Pediatric musculoskeletal nurs 3340 spring 2017

Alterations in Musculoskeletal
Function in Children
Joy A. Shepard, PhD, RN-BC, CNE
Joyce Buck, PhD(c), MSN, RN-BC, CNE
1

Objectives
 Describe pediatric variations in musculoskeletal system
 Plan nursing care for children with structural deformities
of the foot, hip, and spine
 Recognize signs and symptoms of infectious
musculoskeletal disorders and refer for appropriate care
 Collaborate with families and other healthcare providers
to plan care for children with musculoskeletal disorders
that are chronic or require long-term care
2

Objectives Cont’d…
 Plan nursing interventions to promote safety and
developmental progression in children who require
braces, casts, traction, and surgery
 Provide nursing care for fractures and other sports
injuries, including teaching for injury prevention and
evidence-based nursing interventions for the child
who has sustained a fracture or other sports injury
3

Overview of the Musculoskeletal
System (pp. 894-895)
4

Musculoskeletal System
 The structures of the
musculoskeletal system
work together to
provide support and
produce movement
 Anatomy:
 Bones
 Cartilage-type
Tissue
 Joints
 Muscles
http://www.coj.net/NR/rdonlyres/ehzhwybcke723qmg3jwxbebdvvqxdo2t5xi2yjwfk44kcyizjirshuk24wsvhabdx3go3j35xe7nriwdbhqlylleyrh/Girls-playing-soccer.jpg
5

Bones: Rigid Framework
 206 in human body
 Long bones
 Short bones
 Flat bones
 Irregular bones
 Sesamoid bones
McKinney text, p. 1403
6

Long Bones
 Epiphysis (epiphyses)
 Growth of long bones
occurs at the epiphyses
 Epiphyseal plate
 Diaphysis: shaft
 Medullary cavity:
marrow, hematopoiesis
 Periosteum: blood
supply
London text, p. 1319
8

Bone Remodeling: Maintaining
Strong, Healthy Bone
 Resorption
 Osteoclasts:
 Dissolve old bone
 Release calcium into the
blood stream
 Formation
 Osteoblasts:
 Build new bone
 Remove calcium from the
blood stream
http://www.medes.fr/Eristo/Osteoporosis/OsteoCBImage.html
9

Cartilage-Type Tissues: Cushions,
Joins Bones and Muscles
Cartilage—cushions
Ligaments—bone to bone Tendons—muscles to bone
http://www.manordrug.com/FLA/kneeguide.htm
10

http://www.allaboutarthritis.com/image/stock_image/ankle_ligaments_MMG.jpg
Tendons, Ligaments, and
Cartilage
11

Articular System (Joints)
 Where two bones meet
 Allow the skeleton to move
 Ligaments and cartilage
 Synovial—freely movable
(knee)
 Amphiarthrotic—slightly
movable (symphysis pubis)
 Synarthrotic—immovable
(skull)
http://www.octc.kctcs.edu/gcaplan/anat/Notes/Image585.gif
13

Skeletal (Striated) Muscle:
Voluntary, Active Movement
14

Function of the Musculoskeletal
System
 Protection
 Support
 Motion
 Storage of minerals
 Manufacture red
blood cells
http://www.childrens-specialties.com/images/12intrike.jpg
15

Pediatric Differences in MSK
(pp. 896-897)
 Fetus: closely-packed connective
tissue—> cartilage—> bone
(ossifies)
 Infant’s bones: soft
 Fractures in children < 1 yr old:
rare (think abuse or disease)
http://www.worldwideposters.com/mc/fw8736t.jpg
16

Pediatric Differences in MSK
Cont’d….
 Child’s bones more plastic (more
force required to break): will
buckle or bend first
 Child’s bones heal faster
 Soft tissue more resilient
 Ligaments and tendons are
stronger than bones:
dislocations, sprains less
common http://bryankuntz.com/babyGlobe_a.jpg
17

Assessment of the
Musculoskeletal System in
Children
18

Assessment Parameters
 Complete health history
 Family history
 Nutrition
 Any trauma?
 Developmental delays
 Pain
 Structural abnormalities
 Physical limitations/ lifestyle
alterations
 Mobility aids
 Physical assessment
 Structural abnormalities
 Posture and gait
 Muscle symmetry, mass,
tone, strength
 Circulation (color,
temperature, pulses,
capillary filling, edema in
each extremity)
 Movement (ROM in all joints)
 Sensation (pain, can feel)
20

