Musculoskeletal

CHAPTER 31

Pediatric Differences
Ossification nearly complete at birth Posterior fontanel closes 2-3 months of age Anterior fontanel closes approx. 18-24 months of age Most skull growth by 2 years of age Long bones of children porous and less dense than adults Muscles increase in length and circumference, not in number Until puberty, ligaments & tendons are stronger than bone Cartilage replaced by bone & skeletal maturation by approximately 20 years of age

Who am I?

Immobilized Child
Once thought to be restorative for patients with

illness and injury We now know that immobilization has serious consequences

Especially on growth & development of the child

Inactivity leads to decrease in functional capacity of the entire body Can delay age appropriate milestones Decreased muscle mass & strength Decreased metabolism Decreased bone mineralization

Immobilization
Muscular system Decreased muscle strength and endurance Disuse atrophy Loss of joint mobility Skeletal system Bone demineralization
Daily stresses on bone by motion & weight bearing maintain balance between bone formation (osteoblastic activity) and bone resorption (osteoclastic activity).During immobilization INCREASED calcium leaves the bone causing osteopenia (demineralization)

Negative calcium balance

Immobilization psychologically

Movement is critical : immobility deprives child of

natural outlet for feelings Physical growth and development depend on movement instrument of communication, expression and learning Respond to anxiety with increased activity

Not Happy!

Traumatic Injury
Soft Tissue Injury
Muscles
Ligaments Tendons

Sports

injuries Mishaps during play

Contusions
Damage to soft tissue, subcutaneous tissue and

muscle Escape of blood into tissue-ecchymosis-black and blue Swelling, pain disability Crush injuries

Contusions

Dislocations
Occur when force of stress on ligament is sufficient to
Pain increased with active or passive movement of extremity May be an obvious deformity & inability to move joint Most common type :
Phalanges elbow

displace normal position of opposing bone ends or bone ends to socket

Hip dislocation: (< 5 yrs old) potential loss of blood

supply to head of femur Shoulder dislocation: (adolescents) sports related

Reduce ASAP Unreduced dislocations: increased swelling, reduction is difficult, increased risk neurovascular problems

Dislocations

Sprains
Trauma to a joint from

ligament partially or completely torn or stretched by force May have associated damage to blood vessels, muscles, tendons, and nerves Presence of joint laxity is indicator of severity Rapid onset of diffuse swelling with disability

Strains
Microscopic tear to

musculotendinous unit Similar to sprain Swollen, painful to touch Generally incurred over time

Soft Tissue Injury

Therapeutic

Management
RICES and ICES Rest the injured part Ice immediately (max 30 min at a time) Compression with elastic bandages Elevation of extremity Immobilize and support Crutches (proper size and height)

Soft Tissue Injury treatment

Fractures
Common injury in children (rare in infants, except with a

MVA) Clavicle the most frequently broken bone, especially under 10 years. (Neonates if they are too large for moms small pelvis) School aged: bicycle/vehicle or skate board injuries Adolescents: bicycles, ATVs, skateboards, motorcycle sports Patterns of fractures, problems of diagnosis& methods of treatment are different in pediatrics than in adult population

Epiphyseal(physeal) Injuries
Weakest point of long bones: cartilage growth plate

(epiphyseal plate) Frequent site of damage during trauma May affect future bone growth Treatment may include ORIF to prevent growth disturbances

Epiphyseal plate

Types of Fractures
Simple or closed (no break

in the skin) Compound or open: fractured bone protrudes through the skin Complicated: bone fragments have damaged other organs or tissue (lung or bladder) Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue (rare in children)

Types of fractures in children

Bend: Bone is bent but not

broken Buckle or torus: Compression of porous bone, bulging projection at fracture site (more common in young children) Greenstick: compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture Complete: divides the bone fragments

Clinical Manifestations of Fractures

Generalized swelling

Pain or tenderness
Deformity Diminished functional use

May have bruising, severe muscular rigidity, crepitus

Bone healing and remodeling

Typically rapid healing in

children (femoral shaft)

Neonatal period:2-3 weeks Early childhood:4 weeks Later childhood: 6-8 weeks Adolescence: 8-12 weeks

Remember..

