1. DR. Areefa Albahri (Alkasseh) Islamic University of Gaza
24/07/1438
Musculoskeletal (MS) By
DR. Areefa Albahri (Alkasseh)
Assistant Prof. of MCH
Islamic University of Gaza
DR. Areefa Albahri

2. Musculoskeletal (MS)
The main organs and tissues that are part of the musculoskeletal system in humans are
The cartilages
The bones
The muscles

3. Main functions of MS are:
To support & protect vital organs (the brain, heart and lungs)
To keep structure and maintenance of the body spatial conformation.
Allows the body to move (walking, standing, bending). Because soft tissues are resilient in children, dislocations and sprains are less common than in adults
Nutrient storage (glycogen in muscles, calcium and phosphorus in bones).
Spatial= 4 dimention

4. Musculoskeletal: Physical Assessment
Inspect child undressed
Observe child walking
Spinal alignment
Range of Movement (ROM)
Muscle strength
Reflexes

5. Fracture
comminuted

6. Fracture: Clinical Manifestations
Swelling, pain or tenderness
Diminished functional use of the affected part; inability to bear weight
Bruising, severe muscular rigidity
Sometimes crepitus
Less frequent neurological and vascular damage (ischemia), which can be assessed using 5 Ps
Pain
Pallor
Pulselessness
Parasthesia
Paralysis

7. Fracture: Therapeutic Management
Cast: fiberglass or plaster application to immobilize affected body part
Tractions :Is the direct application of force to produce equilibrium at the fracture site
Distraction: involves the use of an external device to separate opposing bones to encourage regeneration of new bone & used to immobilize fractures or correct defects when the bone is rotated or angled

10. Risk for altered tissue perfusion R/F pressure from cast
Fracture: Cast
Risk for altered tissue perfusion R/F pressure from cast
Keep extremity elevated to decrease edema.
assess circulation Q 15 minutes after applying the cast then hourly
assess skin warmth and 5 Ps
Risk for impaired skin integrity R/F pressure from cast
Cast edges must smoothed/covered
Cast remains in place for 4-8 weeks
Discourage itching under the cast

11. Possible concerns Unusual odor under the cast Drainage from cast
Tingling, numbness and swelling in the casted body part
Loose or cracked cast
Unexplained fever
Unusual irritability and pain
Discoloration of finger or toes

12. Manual traction: applied by hand is used during cast
Fracture: Traction
traction refers to the practice of exerting a slow, gentle pull on a fractured or dislocated body part. The purpose is to guide the part back into place and to produce equilibrium at the fracture site
. Traction may also be used to stretch the neck and prevent painful muscle spasms.
Manual traction: applied by hand is used during cast
Skin traction: pull applied directly to the skin surface and indirectly to the skeletal structure
Skeletal traction: pull applied directly to the skeletal structure by a pin, wire, or tongs

14. Purposes of Traction: To realign bone fragments & treat dislocation
To provide rest for an extremity & help prevent or improve contracture deformity.
To allow preoperative or postoperative positioning and alignment.
To provide immobilization of affected body part
To reduce muscle spasm so that bones can be realigned

15. Nursing Care of traction:
Regular assessment of 5 Ps
Skeletal traction is never released by the nurse (do not move the weights)
Assess blood pressure
Skin care for the child’s back, elbows and heels

16. Circulatory impairment:
Fracture Complications:
Circulatory impairment:
Careful assessment of the pulses, skin color, and temperature is crucial
Nerve compression syndromes (e.g., carpal tunnel syndrome, tarsal tunnel syndrome)
Sensory testing with touch and pinprick
Evaluating motor strength by asking the child to move the unaffected joint distal to the injury

17. Compartment syndromes
Is a tissue ischemia due to a compression of nerves, blood vessels, and muscle inside a closed space (compartment) within the body due to increased pressure in that part
The most frequent causes are:
Tight dressings or casts, hemorrhage, trauma, burns, and surgery
Signs & symptoms include:
Motor weakness and pain that does not decrease with medication
The muscle may feel tight or full
Burning sensation

18. Epiphyseal damage: leads to unequal growth
Infection: osteomyelitis (potential problem in open fractures, from pressure ulcers, or when bone surgery)
Pulmonary emboli: blood, air, or fat emboli may produce a life-threatening vascular obstruction and ischemia.
Primary symptom is shortness of breath and chest pain.
Interventions should include:
Place patient in high fowlers
Administer O2 and check chest X-ray