Selected Gross Motor Milestones for Age
21

Normal Development of Posture and Spinal
Curves
22

Laboratory Studies/ Diagnostic
Tests
 Radiologic and other
imaging studies to assess
bones and joints:
 X-ray (most common)
 CT scan
 MRI
 Other important
procedures include:
 Bone scan
 Arthrography
 Arthroscopy
 Joint aspiration
 Ultrasound
 Diagnostics (CK assay,
RA assay, CRP assay,
ESR)
23

Common Nursing Diagnoses
 Impaired Physical Mobility
 Pain
 Risk for Delayed Growth and Development
 Risk for Impaired Skin Integrity
 Risk for Injury
 Risk for Noncompliance
 Diversional Activity Deficit
24

Disorders of the Feet and Legs
25

Metatarsus Adductus
(pp. 893, 898)
 Most common congenital
foot deformity
 Inward turning of the
forefoot at the instep
 Hindfoot is not affected
 Genetic factors, intrauterine
positioning
 Foot can be manually
straightened out
http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9052.jpg
26

Metatarsus Adductus: Treatment
 Depends on degree of
foot flexibility
 Most resolve
spontaneously or with
passive stretching
exercises
 Serial casting - each
used to stretch the
forefoot to a more neutral
position
http://www.rn.com/main.php?uniq=477363&command=manage_courselist&data%5Bsubmit_value%5D=Display%20Entry&data%5Bcourselist%5D%5Bid%5D=229
27

Clubfoot (Congenital Talipes
Equinovarus) (pp. 898-891)
 Congenital malformation
affecting foot, ankle, lower
leg
 True structural defect
 Cannot be straightened
 Three areas:
 Midfoot directed downward
(equinus)
 Hindfoot turns inward (varus)
 Forefoot curls toward heel
(adduction)
London text, p. 1321
http://www.drfoot.co.uk/pictures/clubfootrepair.jpg
28

Clubfoot
 Genetic predisposition
 Multifactorial etiology
 1:1000 births
 Males > females, 2:1
 May be unilateral (one
foot) or bilateral (both
feet)
 Apparent at birth
McKinney text, p. 1414
29

Clubfoot—Casting
 Treatment begun as soon
after birth as possible
 Serial manipulation and
casting q weekly for 8-12
weeks
 Variable response
 Recurrence common
 Long-term follow-up
 Surgery may be necessary if
casting unsuccessful
http://www.vh.org/pediatric/provider/orthopaedics/Clubfoot/Fig22.html
30

Clubfoot—Surgery
 Surgery is required if
manipulation does not correct
the clubfoot
 3-12 months of age
 Releasing tight ligaments or
lengthening tendons to allow
bones to adopt a normal
position
 Foot is seldom completely
normal after treatment
31

Question
 Metatarsus adductus is known
as clubfoot.
 A. True
 B. False
32

Question
 Nonsurgical management of
clubfoot requires serial casting.
 A. True
 B. False
33

Question
 Long-term follow-up for clubfoot is
not necessary after corrective
surgery.
 A. True
 B. False
34

Question
 An infant's clubfoot cannot be
manipulated into proper
alignment.
 A. True
 B. False
35

Question
 Julie's child has clubfoot. She asks the nurse what kind of
treatment she can expect her daughter to go through. The
best response by the nurse is:
 a. Treatment will begin when your daughter is about six months old.
 b. It usually requires about one year of treatment to resolve the
problem.
 c. There is no formal treatment; clubfoot resolves spontaneously.
 d. When serial casting is used as the method of treatment, the cast is
changed every one to two weeks for 8 to 12 weeks until maximum
correction is achieved.
36

Genu Varum/ Genu Valgum
(pp. 901-902)
 Varus: an abnormal
position of a limb that
involves bending inward
toward the midline of the
body
 Valgus: an abnormal
position of a limb that
involves bending outward
away from the midline of
the body
http://www.planete-ortho.com/fr/images/genuVarum.jpg
37

 Genu varum
(bowlegs): knees are
widely separated and
lower legs turned
inward
 Genu valgum (knock-
knees): knees are close
together and lower legs
directed outward
http://www.arthrosedugenou.com/francais/sympt_arthrose.htm
38

