1. Musculoskeletal disorder
Islamic University Nursing College

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

3. Musculoskeletal 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 (flexible) in children, dislocations and sprains are less common than in adults
Nutrient storage (glycogen in muscles, calcium and phosphorus in bones)

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

5. Musculoskeletal: Physical Assessment
Assessment of concerns:
Pain or tenderness & Muscle spasm
Masses
Soft tissue swelling
Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. A child younger than 1 year with a fracture should be evaluated for possible physical abuse or an underlying musculoskeletal disorder that would cause spontaneous bone injury
assess injury site at the last

6. Musculoskeletal: Neurovascular Assessment
Neurovascular checks should be done at least every 1 to 2 hours during the first 48 hours, and usually for as long as the child is in traction
Pain: (location, alleviated and aggravating factors; Does the pain become worse when fingers or toes are flexed)
Sensation: Can the child feel/ touch on the affected extremity
Motion: Can the child move fingers or toes below area of injury / nerve injury
Temperature: Is the extremity warm or cool to touch
Capillary refill; Color; Pulses (distal to injury or cast)

7. Musculoskeletal: Diagnostic procedures
X-ray & Bone scan
Alkaline phosphatase (ALP): ALP is an enzyme found mainly in bone, liver, placenta, and kidney; levels may be elevated in bone disease, fractures, trauma, or liver disease and during periods of rapid growth.
Electromyography (EMG): studies the electrical activity of skeletal muscle and nerve conduction.
Muscle or bone biopsy
Arthoscopy: direct visualization of a joint with a fiberoptic instrument.

8. Fracture Causes of fracture:
Birth trauma, child abuse & injury.
Vehicle accident for children and rare in infants
Fracture line can be transverse, oblique, or spiral, compound

9. 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

10. 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

11. Fracture: Therapeutic Management
Internal Fixation External Fixation

12. 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

13. Fracture: Cast 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 fussiness (carefulness) or irritability and pain
Discoloration of finger or toes

14. Fracture: Traction
Is the direct application of force to produce equilibrium at the fracture site
Types of tractions
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

15. Fracture: Traction Purposes
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 fatigue the involved muscle and reduce muscle spasm so that bones can be realigned (Fatiguing of muscle is accomplished by applying constant stress to the muscle so that the buildup of lactic acid will produce muscle relaxation)

16. Fracture: Traction Nursing Care 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.

17. 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

18. Fracture: Complications
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

19. Fracture: Complications
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

20. Sprained ankle Management ( in the first 6 to 12 hours)
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

21. 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

22. Lordosis
Is an accentuation (stress) 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.

23. 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

24. Scoliosis: Types Functional scoliosis Structural scoliosis
caused by a secondary problem such as unequal leg length.
The curve tends to be a C-shaped curve
can be treated by treating the primary cause first
Structural scoliosis
the cause is idiopathic with a positive family history in some cases
It involves a permanent curvature of spine accompanied by damage to the vertebral.
The curve tends to be S-shaped curve.

25. Scoliosis: Clinical Manifestation
From standing position ( feet together and arms at sided)
Unequal shoulders level
Curved spinal column
Uneven level of the elbows
From bending position ( child bends and touch his toes):
Rotation of the spine becomes more prominent.
Hump (bulge) in the back
One shoulder blade is more prominent than other is
In some cases there are back pain, fatigue and dyspnea

26. Scoliosis: Management
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

27. 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.

28. DDH/CHD: Degrees Acetabular dysplasia (or preluxation) Subluxation
Dislocation

29. DDH/CHD: Degrees Acetabular dysplasia (or preluxation)
The mildest form
The femoral head remains in the acetabulum

30. DDH/CHD: Degrees Subluxation Dislocation
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 ligamentum tears cause 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

31. DDH/CHD: diagnosis Ortolani test Barlow 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)

32. DDH/CHD: diagnosis Other signs of DDH are: Ultrasounds
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

33. DDH/CHD: Management Newborn to six months 6-8 months: Pavlik harness
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.
6-8 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

34. DDH/CHD: Management 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

35. DDH/CHD: Nursing Diagnosis & Management
Knowledge deficit regarding care of harness or cast
Impaired physical mobility
Risk for impaired skin integrity related to pressure from casts or braces
Risk for altered skin perfusion due to casts or braces
Risk for altered growth and development due to limited mobility
Nursing Management
Compliance with corrective devices by parents
Not removed for bathing
Prevent skin irritation
Cast care & Diaper area
Because DDH may reoccur it is important to follow-up until the child reaches skeletal maturity

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. Congenital clubfoot: Management
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. Juvenile Rheumatoid Arthritis (JRA): Pauciarticular
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
Some children with pauciarticular disease outgrow arthritis by adulthood, although eye problems can continue and joint symptoms may recur in some people

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 that typically 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. Juvenile Rheumatoid Arthritis (JRA): Clinical Manifestations
Eye inflammation
Sometimes occurs in children with pauciarticular JRA.
Not present until some time 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:
Age of onset
Arthritis in one or more joints for 6 weeks or longer
Exclusion of other etiologies.
Laboratory tests-- Blood may be taken to test for RF and ANA, and to determine the Erythrocyte 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. Juvenile Rheumatoid Arthritis (JRA): Treatment
NSAIDs: Aspirin, ibuprofen; may cause Reye’s Syndrome
Disease-modifying anti-rheumatic drugs (DMARDs): 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

50. Juvenile Rheumatoid Arthritis (JRA): Side effect of Aspirin
Bleeding
Stomach upset
Liver problems
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

51. Juvenile Rheumatoid Arthritis
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.
After discharge
routine ophthalmologic examinations
Swimming

52. 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

53. Cerebral palsy (CP) Risk factors include: Prematurity LBW Asphyxia
Infections (meningitis, encephalitis)
Head injuries
Metabolic problems such as hyperbilirubinemia and hypoglycemia
Sever dehydration

54. Cerebral palsy (CP): Types
Spastic
Dyskinetic/ athetoid
Ataxic
Mixed type/dystonic

55. Cerebral palsy (CP): Types
Spastic : (most common type)
May involve one or both sides
Hypertonicity with poor control of posture, balance, and coordinated motion (rigid & jerky movement).
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

56. Cerebral palsy (CP): Types
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.

57. Cerebral palsy (CP): 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.

58. Cerebral palsy (CP): Treatment
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