, casts and surgery Rod insertion Adequate nutrition including calcium,
magnesium and vitamins
OI: Nursing Management
Maintain a non-judgmental and supportive attitude Handle child gently and teach family to handle child
gently:– Avoid lifting by a single arm or leg– Use a blanket for extra support when lifting and moving– Never hold by ankles when diapering. Gently lift by slipping a hand
under the buttocks Encourage activities the promote growth and
development while maintaining a safe environment Encourage exercise, such as swimming, to improve
muscle tone and prevent obesity Encourage realistic occupational planning Suggest genetic counseling
Any Questions???