19. Sprained ankle
A soft tissue injury
Management ( in the first 6 to 12 hours)
Controlling the swelling and reducing muscle damage by “RICE” Rest, Ice, Compression, Elevation

20. Kyphosis
Is an abnormally increased convex angulation in the curvature of the thoracic spine
It can occur secondary to disease process such as tuberculosis, chronic arthritis
Treatment
Postural exercises
Bracing (Milwaukee) for more marked deformity

21. Lordosis
Is an accentuation of the lumbar curvature beyond physiologic limits
It may be a complication of a disease process, the result of trauma or idiopathic
Lordosis is a normal observation in toddlers
In older children is often seen in association with flexion contractures of the hip, obesity, congenital dislocated hip and slipped femoral capital epiphysis.

22. Scoliosis
Is a spinal deformity which may involve lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis.
It is the most common spinal deformity.
It can be congenital, or it can develop during infancy or childhood, but it is most common during adolescence (peaks between 8-15 years)
It may be genetic and transmitted as an autosomal dominant trait
It may be multifactorial

23. Scoliosis: Types
Non-surgical management aimed to :
Promoting self-esteem and positive body image
Maintain spinal stability
Prevent further progression of deformity until bone growth is complete and surgical repair can be performed
Mild cases (less than 20%), observation and exercises- swimming is advised & Long-term monitoring.
Moderate (20-40%), exercises, traction, bracing.
Bracing (Milwaukee brace) is successful in halting or slowing the progression of curvatures
Severe (more than 40%), bracing until the skeletal system mature and then surgical intervention
Surgery includes realignment and straightening of the spine with internal fixation

24. Developmental/congenital hip dysplasia/dislocation (DDH/CHD)
Improper formation and function of the hip socket.
Cause of DDH is unknown, but there are predisposing factors such as:
Genetic factors & birth order
Physiologic factors: maternal hormone
Mechanical factors: intrauterine position (breech), oligohydraminos, twining and fetus size, delivery type, postnatal positioning
DDH occurs more commonly in females.
socket= hollow

25. Acetabular dysplasia (or preluxation)
Subluxation_Accounts for the largest percentage of DDH. It implies incomplete dislocation. The femoral head remains in contact with the acetabulum, but a stretched capsule and the head of the femur to be partially displaced.
Dislocation
Femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim
DDH/CHD: Degree:

26. Acetabular dysplasia (or preluxation)
The mildest form
The femoral head remains in the acetabulum

27. DDH/CHD: diagnosis Ortolani test
Abduction of the thighs with external rotation.
If the femoral head can be felt to slip forward into the acetabulum on pressure from behind, it is dislocated (positive Ortolani sign)
Sometimes an audible “clunk” can be heard.
Barlow test
Pressure from the front
If the femoral head is felt to slip out over the posterior lip of the acetabulum and immediately slips back in place when pressure is released, there is dislocation or “unstable” (positive Barlow sign)

30. Other signs of DDH are:
Shortening of the limb on the affected side (limping and toe walking
Positive Trendelenburg sign or gait)
Asymmetric thigh and gluteal folds
Broadening of the perineum(in bilateral dislocation)
Ultrasounds

31. DDH/CHD: Management Pavlik harness Newborn to six months
The harness is used to maintain the infant’s hips in flexion and abduction and external rotation
Pavlik harness device is to be worn continuously.
The child in a Pavlik harness needs special attention to skin care because the infant’s skin is sensitive and the harness may cause irritation.

32. DDH/CHD: Management
six months to 8 months
Gradual reduction by traction is used for approximately 3 weeks.
If the hip is not reducible, an open operative reduction is performed. Following reduction the child is placed in a hip spica cast for 2-4 months

33. Older child:
Operative reduction
After cast removal and before weight bearing is permitted, range-of-motion exercises & rehabilitative measures
The former practice of double-or triple-diaper for DDH is not recommended because it promotes hip extension, thus worsening proper hip development

34. Pavlik harness can be used from birth up to 5 or 6 months of age.
It is anon-invasive device for keeping hips in a continually abducted position, which
allows for the femoral head to remain in contact with the acetabulum.
■■ Infants will wear the harness continuously for 3 to 5 months, until the hip is determined, by radiograph, to be stable. Frequent follow-ups will be needed for strap adjustment.