 Genu Varum:
 Normal 2 to 3 years of age;
beyond abnormal
 Cause: Blount disease, rickets
 Genu Valgum:
 Normal 4 to 5 years years of
age; beyond abnormal
 Treatment:
 Most resolve on own
 Braces
 Osteotomy and casting
39

Question
Genu varum is a normal
variation in toddlers.
A. True
B. False
40

Question
 Genu valgum is almost always
secondary to other disorders.
 A. True
 B. False
41

Casts (p. 930)
 Provides support
 Maintains anatomic
position
 For bone healing or
correction of a deformity
 Plaster of Paris or
fiberglass
 Most casts applied on an
outpatient basis
42

Cast Care—Drying
 Be especially careful with the cast for the first
1-2 days (can easily crack or break)
 Elevate the casted extremity on a pillow above
the level of the heart
 Reposition every 2-4 hours to ensure thorough
drying (plaster cast)
 Can take 48 hours for a plaster cast to harden
43

Cast Care—Drying
 While the cast is wet, handle it gently with the hands
cupped, palm sides up (no fingertips)
 If you lift the extremity, support it by the holding the
joint above and the joint below
 Once dry, the cast should sound hollow and be cool to
the touch
 Avoid getting the cast wet (no swimming, baths, or
showers)
 Cover with plastic and waterproof tape to keep dry (if
necessary)
44

Care for the Child in a Cast
 Circulation, movement and sensation (CMS) checks q
15-30 minutes for 2 hrs, then q 1-2 hrs thereafter for
first 24-48 hrs
 Check the skin around the cast edges for irritation,
rubbing, or blistering
 “Petal” edges of the cast if necessary
 Circle any drainage or bleeding noted through cast
material
 Elevate the cast above heart level (especially for the
first 48 hrs)
45

Care for the Child in a Cast
 Keep the cast dry
 Cleanse the skin just under the cast edges with
rubbing alcohol
 Do not pour powder, lotion, oils, or perfume
into the cast (will cake)
 Do not allow the child to place anything inside
the cast
46

Instruct the Parent to Contact the
Provider if…
 Foul, unusual odor
 Tingling, burning, numbness
 Fingers or toes swell, inability to move
 Fingers or toes turn blue or white
 Drainage through cast
 Sudden, unexplained fever
47

Instruct the Parent to Contact the
Provider if…
 Unusual fussiness, unable to console
 Pain that is not relieved
 Any objects such as coins, rocks, or small toys
get under the cast
 Cast slippage
 Cast crumbles, cracks or breaks
 Cast becomes wet or soggy and soft
48

Developmental Dysplasia of the
Hip (DDH) (pp. 902-905)
 Congenital abnormality
of the hip socket
 Formerly ‘congenital hip
dysplasia’
 1-2 / 1000 births: most
common congenital
defect
 Females > males, 4:1
 Genetic predisposition
 Multifactorial etiology
 Breech birth, very
large babies, spina
bifida, CP
50

DDH
 Femoral head either
comes out of the hip
socket (acetabulum)
or does not fit properly
 Mild, moderate or
severe
 Usually affects one
joint
51

DDH: Symptoms
 Asymmetry gluteal folds
 Leg shorter
 Limited abduction
 Turned outward
(externally rotated)
 Wide space between legs
 Difference in knee height
(Allis sign)
53

DDH: Symptoms
 Older child: gait abnormalities such as toe
walking or limping, or the level of the
pelvis may be unequal
 The longer the disorder goes
undiagnosed, the more severe the clinical
manifestations and difficult to treat
54

DDH—Ortolani and Barlow’s
Maneuvers
 Performed with the
newborn in a quiet,
relaxed state on a firm
surface, with hips and
knees flexed at a 90º
angle
 Positive test—“Clunk” or
palpable dislocation
 Means hip is dislocated or
unstable
55

DDH—Pavlik Harness (p. 905)
 For infants < 3 months
 Pavlik harness—a brace that places
the hips in flexion and abduction
 Centers the head of the femur in the
hip socket by keeping the knees and
hips flexed and the hips abducted
 Makes hip goes back into the joint and
keeps it there
 Worn 23º/day for 3-4 mos
 Until x-ray shows hip is stable
56

