Musculoskeletal Stressors and Adaptation

Common MS disorders in Children Congenital hip dysplasia Clubfoot Fractures Scoliosis Osteogenesis Imperfecta Osgood-Schlatter Disease Osteomylitis Muscular Dystrophy JRA

Congenital hip dysplasia Hereditary disorder, more common in girls, unilateral Improper formation and function of hip socket Head of femur is dislocated Flat acetabulum of pelvis (prevents femur from remaining in the acetabulum and rotating adequately)

Diagnosis Early detection is key Affected leg may appear shorter Asymmetry of gluteal and thigh folds Limited hip abduction “Ortolani click” Uneven gait in older child

Management for infants under 3 months of age Pavlik harness: keeps hips and knees flexed, the hips abducted, and the femoral head in the acetabulum worn continuously for 3 to 6 months effective 90% of time

Management for infants >3 months age Hip spica cast: maintains abduction (frog-like position) 3-18 months age Worn for 1 year Must be changed as child grows ORIF (surgical insertion of pin) For child >18mos Successful reduction is difficult after age 4

Clubfoot Congenital deformity Can affect one or both feet Portions of foot and ankle are twisted out of normal position Pseudo-deformity vs True-defect Varying degrees of severity & combinations of abnormal positions

Part of newborn assessment Early detection Part of newborn assessment Treatment: Begins soon after birth, before discharge Manipulation with serial casting for 8-12 weeks (due to rapid growth) Cast extends above infant’s knee to ensure correction

If ineffective: surgical correction btw 4-12 mos, realignment of bones, pin insertion, cast for 6-12 weeks Denis Browne Splints: shoes attached to metal bar to maintain correction

Nursing care Neurovascular assessment Pain assessment Frequent diaper changes Infection Skin integrity Activity Follow-up

Fractures Break in bone from stress Frequent in children- bones are not as dense and more porous Usually occur from Falls Sports MVA Bone disease

Fractures Symptoms: Pain Abnormal limb positioning Decreased ROM Edema Ecchymosis Crepitus Refusal to play with extremity, guarding

Common Fractures in Children Complete- break across entire bone Spiral- twisting Greenstick- compression Comminuted- fragments Open- through skin Closed- not through skin

Management Cast Surgery Pins and external devices Traction- used to align bone Skin Pull is applied to the skin and muscle Skeletal Pull is applied to the bone pins

Management Prevention of complications Infection Neurovascular injury Compartment Syndrome Immobility Malignment Growth and Development issues

Cast Care in Children observe for swelling, pain, discoloration, movement, loss of pulses keep extremity elevated for 1st day keep cast free of foreign objects cast becomes part of body, fear removal relate it to a haircut, doesn’t hurt “tickly” sensation, extremity may become hot from vibrating cast cutter

Scoliosis Most common type of spinal deformity, girls 5:1 ratio Lateral curvature of spine Can be congenital or develop in infancy or childhood Dx: by observation All children screened in 5th grade Ill fitting clothes Uneven shoulders, scapulae, hips Scoliometer: degree of curvature

Treatment Mild Moderate Life Long monitoring Bracing Exercises to improve posture and flexibility Electrical Stimulation to back muscles

Treatment for Severe Milwaukee brace worn 16-23 hours/day Surgical correction: spinal realignment & straightening (Harrington Rod) Nursing Care Log Roll Skin Care Circulation and Neuro status

Osteogenesis Imperfecta Connective tissue disorder, leads to fragile bone formation Causes recurrent pathological fxs Will not have normal growth in height 2 types: Severe autosomal dominant form Infant born with fxs from birth Autosomal recessive Occurs later in life, associated deafness and dental deformities

Goal: protect from trauma Reduce the number of fractures Early intervention Splints, Braces, Surgical Rods Handle child gently Childproof home

Osgood-Schlatter Disease Thickening & enlargement of tibial tuberosity, results from microtrauma (sports-related) Bilateral knee pain exacerbated by running, jumping, climbing stairs Treatment: Self-limiting condition: rest, ice, heat, NSAIDs Immobilization of limb may be necessary

