1. MUSCULOSKELETAL DISORDERS Presented by Marlene Meador RN, MSN, CNE

2. Newborn Musculoskeletal System Flexibility – prevents injury Long bones – porous Epiphyseal plates – cartilaginous Muscular system – complete at birth

3. Clubfoot: Talipes Equinovarus Adduction and supination of forefoot with an inversion (varus) of the heel and fixed plantar flexion and the midfoot directs downward (equinus).

4. Clinical Manifestations Focus on early detection Assessment Diagnostic tests

5. Treatment Ponseti method - Serial manipulation with corrective casting Dennis Browne splints - horizontal bar attached to foot plates Dennis Browne splints Surgical correction

6. Nursing Care & Evaluation Provide Emotional Support Promote bonding Cast Care Referrals Regular check-ups Prognosis ROM after removal of casts

7. Developmental Dysplasia of the Hip Malrotation of the hip at birth Improper formation or function of acetabulum

8. Clinical Manifestations Infant Gluteal folds + Ortolani’ s - Barlow’s Maneuver Children Limited ROM Short femur Gait

9. Diagnostic Tests: Ultrasound CT and MRI X-ray

10. Treatment: Splinting of hip - Pavlik harness Hip maintained in flexion and abduction Deepens acetabulum from pressure of femur head

11. Treatment cont’d. Skin Traction Relocates femoral head while stretching restrictive soft tissue

12. Surgical Treatment & Spica Cast: Release muscles and tendons Application of body spica cast

13. Promoting Developmental Needs Bonding Environment Activity

14. ????? A parent asks why her infant must wear a Pavlik harness. The nurse responds that the purpose of this device is to: A. provide comfort and support. B. shorten the limb on the affected side. C. maintain the femur within the acetabulum. D. provide outward displacement of the femoral head.

15. Cast Care & Assessment Use palms to handle wet cast Elevate extremity & change position Keep cast clean & dry Petal cast Bar between the legs is not a handle! Assess CMS (circulation, movement, sensory); bleeding, temperature, skin integrity.

16. Complications Associated with Casts Compromise to circulation and inerva tion Compartment Syndrome Parathesia Pain Pressure Pallor ** Paralysis ** Pulselessness **

17. Nursing Management for the Casted Child Encourage cuddling Teach parent application of harness Developmental needs Bring environment to child Protect skin Diet Safety

18. ????? An 18 month old is scheduled for application of a plaster cast to correct a clubfoot. The post-op plan should include which of the following measures? a. Elevate the cast above the level of the heart b. Handle cast with fingertips c. Reposition the child every 2 hours d. Spray the cast with an acrylic protectant

19. Fractures Occur as a result of direct force Greenstick fracture MVA Repeated stress on the bone Pathologic conditions

20. Patho-physiology Epiphyseal plate Pliable and porous Healing is Rapid in children 1 week for every year of life up to 10 years of age

21. Assessment Pain Tenderness Edema Limited movement Distortion of limb

22. Treatment Casting Traction Surgical intervention

23. Complications associated with orthopedic trauma: Fat Embolism Particles of fat are carried through circulation and lodge in lung capillaries causing: Pulmonary edema Respiratory distress with hypoxemia and respiratory acidosis Treatment Increase in IV fluids Respiratory support and adequate oxygenation

24. Legal & Ethical implications when caring for a child with a fracture: All fractures entering the hospital via ER require social service consult for documentation of suspected abuse or neglect. The nurse must report all suspected abuse to the appropriate authority. Do not discuss the possibility of abuse with the parents or guardians!! Do not attempt to prove or disprove abuse.

25. Scoliosis Lateral “S” or “C” curvature of the spine > 10° Structural Idiopathic (70-80% of all cases) Congenital Neuromuscular –Poliomyelitis –Cerebral palsy –Muscular dystrophy

26. Scoliosis

27. Manifestations Screening 5 th & 7 th grades Classic Signs: Truncal asymmetry Uneven shoulders and hips A one-sided rib bump Prominent scapula

28. Treatment of Scoliosis Mild 10-20° Exercises improve posture Moderate 20-40° Bracing maintains existing curvature Severe 40° or > Spinal fusion (> 80% = compromised respiratory function) Goal: limit or stop progression of curvature

29. ???? The school nurse would screen an adolescent for scoliosis by instructing him/her to: A. Bend forward at the waist, holding hands together B. Lie prone on an examination table C. Stand with shoulders placed against the wall D. Sit on a chair and raise shoulders

30. Bracing Used for skeletally immature http://milwaukee.brace.nu/

31. ???? An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen? A. Discourage participation in ADL’s. B. Teach appropriate application, removal and care of skin and brace. C. Discourage sports like golf and tennis encourage sedentary activities. D. Teach non-weight bearing techniques.

32. Rods: Recommended for curves > 40 degrees Goal: fuse spine to prevent progression

33. Surgical Care Pre-op Mentally prepare Demonstrate incentive spirometer, TCDB, log roll PCA pump Post – op Pain management Monitor neurovascular status Monitor H&H Log Roll, sit, ambulate ROM Dressing changes

34. What would you teach a child to expect in the immediate post-op period? a. Frequent neurovascular assessments b. Need to CT&DB every 2 hours (IS) c. Possibility of IV, chest tubes d. Use of post-op analgesia

35. Discharge No heavy lifting, bending or twisting at the waist. Brace application Follow-up X-rays Once fused may resume normal activity levels, skiing, sports, etc…

36. Muscular Dystrophy Muscle fiber degeneration and muscle wasting. Duchennes Onset of symptoms 3-4 years of life Terminal disorder

37. Clinical Manifestations & Diagnosis S/S Delayed walking, frequent falls, tire easily, toe walking, hypertrophied calves, waddling gait, lardosis, + Gower’s maneuver, mental retardation Dx: Muscle biopsy (↓ distrophin) ↑ Serum enzyme CK Electromyogram EEG (75% are abnormal)

38. Prognosis: 1:3500 children effected Ability to walk lost by age 9-12 Death occurs 9-10 years after diagnosis

39. Nursing Care: Promote optimal health Goal: keep child ambulatory Assess muscle weakness Respiratory function Nutritional status OT, PT, RT

40. Psychological Impact What are some psychological issues that may affect a family caring for a child with muscular dystrophy?

41. Family Centered Care: Financial resources Community resources Cultural influences Support groups

42. Please contact me if you have any questions or concerns regarding this presentation. Marlene Meador RN, MSN, CNE mmeador@austincc.edu