Fractures
Diagnostic evaluation: x-ray

is most useful tool Therapeutic management goals Nursing considerations

Nurses make initial evaluation (calm quiet voice)

Calm the child and the parent to better assess

Good history of what occurred to see if abuse is possible Spiral fx in young child may indicate abuse Multidisciplinary team to further assess

Assess Extent of Fractures The 5 Ps

Pain and point of

tenderness Pulse distal to fracture site Pallor: capillary refill Paresthesia: sensation distal to fracture site Paralysis: movement distal to the fracture site

Neurovascular Assessment
PULSES COLOR MOVEMENT AND

SENSATION TEMPERATURE SWELLING PAIN

The Child in a Cast

Cast application techniques

Plaster of paris: drying fiberglass Nursing Care management First few hours after application: Elevate extremity assess sizing and monitor for degree of swelling Assess for hot spots Casts of open fracture has window over wound for assessment First few hours after surgical reduction (casted as closed fracture) bleeding may soak through the cast. Outline area to monitor Educate parent on time to dry of plaster cast S/S that cast too tight If cast too loose Home environment Car seats Protecting the cast transparent dressing or diaper

Nursing Considerations
Swelling may continue thus cast becomes a

tourniquet, circulation diminished, neurovascular complications Elevate extremity If swelling is severe: casts are bivalved Permanent tissue damage can occur within 6 to 8 hrs

COMPARTMENT SYNDROME

Compartment Syndrome
Pain

Swelling
Discoloration Decreased pulses

Decreased temperature
Inability to move distal exposed part CALL PHYSICIAN IMMEDIETLY

Compartment Syndrome

Casting

Child in Traction
Traction: Extended pulling force

Purposes: Fatigue muscle involved and reduce muscle spasm so bones can be realigned Position distal and proximal bone ends in desired alignment Immobilize until healing has taken place to permit casting or splinting Help prevent or improve contracture deformity Promote immobilization Reduce muscle spasms

Traction: Essential Components

Traction: Forward force Attaching weight to distal bone fragment Counter traction: backward force Body weight provides this ( for free) Frictional force: provided by patients contact with

the bed

Types of Traction
Manual Traction: applied by the hand distal to

fracture site Skin Traction: Directly to skin surface and indirectly to skeletal structures Skeletal traction: directly to skeletal structure with a pin (ouch)

Skeletal Traction Pins

Types of Traction
Upper Extremity Traction: Humerus
Overhead

suspension: arm bent at elbow and suspended vertically & traction applied to distal end of the humerus. Dunlop traction: Lower arm is flexed and suspended vertically with traction, while upper arm maintains longitudinal direction and pull

Lower Extremity Traction

Bryant: running traction, pull in 1 direction

Bucks Extension: legs in an extended position

Russell Traction: skin traction with a padded sling 90-90 traction: most common skeletal traction Steinmann pin or Kirschner wire distal in femur at 90 angle both at hip and knee Balance suspension traction with

Thomas splint

Types of Traction

Cervical Traction
Halo Brace (vest) attached to head with 4 screws in

outer skull: bars connected to vest> greater mobility of rest of the body

Cervical Traction
Crutchfield tongs (Barton, Gardner-Wells) burr holes

in the skull & weights attached to the head

Nursing Care Management

Know the reason WHY traction is applied Assess patient Assess pulses bilaterally Alteration in sensation or increased pain Assess any change in color of skin or nail bed Skin breakdown/ massage pressure areas to stimulate circulation Position changes Wash and dry skin daily Any neurovascular changes: record and call MD Assess traction apparatus Check line of pull/ weights Bandages in place/ excessive tightness Do not remove unless under supervision of physician Diet Balanced diet with fruits and vegetables (fiber) calcium Encouraging fluids Offering laxatives Encourage deep breathing and Incentive Spirometry Prevent foot drop Encourage socialization/ discourage isolation

Nursing Care Management

Pain management: increased initially as traction pull

is fatiguing the muscle

Analgesics Muscle relaxants

Pin care: according to hospital policy or physician

order

Frequently assessed and cleaned to prevent infection After first 48 to 72 hours assessment needed less frequently