DDH—Traction and Surgery
 Skin traction (Bryant
Traction) and/or surgery is
used if the harness is not
successful or if the child is
older than 3 months
 Traction stretches the soft
tissue and moves the femoral
head back into the hip socket
 Surgery may be performed to
put the hip back into place
manually
 A hip spica cast is used to
keep the hip in the joint after
the operation
57

DDH—Hip Spica Cast Care
 Monitor neurovascular status (CMS)
 Assess for fever, wound drainage,
and discomfort
 Standard cast care
 Elevate the cast above the level of
the heart to decrease swelling
 Rough edges can be padded to
protect the skin from scratches
 Check for cracks or breaks in the
cast
 Keep the cast clean and dry
 Cover the cast during feedings to
prevent spills from entering the
cast
 Tuck a disposable diaper beneath
the entire perineal opening in the
cast to keep the cast clean and
dry
 Do not use the abduction bar on
the cast to lift or carry the baby
 Perform ROM exercises
 Provide environmental and
developmental stimulation
58

Question
 When developmental dysplasia of the hip is
diagnosed:
 A. Treatment is begun immediately
 B. Treatment is postponed until the child is able to
bear weight
 C. Surgery is scheduled as soon as the child weighs
10 pounds
 D. Bilateral casting is done at 1 month of age
59

Legg-Calvé-Perthes Disease
(LCPD) (pp. 905-907)
 A deterioration of the head
of the thighbone (femur)
due to insufficient blood
supply to the area
 Avascular necrosis of the
femoral head
 Boys 4-8 yrs
 Painful limp, limited
abduction
60

LCPD—Diagnosis
 Usually unilateral
 Flattening of the
top of the femur
 Diagnosis by X-ray,
bone scan, or MRI
http://www.uwec.edu/kin/majors/AT/aidil/images/leggsap.JPG
61

LCPD—Treatment
 Treatment goal: avoid
permanent deformity and
degenerative arthritis
 Femur head put back into
the socket and held there
 Bedrest, stretching
exercises
 Activity restrictions
 Bracing (abduction, no
weight bearing)
 Non-weight-bearing
exercises
 Surgery (osteotomy)
62

LCPD—Nursing Care
 Psychosocial issues
 Educate parents on
purpose, application, and
care of the brace
 Educate parents: CMS
checks
 Safety issues
 Skin care
64

Question
 LCPD can result in arthritis and
skeletal deformities.
 A. True
 B. False
65

Question
 LCPD results in avascular
necrosis of the femoral head.
 A. True
 B. False
66

Question
 Limping and limited hip adduction
are clinical manifestations of LCPD.
 A. True
 B. False
67

Slipped Capital Femoral Epiphysis
(SCFE) (pp. 907-908)
 Femoral head displaced
from femoral neck at
growth plate
 Adolescent growth spurt
 Overweight boys, ages 8-
16
 Acute vs chronic
 S/S: limp, pain, limited
ROM
68

SCFE—Diagnosis and Treatment
 X-ray
 Early diagnosis important
 Goal: stabilize femoral head;
retain hip function
 Treatment:
 Surgery
 Steel pin to hold the femoral
head onto the femur to
prevent it from slipping further
 Physical therapy
 Following surgery, to help
strengthen the hip and leg
muscles
69

Scoliosis (pp. 909-912)
 Abnormal lateral
curvature of the spine
 S or C-shaped
 Compensatory
 3-dimensional, with
rotation of the
vertebrae
 Misshapen spine, rib
cage, and pelvis
71

Scoliosis—Incidence
 Most common spinal
deformity
 10% of children
 Runs in families
 Most frequently affects
adolescent girls, ages 10-
13
 Common in children with
neuromuscular disorders
72

Scoliosis—Manifestations
 Visible curve of spine
 Mild to severe “C” or “S”
lateral curvature
 Uneven waist or shoulders
(scapula)
 Rib hump
 Asymmetrical hips
 Usually no pain
 Severe cases: reduced vital
capacity (shortness of
breath)
73

Scoliosis—Screening/ Diagnosis
74

Question
 Screening for scoliosis is done:
 A. Prenatally
 B. In the newborn period
 C. During the school-age years
 D. In middle adolescence
75

Scoliosis—Treatment
• Curve 10-20º - Slight curve, spinal exercises
• Curve 20-40º - Brace
• Curve > 40º - Surgery
• Curve > 80º - Respiratory compromise
• Requires long-term monitoring, because the
curvature will progressively worsen over time
76