Osteomyelitis Bacterial infection of bone Can follow open fractures, burns, skin abscess, foreign body Signs and Symptoms Pain, warmth, tenderness, limited ROM localized to the area of infection In younger child- more subtle symptoms, irritability

Osteomyelitis Dx: increased WBC’s, sed rate, positive blood culture, on MRI bone purulence, edema Treatment: 4-6 weeks of ABX (PICC line) Limit weight bearing on extremity

Muscular Dystrophy Inherited disease with progressive deterioration of muscle cells Causes progressive muscle weakness and atrophy Several different types All differ by age of onset and severity

Duchenne’s Muscular Dystrophy Most common type Sex-linked recessive, boys, s/s by age 3 Will meet motor milestones, but later Age 3 see waddling gait, difficulty climbing stairs

Gower’s Sign: press hands against ankles, knees & thighs to stand up

Duchenne’s Muscular Dystrophy Speech & swallowing become impaired More pronounced muscle weakness (scoliosis) Wheelchair by junior high Tachycardia Pneumonia Heart failure age 20 Treatment: Maintain ambulation & independence Muscular Dystrophy Association, mdausa.org

Juvenile Rheumatoid Arthritis Chronic inflammation of synovium with eventual erosion of articular cartilage Cause is autoimmune + ANA (antinuclear antibodies) and + RF (rheumatoid factor) Peak: 1-3 years or 8-12 years, girls affected more Follows one of three clinical courses Systemic:elevated temperature, rash, any # of joints affected Pauciarticular: involves 4 or less joints, usually large joints Polyarticular: involves 5 or more joints, smaller joints or weight bearing joints

Clinical manifestations Increased WBC’s & sed rate Stiffness in AM Swelling Tenderness Painful to touch Warm to touch, seldom red Loss of motion

Juvenile Rheumatoid Arthritis Goals of care: Maintain joint fx (splints, ROM) Prevent physical deformities Relieve symptoms (pain & inflammation) NSAID’s (aspirin, ibuprofen, naproxen) SAARD’s Slower Acting Antirheumatic Drugs(gold, D-penicllamine)

Nursing Care Facilitate medication compliance Encourage child to be as independent as possible Moist heat (bath or whirlpool) especially in morning Most common complications: severe hip involvement with loss of function possible blindness r/t iridocyclitis (inflammation of iris & ciliary body)

Case Study

A newborn is found to have Congenital hip dysplasia prior to discharge A newborn is found to have Congenital hip dysplasia prior to discharge. You will be the nurse caring for this baby and new mother after discharge from the nursery and will be admitting the infant to the pediatric unit.

What assessment findings would you expect in the newborn?

How will this condition be treated?

What teaching needs to be completed with the parents of this newborn?

The parents ask you about what they can expect regarding long-term consequences. How should you respond?

A 3-year-old child is suspected of having Duchenne’s muscular dystrophy. Which of the following assessment findings by the nurse would support this diagnosis? A history of delayed crawling Outward rotation of the hips Difficulty climbing stairs Wasted muscle appearance

A child is admitted to the hospital with a diagnosis of rule out osteomyelitis. Which of the following serum laboratory values noted by the nurse supports this diagnosis? Decreased WBC Positive Blood Cultures Increased HCT Increased BUN

An adolescent diagnosed with idiopathic structural scoliosis describes all of the following symptoms. Which one would the nurse conclude is not associated with this diagnosis? Back pain Skirts that hang unevenly Unequal shoulder heights Uneven waist angles

A 4-year-old child with osteogenesis imperfecta is admitted to the hospital unit for an unrelated condition. The nurse determines that which nursing diagnosis has the highest priority for this child? Impaired skin integrity related to cast Pain related to fractures Risk for injury related to disease state Disturbed body image related to short stature

Which item should the nurse remove from the bedside table of a 4-year-old child who has just been placed in bilateral long leg casts? Legos Etch-a-sketch Fireman’s hat Coloring book