Developmental Dysplasia of Hip DDH

Spectrum of disorders describing abnormal

development of hip that can occur

Infancy childhood Fetal life

Cause unknown Gender, birth order, family history, positioning, delivery type, joint laxity & post natal positioning

Developmental Dysplasia of Hip DDH

Diagnostic Evaluation

Not detected at initial exam after birth Most often found in pediatrician office for well baby check up

Exhibits as hip joint laxity and NOT out right dislocation

Shortening of the limb on affected side Asymmetric thigh and gluteal fold Broadening of the perineum Ortolani and Barlow tests most reliable from birth to 3 months

Barlow: thighs are adducted Ortolani: abducting the thighs to test for hip subluxation or dislocation

DDH

Ortolani Test limited hip abduction in flexion

Barlow Test thighs adducted

Signs of DDH asymmetry of gluteal and thigh folds

Therapeutic Management
Treatment initiated as soon as recognized

GOAL: obtain and maintain a safe and congruent

position of hip joint to promote normal development

Early intervention more favorable in restoration of normal bony architecture and function.

Therapeutic Management
Newborn to 6 months

Pavlik Harnace Hip joint in dynamic splint Proximal femur centered in acetabulum Worn continuously until proven stable on exam and with x-ray

Therapeutic Management
Ages 6 to 18 months
Gradual

reduction by traction for 3 weeks Closed reduction of hip under general anesthesia If not successful then open reduction Then placed in hip spica cast for 2 to 4 months Once hip is stable a flexion abduction brace is applied

Hip Spica cast

Therapeutic Management
Older Child Increasingly difficult after age 4 Impossible or inadvisable > 6 yrs
Contractures of muscles Deformity of femoral and acetabular structures

Correction is challenging as most likely is secondary to arthritis or CP Operative reduction with or without presurgical traction
Contracted muscles Osteotomy procedures

Nursing Management
Nurses can detect DDH on initial assessment

Ambulatory child who displays limp or unusual gate

is referred Primary Nursing Goal: Teaching Parent WHY DEVICE BEING USED!!

Application of device Maintenance of device

Keep

in mind rapid growth of the infant/child (check straps)/check for rubbing/ red marks

Nursing Management
Normalcy is the goal

Involve the child in all activities of any other child in

same age group Maintain active role in family and activities

Congenital Clubfoot
Deformity of ankle and foot which includes

adduction Midfoot supination Hindfoot varus Ankle equinus Most common talipes equinovarus Foot is pointed downward and inward in varying degrees

forefoot

Congenital Clubfoot
Cause unknown

Some attribute to abnormal positioning and

restricted movement in utero Arrested or abnormal embryonic development Increased risk of hip dysplasia

Congenital Clubfoot
Classification Positional: intrauterine crowding

Responds to simple stretching and casting

Syndromic (teratologic): associated with other congenital anomalies

More severe form/ often resistant to tx Surgical intervention may or may not be effective

Congenital/idiopathic: can occur in otherwise normal child

Always requires surgical intervention because there is a bony abnormality

Diagnostic Evaluation
Detectable prenatally through U/S

Noted at birth

Therapeutic Management
Goal: achieve a painless, plantigrade and stable foot Serial casting before discharge Successive casts encourage gradual stretching and accommodate rapid

growth Maximum correction achieved within 8 to 12 weeks If no positive result after 3 months= surgical intervention

Three stages

Correction of deformity Maintenance of correction until normal muscle balance is regained Follow up observation to prevent possible recurrence

Ponseti

Nursing Care Management

Casted child:
observation

of skin and circulation Rapid growth Educate the parent Signs of skin breakdown Signs new cast needed Help the child to live as normally as possible

Metatarsus Adductus (Varus)

Most common congenital foot deformity

Result of abnormal intrauterine positioning

Type I: foot flexible and corrects easily Type II: partial flexibility in forefoot

Type III: foot rigid and will not stretch

Treatment
Type I & II Often times corrected with gentle manipulation

Passive stretching of foot Parent teaching performed Continue for 6 weeks

Type III Serial manipulation and casting

Nursing Management
Teaching the parent

hold heal firmly and to stretch ONLY the forefoot Cast teaching Signs of skin breakdown Signs new cast needed Help the child to live as normally as possible