Scoliosis—Nursing Diagnoses
 Deficient Knowledge
 Ineffective Breathing
Pattern
 Risk for Injury
 Pain, Anxiety
 Impaired Physical
Mobility
 Disturbed Body Image
 Interrupted Family
Processes
 Risk for Impaired Skin
Integrity
 Risk for Noncompliance
 See CP pp. 911-912
77

Scoliosis—Bracing
 Curvature 20-40º
 Milwaukee brace: most
common type
 Plastic, metal, & a chin
extension
 From jaw to hips,
stretching / pushing
 Worn 23 hrs /day with time
out for hygiene & skin care
78

Scoliosis—Bracing Cont’d…
 Worn for 1-2 years
 Brace must be adjusted
with growth
 Observe for skin
breakdown
 Should wear a light cotton
tee shirt under the brace
 Body image disturbances,
reaction of peers
79

Scoliosis—Surgery
 Spinal fusion: > 40º curve
 Results in cessation of growth
of fused vertebrae
 Delayed as long as possible
to allow maximal skeletal
growth
 Harrington rod (posterior
fusion)—most common
 Risk for injury (nerve
damage, bleeding)
 Risk for infection
80

Scoliosis—Postoperative Care
 Immobilization on Stryker Frame
postoperatively
 Will be in hospital at least 5 days
 CMS checks lower extremities q2 hrs for 1st
24º; then q4 hrs
 Pulmonary hygiene: IS
 Position: log-rolling q2 hrs
81

Scoliosis—Postoperative Care
 Monitor pain, shock, wound site,
infection
 Encourage participation in activities
within limitations
 Mesenteric artery syndrome:
complication following surgery caused
by mechanical changes in the position
of the abdominal contents; causes
vomiting and abdominal distension
82

Scoliosis—Case Example
 This is a 13-year-old
with a progressive right
thoracic scoliosis
measuring 55°
 Postoperatively, the
curve is reduced to 15°
 Correction was by
surgical implantation of
metal rods
83

Question
 Uncorrected scoliosis can result in:
 A. Superior mesenteric artery syndrome
 B. Reduced respiratory function
 C. Fusion of the vertebrae
 D. None of the above
84

Question
 Scoliosis is most often detected in
children between six and eight years
of age.
 A. True
 B. False
85

Disorders of the Bones and Joints
86

Osteomyelitis (pp. 915-916)
 Infection of bone and
marrow
 Most often long bones of
lower extremities
 Acute or chronic
 Most common: boys
younger than 5 years
 Bacterial, viral, fungal
87

Osteomyelitis
 Two principle ways to
contract:
 Endogenous routes (organism
spreads through bloodstream,
abscessed teeth, skin infection
over bone)
 Exogenous routes (penetrating
injury to bone, surgical
procedures)
 Pus pockets in bone
(sequestrum): very resistant
to antibiotics
88

Osteomyelitis with Draining Sinus
89

Osteomyelitis of Right Lower
Humerus with Pus Pocket
90

Osteomyelitis
 S/S: severe pain, impaired physical mobility
 Diagnostics:
  WBC, ESR, C-reactive protein
 X-ray, bone scan
 Needle aspiration, blood culture
 Review Nursing Diagnoses, Planning, Interventions –
pp. 915-916
 Treatment:
 Extended IV antibiotic therapy (6 weeks)
 Multiple, broad-spectrum
91

Question
 Osteomyelitis is most common in
children between the ages of 16
and 18.
 A. True
 B. False
92

Question
 Antibiotic therapy treatment for
osteomyelitis most often lasts for
one week.
 A. True
 B. False
93

Question
 Areas of sequestrum are highly
susceptible to antibiotics.
 A. True
 B. False
94

Osteogenesis Imperfecta (OI)
(pp. 918-919)
 “Brittle bone disease”
 Inherited disorder of collagen
(autosomal dominant)
 Wide variety of symptoms:
 Osteoporosis
 Frequent fractures
 Blue sclerae
 Discolored teeth
 Deafness by early adulthood
 Short height due to compression fractures
of the spine
  ROM of joints due to relaxed ligaments
95