35. Nursing Actions
☐☐ Check skin integrity frequently.
☐☐ Ensure proper positioning at all times.
☐☐ Determine the family’s ability to adjust the harness.
Client Education
☐☐ Instruct families to keep the harness on continuously, except during bathing, if prescribed.
☐☐ Instruct families to return for follow-up visits.
☐☐ Reinforce teaching about skin care.
Encourage application of a cotton shirt and cotton socks under the harness to prevent irritation and the avoidance
of powders and lotions.

36. Congenital clubfoot (Talipes)
Deformity of the ankle and foot
Categories of Talipes
Positional clubfoot (transitional, mild or postural),
may occur from intrauterine crowding
responds to simple stretching and casting.
Syndromic (tetralogic ) clubfoot
associated with other congenital abnormalities such as myelomeningocele,
more severe form of clubfoot that is often resistant to treatment.
Congenital clubfoot (idiopathic )
has a wide range of rigidity and prognosis

37. Congenital clubfoot: Management
Goal of management: is Correction of the deformity & Maintenance of the correction until normal muscle is gained
Management:
Casts:
Begin immediately or shortly after birth and continue until marked overcorrection is reached.
Weekly manipulation and cast changes proceed for the first 6 to 12 weeks of life.
Surgery:
If casting and manipulation are not successful
Followed by brace and cast

38. Nursing Care:
Observation of skin and circulation (particularly important in young infants because of their normally rapid growth rate): swelling in the toes, foot temperature
Parents need to understand the diagnosis, the overall treatment program, the importance of regular cast changes

39. Juvenile Rheumatoid Arthritis (JRA)
Is an inflammatory disease of the body joints and sometimes affects blood vessels and connective tissue
Unknown cause but a slight tendency to occur in families
Peak ages: 2 – 5 years and between years of age
JRA is similar to the adult disease with some distinguishing features
Onset before puberty
A negative rheumatoid factor (RF).

40. Juvenile Rheumatoid Arthritis (JRA): Courses
Pauciarticular
Polyarticular
Systemic

41. Juvenile Rheumatoid Arthritis (JRA): Pauciarticular
4 or fewer joints are affected
The most common form of JRA; about half of all children with JRA have this type
Affects large joints, such as the knees
Girls under age 8 are most likely to develop this type of JRA.
Some children have special kinds of antibodies in the blood.
Antinuclear antibody (ANA)
Rheumatoid factor

42. Eye disease:
affects about 20 to 30% of children with pauciarticular JRA
Up to 80% of those with eye disease also test positive for ANA
The disease tends to develop at a particularly early age in these children
Regular examinations by an ophthalmologist are necessary to prevent serious eye problems such as iritis or uveitis

43. Juvenile Rheumatoid Arthritis (JRA): Polyarticular
30% of all children with JRA have polyarticular disease
5 or more joints are affected. The small joints (hands and feet) are most commonly involved, though large joints may be affected
Symmetrical; that is, it affects the same joint on both sides of the body
Some children have an antibody in their blood called IgM rheumatoid factor (RF)
These children often have a more severe form of the disease

44. Juvenile Rheumatoid Arthritis (JRA): Systemic (Still’s disease)
Joint swelling, & fever and a light skin rash
May also affect internal organs such as the heart, liver, spleen, and lymph nodes
Almost all children with this type of JRA test negative for both RF and ANA
Affects 20% of all children with JRA. A small percentage of these children develop arthritis in many joints and can have severe arthritis that continues into adulthood.

45. Juvenile Rheumatoid Arthritis (JRA): Clinical Manifestations
Joint swelling:
Stiffness is worse in the morning or after a nap
Pain may limit/loss movement of the affected joint
Commonly affects the knees and joints in the hands and feet
One of the earliest signs of JRA may be limping in the morning because of an affected knee.
Besides joint symptoms, children with systemic JRA have
A high fever and a light skin rash. The rash and fever may appear and disappear very quickly.
Swelling in the lymph nodes located in the neck and other parts of the body
In some cases (< 50%), internal organs (heart and, very rarely, the lungs) may be involved.

46. Eye inflammation: Growth problems:
Sometimes occurs in children with pauciarticular JRA.
Not present until sometime after a child first develops JRA
Typically, there are periods when the symptoms of JRA are better or disappear (remissions) and times when symptoms are worse (flare-ups).
Growth problems:
Depending on the severity of the disease and the joints involved, it may cause joints to grow unevenly or to one side causing one leg or arm to be longer than the other.
Overall growth may also be slowed.

