Musculoskeletal Disorders

Pediatric Considerations
More Cartilage Rapid Growth

Rapid Healing
Increased Vascular Supply childhood fractures can result in abnormal bone growth

Club Foot

Talipes Equinovarus (TEV)

Most common foot deformity 1/700 live births

Boys affected two times greater than girls

Cause is unknown Deformity is readily apparent at birth

Therapeutic Management
Correction of the Deformity Maintenance until normal muscle balance is regained Avert recurrence of the deformity

Nursing Interventions
Maintain skin integrity Assess circulation distal to the cast Parental Support Facilitate normal development

Congenital Dislocated Hip

Incidence = 10/1000 live births Left hip involved more than right and bilateral (60% versus 20%) 60% of patients are female Caucasians have higher incidence

Clinical Manifestations
Shortening of limb on affected side Unequal gluteal folds (infant prone)

Restricted abduction of hip

Positive Ortolani test

Treatment
0-6 mos = Pavlik Harness worn 23 hours per day

6-18 mos = traction and cast immobilization

Greater than 18 months = surgical correction

Nursing Interventions
Astute assessment for early detection Parent education

Skin Integrity
Parental Support

Legg-Calve-Perthes Disease
Idiopathic avascular necrosis of the femoral head Most commonly affects boys 4-8 years of age

Most affected children have delayed bone age

Cause is unknown Middle childhood = circulation to femoral capital epiphysis can become obstructed more readily than at other ages

Clinical Manifestations
Limp on affected side Leg pain/soreness

Quadriceps muscle atrophy

Pain can be referred to femur and knee Limited range of motion History of trauma

Management
Early recognition and treatment to prevent femoral damage and reducing the risk of degenerative arthritis
Treatment is dependent upon severity of necrosis with the goal of maintaining the spherical shape of the femoral head Early = Rest and non-weight bearing Later = active motion is encouraged by some physicians

Conservative therapy = up to 4 years if needed; bracing

Surgical treatment = reduces treatment time and eliminates difficulty associated with adhering to treatment

Nursing Interventions
Assist in early identification Family education (neurovascular assessments, OT, PT, skin care, ROM, psychosocial support) Facilitate compliance with the treatment regimen; adjusting to bracing and reentry to school Develop a plan for the child who feels well but must have activity restricted

Slipped Femoral Capital Epiphysis (SFCE)

Displacement of proximal femoral epiphysis in a posterior, inferior direction Most common hip disorder of adolescence

Occurs during the growth spurt

More common in males 2:1 over females Idiopathic, but associated with obesity, endocrine disorders, growth hormone therapy, and radiation therapy

Clinical Manifestations
Limp on affected side Pain in Hip

Shortening of lower extremity

Restricted internal rotation on adduction (the leg is externally rotated)

Management
Goals: Avoid avascular necrosis Prevent further slippage Correct the deformity Treatment modality: surgical correction with casting Presurgery = traction and bed rest

Scoliosis
Lateral Curvature of Spine Spinal Rotation Thoracic Hypokyphosis

Scoliosis
Most common spinal deformity Most common during the growth spurt Can be congenital or develop in infancy Commonly idiopathic Can occur in association with other neuromuscular diseases

Clinical Manifestations
Uneven fit of clothing Uneven hem length Shoulder asymmetry Prominent scapula and hip Spinous processes misaligned

Management
Standing Radiographs Bracing Traction Surgical Spinal Fusion

Nursing Interventions
Prevent Neurological Deficits
Promote Mobility Pain Management

Promote Social Interaction

Promote a Positive Body Image Skin Integrity Promote Optimal Nutrition

Juvenile Rheumatoid Arthritis

Inflammatory disease = exact cause unknown
Two peak ages of onset = 1-3 years and Incidence = 4/100,000 8-10 years

Twice as common in females

Pauciarticular = onset in 4 or fewer joints (50% of cases) Polyarticular = onset in 5 or greater joints (40% of cases) Systemic = variable arthritis and systemic effects (10% of cases)

Clinical Manifestations
Stiffness, swelling, loss of motion in affected joint
Synovial thickening Pain/Tenderness

Warm to touch without erythema

Children have NEGATIVE rheumatoid factor in 90% of cases Leukocytosis is present during flares of systemic disease Systemic Disease = fever, maculopapular rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy

Therapeutic Management
No Cure
Goal = preserve joint function NSAIDS

Cytotoxic Drugs (Methotrexate)

Corticosteroids Immune Modulator Drugs

Nursing Interventions
Individualized PT and OT
Nighttime splinting (knees, hands, wrists) Pain Control

Optimize Nutrition
Coordinate immunizations with Rheumatologist Prevent Infection (can exacerbate symptoms) Facilitate success with ADLs (adapt clothing, work with school) Promote physical and psychosocial development Emotional support of family