OI—Nursing Considerations
 Often normal or above normal
intelligence
 No cure
 Often mistaken for child abuse
 Highest priority: prevent
fractures, maintain muscles and
joints
96

OI—Often Mistaken for Child
Abuse
97

OI—Nursing Considerations
 Goal: optimal
functioning and
mobility
 Good nutrition
 Calcium, vitamin D,
vitamin C
 Coping with chronic
illness
 Safety issues
98

Question
 Osteogenesis imperfecta is a connective
tissue disorder of the bones characterized
by defective collagen, the protein that
gives the bones strength and structure.
 A. True
 B. False
99

Juvenile Idiopathic/ Rheumatoid
Arthritis (JRA) (pp. 634-636)
 Chronic condition that causes
inflammation in one or more joints and
begins before the age of 16
 Symptoms present  6 weeks
 Autoimmune
 Multisystem (connective tissue)
 Leading cause of blindness and
disability in children
 Children 2-5 or 9-12 yrs of age
 May disappear in adolescence
100

JRA—Pathophysiology
 Synovial joints
 Chronic inflammation of
the synovial membrane
 Destruction of the
articular cartilage
 Wear and tear on the
bone, pain
 Limited joint mobility
101

JRA—Manifestations
 Periods of remission and exacerbation
 Joint inflammation
 Pain, warmth
 Morning joint stiffness
 Limited mobility of joints involved
(stiff, bent joint)
 Physical growth may be stunted
during periods of exacerbation
 Decreased activity level, weakness
 Uveitis
102

JRA—Diagnostic Evaluation
 Complete health history
 Physical examination
 No specific diagnostic tests
for JA
 Laboratory tests to help rule
out other diseases
 X-rays of bones and organs
to check for infections,
tumors or fractures
 Uveitis—eye examinations
103

JRA—Nursing Goals
 Read Nursing Diagnoses,
Planning, Interventions – pp.
635
 Keep the child free from
injury
 Pain control
 Enhance physical mobility
 Promote age-appropriate
developmental behaviors
104

JRA—Therapeutic Management
 Adequate rest
 Referral to PT/ OT
 Low resistance-exercise program, ROM exercises, to
prevent contractures and deformities
 Proper positioning of the affected joints to prevent MSK
complications; Splints
 Heat/ cold
 Children should participate in regular school activities,
extracurricular activities and family responsibilities, as
much as possible
105

JRA—Drug Therapy
 Reduce inflammation, relieve
pain and swelling, maximize
function
 Medications: NSAIDs and
Salicylates (ibuprofen,
naproxen, ASA)
 Severe disease: SAARDs
(hydroxycholoroquine,
sulfasalazine, gold salts,
penicillamine)
 Crippling disease:
immunosuppressive agents
(methotrexate, azathioprine,
cyclophosphamide)
106

Question
 In taking the history of a child with juvenile
arthritis, the nurse would probably discover that
the child is taking:
 A. Acetaminophen
 B. Aspirin
 C. Morphine
 D. Prednisone
108

Muscular Dystrophy (MD)
(pp. 919-923)
 Group of progressively
degenerative inherited
diseases
 Muscles waste away
 Various patterns of
inheritance and age of
onset
 Duchenne muscular
dystrophy (DMD)—most
common type
110

Duchenne Muscular Dystrophy
(DMD)
 X-linked recessive
disease; affects males (1:
3000 boys)
 Onset early childhood—3-
7 yrs
 Waddling, wide-based
gait
 Calf hypertrophy
 Lordosis, scoliosis
111

DMD
 Loss of walking by 12
yrs—will need a
wheelchair
 Death: late teens, early
20s
 Cardiopulmonary
complications
(respiratory failure,
heart failure,
pneumonia)
112

Muscular Dystrophy—Gower’s
Sign (p. 920)
113

X-Linked Recessive
One-half of the male children of the mother carrier will have the disease.
114

DMD—Diagnostics
 Serum creatine
kinase (CK) levels
elevated early
stages
 Electromyography
 Muscle biopsy
115

DMD—Nursing Goals
 Maintain physical activity
 Promote respiratory function
 Weight management
 Reduce the impact of the disease on the
child’s development
116

DMD—Nursing Care
 Supportive care
 Maintain mobility—good ROM, turn q2 hrs
 Prevent foot drop, contractures (splints, orthotics)
 Prevent obesity—reduced calorie diet
 Respiratory—assess lungs, encourage to cough and
deep breathe
 Bowel—stool softeners, fiber, laxatives
 Support family; referral for genetic counseling
117