Skeletal Limb Deficiency

Underdevelopment of skeletal elements of

extremities Can range from minor defects (missing digit) to serious abnormalities

Amelia: loss of entire extremity Meromelia: partial absence of an extremity Phocomelia: seal limbs

Most are primary defects of development of limb

Prenatal destruction can occur due to constriction of

amniotic band

Meromelia partial absence of extremity

Skeletal Limb Deficiency

Therapeutic Management Prosthetic devices Applied at earliest possible stage Nursing Care Management Teaching parent about prosthetic application Occupational therapist Encourage parent to assist the child in making age appropriate advancements Do not OVERPROTECT child

Legg- Calve-Perthes Disease

Self limiting disorder with

femoral head aseptic necrosis Affects ages 2 to 12 Most commonly in boys ages 4 to 8 Cause unknown Can take place over 18 months or as long as several years

Camerons Personal Story

Legg- Calve-Perthes Disease

Insidious onset

History may reveal intermittent limp or persistent

ache or stiffness Diagnosed with x-ray and confirmed with MRI

Revealing osteonecrosis

Legg- Calve-Perthes Disease

Therapeutic Management

Goal: Keep head of femur in acetabulum

Treatment varies based on: Age Appearance of femoral head vasculature and position within acetabulum

Rest and non weight bearing

At times traction applied to stretch tight adductor muscles Non weight bearing devices: Abduction brace Leg casts Leather harness sling Surgery in some cases

Legg- Calve-Perthes Disease

Self limiting

Younger children have better prognosis for complete

recovery

Epiphysis are more cartilaginous

Children 10 and older have high risk for degenerative

arthritis The later the diagnosis, the more damage to femoral head

Legg- Calve-Perthes Disease

Nursing Care Management
Identify

the affected child and refer Educate the parent Why device being ordered Management and application of corrective device Signs of skin breakdown Signs that a new size needed Help the child to live as normally as possible

Skeletal deformity
Kyphosis: increased convex angulation in curvature

of the thoracic spine

Secondary to
TB Arthritis Osteodystrophy Compression fractures of thoracic spine

Lordosis: accentuation of cervical or lumbar

curvature
Trauma idiopathic

Idiopathic Scoliosis
Complex spinal deformity in three plains Lateral curve Spinal rotation causing rib asymmetry Thoracic kyphosis Most common spinal deformity

Classified according to age of onset Infantile: birth to 3 yrs Juvenile: develops during childhood Adolescent: develops during the growth spurt of early adolescents. Most noticeable during the pre adolescent growth spurt

Idiopathic Scoliosis

diagnostic evaluation
Observation: behind standing child Symmetry of shoulder height Scapular or flank shape Hip height and alignment As child bends forward at the waist (Adams test)

with hanging arms

Assymetry of ribs and flanks may be noted Scoliometer used to measure truncal rotation

Definitive diagnosis made by radiograph

of child in standing position

Idiopathic Scoliosis Therapeutic Management

Observation with clinical and radiographic evaluation

Curve < 10 degrees is postural variation Curve < 20 degrees is mild Boston, Wilmington, TLSO (thoracolumbosacral orthosis),Milwaukee, Charleston Nighttime Bending Brace

Orthotic intervention (bracing)

Surgical spinal fusion: realignment and straightening

with internal fixation and instrumentation combined with bony fusion of the realigned spine.

Curve >40 degrees Paralytic and Congenital curves generally -progress

Idiopathic Scoliosis Nursing Care Management

Treatments extends over years

Childs identity (physical and psychological) is

formed in adolescents Nursing care must take into consideration the adolescents perspective

Positive reinforcement Encouragement Independence Selection of clothing Participation of activities Socialization with peers

Idiopathic Scoliosis Nursing Care Management

Preoperative Care Educate on complexity of surgery
Teach patient to manage own PCA How to Log Roll Prepare for foley catheter Possibility of a chest tube Possibility of NG tube

Have a favorite toy, stuffed animal, iPad Meeting with a peer who has undergone similar surgery as well