Osteomyelitis
Infectious process in the bone Twice as common in males Common between ages of 5-14 years Staphylococcus aureus in children over 5 years Haemophilus influenza most common in younger child Exogenous = acquired from outside sources (penetrating wound) Hematogenous = spread from preexisting infection

Clinical Manifestations
History of trauma to affected bone and/or infection
Leukocytosis Elevated Sedimentation Rate

Irritability
Elevated Temperature Local tenderness, swelling, and pain Extremity often held in semiflexion Positive bone cultures

Treatment
IV antibiotic therapy for at least 3-4 weeks Immobilization Surgical intervention

Nursing Interventions
Administer IV antibiotics and monitor for side effects Pain Management Immobilization/Weight bearing restrictions Contact Isolation (open wound) Optimize nutrition (high calorie diet) Extensive family education

Diversional activities
Facilitate development Maintain functioning of non-affected extremities

General Considerations for the Immobilized Child

Skeletal muscle weakness and atrophy Muscles, tendons, ligaments shorten and reduce movement Demineralization of bones (osteopenia and pathologic fractures)

Decreased GI motility
Urinary retention, infection, renal calculi Anxiety related to decreased activity

Sensory deprivation (decreased learning, depression, devo. Delay)

Language delay in children under age 3 Hallucination, disorientation, and regressive behaviors

Nursing Interventions
Frequent position changes/ROM
Antiembolic stockings High-calorie, High-protein diet

Small, frequent feedings

Promote hydration Skin Integrity Promote transportation and exposure to environmental stimuli Promote school activities Behavior modification

Fractures
Apply principles of growth and development when assessing trauma and related fractures Common sites: ulna, clavicle, tibia, femur Signs: site pain, immobility, deformity, edema Treatment: reduction and retention Complications: fat embolism (usually within 3 days), compartment syndrome (common in forearm fractures = early detection, elevate, relieve pain, notify MD)

Cast Considerations
Review Fractures: pg. 1426 Primary use = immobilization

Available in plaster or fiberglass

During application = ensure that nothing is placed under the cast Assess fit of cast

Provide education regarding extremity and cast care

Consider individualized plan related to the injury and cast type

Cast Types
Plaster
Molds easily Heavy Inexpensive 24-48 hours to dry Can not get wet

Fiberglass
Does not mold well 1 hour to dry High cost Water Resistant Not optimal for young children or severe breaks

Types of Casts

Assessment
Pain and Point Tenderness Pallor Pulse Paresthesis Paralysis

Temperature
Capillary Refill

Nursing Interventions
Observe skin
reposition at least q 2 hours protect bony prominances

moisture barrier
assess for objects placed inside cast assess for pressure points around the case Prepare child for cast removal (vibration and heat) Clean skin after cast removal (sebaceous secretions and desquamated skin)

Traction
Provides Rest Prevent or improve contractures

Correct deformity
Treat Dislocation Preoperative and postoperative positioning and alignment

Immobilization

Types of Traction
Manual = applied to body part by hand; placed distally to fracture site (usually done during cast application)
Skin = applied to the skin surface and indirectly to skeletal structures; applied over soft foam backed traction straps to distribute the traction pull (Dunlop, Buck)

Skeletal = applied directly to the skeletal structure by a pin, wire, or tongs inserted into or through the diameter of the bone distal to fracture site (cervical, 90/90 femoral traction)

Nursing Considerations
Understand the therapy (purpose and function)
Maintain traction (check line, weights, ropes, bed position) Maintain Alignment (observe, check after repositioning, restraints, correct angles of joints) Skin Traction (assess bandages, replace straps when needed) Skeletal Traction (assess pin sites, cleanse pin sites, note pull of traction on pin, ensure that screws are tight) Prevent skin breakdown Assess 5 Ps, neurovascular assessment, care of the immobilized child

Skeletal Traction is never released by the RN Do not lift the weights that are applying traction

Cerebral Palsy
Nonspecific term
Characterized by early onset of impaired movement and posture Nonprogressive

Most common permanent physical disability

1.5 - 3/1000 live births Results from prenatal brain abnormalities Premature delivery single most important risk factor 24% of cases have no determined cause

Clinical Manifestations
Delayed gross motor development
Early preferential unilateral hand use Feeding difficulties (uncoordinated feeding)

Asymmetric crawl
Persistent tongue thrust Opisthotonic posture Stiffness Persistence of primitive reflexes Hyperreflexia

Diagnostic Evaluation
Detailed history
Detailed neurological examination MRI (structural defects)

Metabolic Screen
Electrolyte Analysis EEG Neurophsychological Testing (beyond age 3-4)

Aims of Therapy
Establish locomotion, communication, and self-help Gain optimum appearance and integration of motor function

Correct associated defects

Provide educational opportunities Promote socialization

Nursing Interventions
Early recognition
Individualize plan based on childs disabilities Physical Therapy, Occupational Therapy, Speech Therapy

Promote independence and acquisition of developmental milestones

Develop individualized feeding strategies

Optimize nutrition
Skin Integrity Support parent and child adjustment