Question
 All of the following statements about Duchenne's
muscular dystrophy are true except:
 a. Duchenne's muscular dystrophy affects girls more than
boys.
 b. In children with Duchenne's muscular dystrophy, the calves
appear large and strong, but in actuality they are weak
because of infiltration of the muscles with fat and connective
tissue.
 c. Most deaths from Duchenne's muscular dystrophy are due
to respiratory infections or cardiac failure.
 d. There is no cure for Duchenne's muscular dystrophy.
119

Question
 Of the following, which is the priority nursing
intervention for the child with Duchenne's
muscular dystrophy?
 a. nutritional status
 b. genetic counseling
 c. respiratory status
 d. renal status
120

Injuries to the Musculoskeletal
System
121

Musculoskeletal Injuries in
Children (pp. 923-931)
 Movement is critical to a
child’s development
 MSK injuries occur because
of:
 Vigorous motor activities
 Rapid growth of skeletal
system
 Most are short-term
http://www.wendychao.com/skate/wendy_skateboard_med.jpg
122

Fractures
 Fracture: break in a
bone
 Most happen because
of:
 Sudden trauma
 Bone disease (OI)
 Diagnosis: usually by
x-ray
123

Pediatric Fractures
 One of most common childhood MSK injuries
 Peak incidence: age 5-9 years (boys and girls)
 Seldom complete breaks
 Children’s bones tend to bend or buckle because of
increased flexibility
 Flexibility due to thicker periosteum and increased
amounts of immature bone
 Most common sites: clavicle, tibia, ulna, and femur
(distal forearm)
124

Pediatric Fractures and Falls
McKinney Text, p. 1424
125

Question
 School-aged children are most at risk
for musculoskeletal injury when
compared to other age groups of
children.
 A. True
 B. False
126

Fractures—Signs and Symptoms
 Pain, tenderness around
area
 Deformity
 Immobility,  ROM
 Loss of function of that
part of the body
 Swelling
 Soft tissue injury
 Bleeding under the skin
(ecchymosis,
hematoma)
 Muscle spasm
(physiological splinting)
 Crepitus—grating sound
heard when bone
fragments are rubbing
together
127

Question
 Musculoskeletal pain associated with soft tissue
damage fractures, muscle spasms, surgical
procedures, and immobilization devices is one of
the most severe types of pain that can be
experienced.
 A. True
 B. False
128

Types of Fractures (p. 925)
129

Types of Fractures (p. 925)
130

Epiphyseal Growth Plate
 Epiphyseal growth plate:
vulnerable area, weakest part
of long bone
 Absorbs shock, protecting
joint surfaces from serious
fractures
 Damage to growth plate
causes growth disruption,
arrest, or uneven growth (in
the child who has not
reached skeletal maturity and
is still growing)
132

Injuries to the Ephiphyseal Plate
(p. 926)
133

Reduction—Setting the Bone
 Reduction (realignment)—repositioning the
bone fragments into normal alignment
 Closed reduction—manual alignment of the
bone fragments (without surgery)
 Open reduction—surgical insertion of internal
fixation devices (rods, wires, pins) to help
maintain alignment while healing occurs
134

Fixation
 Device put in bone
to maintain
alignment to aid in
healing
 Two types:
 Internal fixation
 External fixation
135

Reduction with Internal Fixation
136

Reduction with External Fixation
137

Retention—Support, Protection, &
Alignment
 Device or mechanism
(cast, splint) for
protection, support, &
alignment
 Supports bony callus
which is forming to bind
the bony fragments
together
138

Hip Spica Cast (p. 903)
 Close observation is needed
to check for cast tightness
and circulatory changes
caused by swelling or by the
normal growth process
 The child must be turned
regularly to prevent skin
problems and to provide
maximum comfort
 Position the child with head
and upper body elevated at
all times
139

Traction (p. 927)
 Application of force to stretch certain parts of
the body in a specific direction
 Consists of pulleys, strings, weights, and a
metal frame attached over or on the bed
 Can only come off or be adjusted with
provider’s order
 Review: Box 29-2, p. 927; Box 29-3, p. 929
140