Idiopathic Scoliosis Nursing Care Management

Postoperative care Monitored in an acute care setting
Neurological assessments of extremities critical Delayed paralysis may develop Most common post op issues

Neurological injury Spinal cord injury Hypotension from blood loss Wound infection

Log rolled Skin care

Risk for pressure ulcers

Pain management

Scoliosis
Ambulation begins 2 or 3 P.O.D. Discharged after 1 week

Adequate urine output Fluid and electrolyte balance ileus Skin integrity

Start PT as soon as patient able Self care always encouraged Teaching of family

Body image American Association Orthopedic Surgeons Scoliosis Research Society

Refer family to resources

Osteomyelitis
Inflammation and infection of bony tissue

May be caused by exogenous reasons ( trauma/

puncture wound/ or surgery) Or hematogenous sources (pre existing infection/ tonsillitis/ impetigo where the organism travels)

Osteomyelitis
Exogenous: infectious agent invades the bone following penetrating wound, open fracture, contamination in surgery or secondary extension from abscess or burn. Hematogenous: Existing infection spreads to bone Sources may be furuncles, skin infection, URI, abscessed teeth, pyelonephritis Any organism can cause osteomyelitis Infective emboli travel to arteries in bone metaphysis, causing abscess formation and bone destruction

Anna

Osteomyelitis
Staphylococcus aureus is most common causative

organism Signs and symptoms begin abruptly, resemble symptoms of arthritis and leukemia Marked leukocytosis and elevated Sed rate Early x-ray may appear normal CT, Bone scan , MRI Bone culture obtained from biopsy or aspirate

Osteomyelitis therapeutic management

May have sub-acute presentation with walled off

abscess rather than spreading infection Prompt, vigorous IV ABT for extended period (3-4 weeks or up to several months)

Monitor hematologic, renal, hepatic responses to treatment

Osteomyelitis Nursing Considerations

Complete bed rest and immobility of limb

Casting at time necessary

Pain management: position and medicate Surgery may be necessary Long term IV access (for ABT administration) Nutritional considerations

Child may have vomiting and poor appetite As infection controlled appetite returns

Long term hospitalization/ Physical Therapy to

ensure restoration of optimum functioning Psychosocial needs

Diversional and constructive activities

Juvenile Idiopathic Arthritis (juvenile rheumatoid arthritis)

Chronic Autoimmune inflammatory disease causing

inflammation of joints and other tissue

Starts before age 16 with peak onset between ages 1 and 3 years Twice as many girls are affected 13.9 per 100,000 children per year in caucasian children 113 per 100,000 children overall Unknown cause
Immunogenic susceptibility Environmental or external trigger such as a virus

Pathophysiology of JIA
Chronic inflammation of synovium with joint effusion eventual erosion destruction fibrosis of the articular cartilage If inflammatory process continues adhesions between joint surfaces ankylosis of joints

JIA

Clinical Manifestations
Variable and unpredictable

Not life threatening but can cause significant disability 70% of cases eventually becomes inactive

However child may have severe or minimal joint damage by time disease process abates Significant joint deformity and functional disability Medical evaluations PT Possible joint replacements Chronic or acute uveitis may occur

30% have progressive disease into adulthood

Diagnosis
Diagnosis of exclusion

Clinical criteria at age of onset before 16 years

Swelling and pain

Lab tests may or may not provide evidence

Sedimentation rate may or may not be elevated Leukocytosis usually present with acute exacerbation Antinuclear antibodies common but not specific

Radiology studies

Show soft tissue swelling and joint space widening with increased synovial fluid

Uveitis
Inflammation of anterior chamber of the eye Can be sight threatening

Therapeutic Management
Control pain NSAIDS Preserve Joint ROM and function PT: active range of motion Minimize effects of inflammation/ Joint deformity

NSAIDs/PT/OT

Promote normal growth and development Pool therapy Nighttime splinting reduce flexion deformity

Medications

NSAIDS Naproxen, ibuprofen and tolmetin Take with food Hydrate bruising Methotrexate Second line tx for children who have failed NSAIDs alone Used in combination with NSAID CBC and LFTs Corticosteroids Potent immunosuppressives Incapacitating arthritis/ uveitis/life threatening complications Etanercept (TNFI) (Enbrel) Tumor necrosis factor receptor blocker SAARDS Slow acting anti rheumatic drugs Work in combination with NSAIDS Sulfasalazine Hydroxychloraquine, gold, D-penicillamine.