47. Juvenile Rheumatoid Arthritis (JRA): Diagnosis
Diagnosis of JRA is based on:
onset
Laboratory tests-- Blood may be taken to test for RF , and Sedimentation Rate (ESR).
Positive RF is detected in just 10% of the cases. The RF test helps the doctor tell the difference among the three types of JRA.
ANA is found in the blood more often than RF, and both (ANA & RF) are found in only a small portion of JRA patients.
ESR indicates inflammation in the body. Not all children with active joint inflammation have an elevated ESR.
Lab. tests may include elevated WBCs

48. Juvenile Rheumatoid Arthritis (JRA): Therapeutic Management
Preserve joint function,
Prevent physical deformities, and
Relieve symptoms
Goals
Nonsteroidal anti-inflammatory drugs
Disease-modifying anti-rheumatic drugs
Corticosteroids
Biologic agent
Physical therapy
Treatment
Reye Syndrome
Free of treatment related harm

49. Disease-modifying anti-rheumatic drugs (DMARDs) such as (Cytoxan, Methotrexate…): most given in combination with NSAIDs to slow the progression of JRA.
Corticosteroids: to control severe symptoms; can interfere with a child's normal growth, a round face, weakened bones, and increased susceptibility to infections.
Biologic agents: Etanercept (Enbrel) blocks the actions of tumor necrosis factor, a naturally occurring protein in the body that helps cause inflammation.
Physical therapy: Exercise to maintain muscle tone and preserve and recover the range of motion of the joints; rest of affect body part and heat application.
Bleeding.
Stomach upset.
Liver problems

50. Reye’s Syndrome:
Is sudden (acute) brain damage (encephalopathy) & liver function problems.
Abnormal accumulations of fat begin to develop in the liver and other organs of the body, along with a severe increase of pressure in the brain.
Without proper treatment, death is common within a few days.
During painful episodes of the disease:
Proper positioning is important to support and protect affected joints. Isometric exercises and passive range-of-motion exercises will prevent contractures and deformities. Swimming in warm water provides strengthening and range-of-motion exercises while protecting the joints.

51. Cerebral palsy (CP)
It is a group of non-progressive disorders (meaning the brain damage does not worsen, but secondary orthopedic difficulties are common) of motor neuron impairment that result in
Motor dysfunction
May be accompanied by perceptual problems, language deficits, and intellectual involvement.
The disabilities usually result from injury to the cerebellum, basal ganglia, or motor cortex.
The exact cause is unknown; it may results from injury to the brain before, during, or shortly after birth
Risk factors include:
Prematurity
LBW
Asphyxia
Infections (meningitis, encephalitis)
Head injuries
Metabolic problems such as hyperbilirubinemia and hypoglycemia
Sever dehydration

52. Types of Cerebral Palsy:
Spastic : (most common type)
May involve one or both sides
Hypertonicity with poor control of posture, balance,
Impairment of fine and gross motor skills
Dyskinetic/ athetoid:
Abnormal involuntary movement
Slow, wormlike, writhing (rolling & twisting) movements that usually involve the extremities, trunk, neck, facial muscles, and tongue.
Involvement of the pharyngeal, laryngeal, and oral muscles causes drooling and dysarthria (imperfect speech articulation)
Involuntary irregular jerking movements
Ataxic
Rapid, repetitive movements performed poorly.
Disintegration of movements of the upper extremities when the child reaches for objects
Mixed type/dystonic:
Combination of spasticity and athetosis.

53. Cerebral Palsy Clinical Manifestations:
Delayed gross motor development.
Alteration in muscle tone: increased or decreased resistance to passive movements.
Abnormal posture :opisthotonic postures (exaggerated arching of the back) and may feel stiff on handling or dressing.
Reflex abnormalities: persistence of primitive infantile reflexes is one of the earliest clues to CP.
Possible Associated disabilities and problems:
Convulsion/seizure
Visual and hearing impairments
Communication and speech difficulties
Some may have varying levels of mental retardation.

54. Cerebral Palsy Treatments:
Goals of Treatment:
Establish locomotion, communication and self-help.
Gain optimum appearance and integration of motor functions.
Correct associated defects.
Adaptation.
Management:
Provide safe environment to prevent injury.
Prevent physical deformities by using braces and provide ROM exercises.
Appropriate motor activities.
Medications such as sedatives, muscle relaxants, anticonvulsants.
Encourage ADLs.
Occupational to improve small muscles development
Speech therapy