Traction—Purpose
 Maintain corrected position (put bones, joints in proper
position)
 Stabilize fractured bones
 Muscle spasms or nerve irritation
 Most often temporary (can’t operate on the bone right
away)
 Disadvantage: prolonged immobilization, must be in
hospital
 Traction being replaced by early casting & pinning
141

Skin Traction
 Traction can either be applied directly to the skin (skin
traction) or through pins inserted into bones (skeletal
traction)
 Skin traction:
 Noninvasive (force directly on body surface)
 Limited pulling force (limited weight)
 Young children (< age 2 or 3)
 Continuous or intermittent
 Short-term use
 Risk for skin breakdown and circulatory compromise
142

Skeletal Traction
 Skeletal traction
 Invasive (metal device inserted into bone)
 Greater pulling force
 Older children
 Always continuous
 Long-term use
 Risk for infection
 Osteomyelitis—most serious complication
 Pin care: ½ H202 or saline, antibiotic ointment, gauze (p.
929)
143

Skin Traction Types (p. 927)
144

Skin Traction Types (p. 927)
145

Skeletal Traction Types (p. 927)
146

Skeletal Traction Types (p. 927)
147

Question
 With Buck's extension traction, a
boot or circular wrap is applied to
the skin.
 A. True
 B. False
148

Question
 Which of the following statements about traction is
true?
 a. Traction is the application of pulling force to a body part
against a counter traction pull exerted in the opposite
direction.
 b. The process is used only to treat long bone fractures.
 c. Skin traction has a high risk of infection due to needed
breakdown of the skin barrier.
 d. Traction causes muscle spasms and should be avoided in
those types of fractures where muscle spasms are a common
complication.
149

Neurovascular Assessment
(p. 928)
Circulation
Movement
Sensation
Skin color
Temperature
Quality of pulses
Capillary refill
Can the child freely
wiggle her toes, move
her fingers?
Any pain?
Have the child close her
eyes,
and tell you which toe
you are touching
150

Neurovascular problems
 Early detection may
mean no or slight
disability in the future
 Assess carefully &
knowingly!
151

Question
 What is the best way to assess sensory function
in a 6-year-old child with a lower leg cast?
 A. Ask, “Do you feel this?” when pressing down
on the little toe.
 B. Check capillary refill in the middle toe.
 C. Tell the child to wiggle his toes.
 D. Ask, “Which toe am I pinching?” when pinching
the great toe.
152

Compartment Syndrome
(p. 928)
 Most serious complication of closed
fractures
 Occurs when swelling causes pressure to
rise within closed spaces of an extremity
 Increased pressure compromises circulation
to muscles and nerves, causing paralysis
and necrosis
153

Compartment Syndrome
(p. 928)
154

5 P’s = Orthopedic Emergency
 Pain
 Pallor
 Pulselessness
 Paresthesia
 Paralysis
***ASSESSMENT BEFORE NARCOTICS***
155

Question
 List the 5 “P’s” of vascular impairment
 Pain
 Pallor
 Pulselessness
 Paresthesia
 Paralysis
156

Question
 A child has a closed fracture of the right radius, with
slight ecchymosis below the elbow. She complains of
extreme pain. Her right hand is cooler than her left, and
she cannot extend the fingers of her hand because they
“burn.” She is probably experiencing:
 A. Compartment syndrome
 B. Epiphyseal injuries
 C. Early signs of an infection
 D. All the above
157

Treatment—Fasciotomy
 Treatment consists of
relieving pressure by
removing the cast or
by performing a
fasciotomy (incision
into the fascia to
relieve pressure on the
nerves & blood vessels)
158

Sprains, Strains (p. 924)
 Uncommon in children
 Soft tissues are resilient
 Ligaments and tendons
are stronger than bones
 ‘RICE’ for 24-36°
 NSAIDs (no aspirin) to
alleviate pain and
reduce inflammation
159

Question
 In young children, sprains and strains are very
uncommon because the growth plates, or
epiphyses, are weaker than the ligaments and
will usually separate before a ligament will tear.
 A. True
 B. False
160

Question
 An appropriate intervention for a child’s
sprained ankle is:
 A. Aspirin and elevating the foot
 B. Ice packs and rest
 C. Elastic bandage wrap and acetaminophen
 D. All of the above
161

Pediatric musculoskeletal nurs 3340 spring 2017

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