Nursing Care Management

Assessment of all aspects of the child General health Status of involved joints Emotional response Support of the parents Parental concerns of prognosis Financial concerns Spouse and sibling relationships Job and schedule conflicts

Referral to social worker, counselors and support groups

Nursing Care Management

Relieve Pain Provide as much relief as possible

Medications Opioids avoided Non pharmacologic Behavior therapy Relaxation techniques

Promote general health Well balanced diet with sufficient caloric intake Sufficient rest Communication between family/PCP/rheumatology team is critical Normalcy Encourage independence!!! Attending school important

Communicate with school and school nurse

Nursing Care Management

Educate the patient and family on Medications

Therapeutic levels r/t schedules Signs and symptoms of toxicity

Proper placement and reason for device

splints and appliances

available resources

Benefits of heat application Moist heat Bathtub Electric blankets Exercise

Pools : range of motion

Prevent isolation and foster independence Encourage child to perform ADLs independently Encourage family to pursue normal activities

Osteosarcoma
Most common bone

cancer in children Peak incidence between 10 and 25 years of age Primary tumor sites in metaphysis of long bones (most likely in lower extremities)

>50% femur Humerus, tibia pelvis, jaw and phalanges

Therapeutic Management
Surgery and chemotherapy Biopsy followed by limb salvage or amputation

Nursing Care Management

Education for family and child

Salvage vs amputation Prosthesis fitting promotes early functioning Chemotherapy and side effects Anger and depression are normal and expected

Honesty and straightforward answers

Be in the room when physician explains Everyone grieves and learns differently

Phantom limb pain

Sensations such as tingling itching and pain in amputated limb Elavil

Nursing Care Management

Promote normalcy and resumption of pre

amputation activities

Pick clothing that does not draw attention to amputation Body image critical to adolescents

Ewing Sarcoma
Primitive neuroectodermal tumor

Second most common malignant bone tumor in

childhood Under age 30 majority being between ages 4 and 25 Originates in the shaft of long and trunk bones

Femur tibia fibula humerus ulna vertebrae scapula ribs pelvic bone and skull

Therapeutic Management
Intensive irradiation of the bone combined with

chemotherapy Amputation last resort

Nursing Care Management

Less traumatic for family related to likelihood that no

amputation will be necessary Need education r/t

Diagnostic testing (BMT, biopsy) Radiation and chemotherapy

Intense radiotherapy causes skin reaction Dry or moist desquamation then hyperpigmentation Increased sensitivity of area Child should wear loose fitted clothing over the area to minimize additional skin irritation

Chemotherapy

Hair loss, n/v, peripheral neuropathy and possible cardiotoxicity

Encourage resumption of normal lifestyle and activities

Systemic Lupus Erythematosus (SLE)

Autoimmune disease of connective tissues and blood

vessels Chronic Multisystem

Result of genetics as well as a trigger

Exposure to ultraviolet light Estrogen/pregnancy Infections drugs

Multisystem

SLE
Clinical Manifestations

Malar rash Discoid rash Photosensitivity Oro nasal ulcers Arthritis Serositis Renal disorder Neurological disorders Hematologic disorders

Therapeutic Management
Balance medications needed to avoid exacerbation and

complications While preventing or minimizing treatment associated morbidity

Corticosteroids Antimalarial: rash and arthritis NSAIDS Immunosuppressive: cyclophosphamide

Nutrition Sleep Exercise Limited exposure to sun & UV light

Nursing Care Management

Goal: assist family to positively adjust to disease & therapy Recognize exacerbation Recognize complications of medications Discuss with health care provider Body Image Problems Rash/hair loss/ steroid therapy Support Groups Lupus Foundation of America Arthritis Foundation Teaching Regular medical supervision Seek attention QUICKLY during illness or prior to elective surgical procedures Avoid sun and AVB exposure

Wear sunscreen and sun resistant clothing Limiting outdoor activities