1. Pediatric Musculoskeletal Disorders

2. Musculoskeletal Development
Infant bones are only 65% ossified
Long bones are porous and less dense and can bend, buckle or break easily
Growth takes place in Epiphyseal plates, and if these are injured, can cause abnormal growth
Growing bones heal quickly and decrease need for treatment
How does the growth process contribute to complications in musculoskeletal development?

3. Clubfoot
A congenital abnormality in which the foot is twisted out of its normal position.

4. Talipes Equinovarus (Clubfoot)
Muscles, tendons, and bones are involved in the abnormality.
Adduction and supination of forefoot
Inversion of the heel
Fixed plantar flexion
Assessment findings- adduction and supination of forefoot with an inversion of the heel and fixed plantar flexion. Equinus Varus= Equinus is the midfoot is directed downward, Varus= The hindfoot turns inward, and the forefoot curls toward the heel
Provide emotional support for family throughout discovery (loss of “perfect child”)
Orthopedic specialists, OT and PT for consult. May also need financial consultation as the treatment requires multiple castings or surgical repair

5. Return the foot to a maximal anatomic position
Goal of Care
Stretch tightened ligaments and
tendons gently to
Return the foot to a maximal anatomic position
What is the priority goal in the care of the infant with a clubfoot?

6. Treatment for Clubfoot
Serial manipulation
Corrective casting
Splints
Surgical correction
Compare the medical measures utilized in aligning the clubfoot – discuss specific
nursing interventions/teaching related to each type of treatment?
a. serial manipulation- rotation of the ROM and manipulation of the foot into correct alignment for
approximately 8-12 weeks until maximum correction achieved. then corrective splints or shoes to maintain
correction
b. corrective Serial casting
c. Dennis-Brown splint-
d. Surgical correction- timing varies among surgeons- most treat between 3-12 months of age. Realigns bones
of the foot and reconstruction of soft tissue. Bones are held in proper position by stainless steel pins, then
casted with knee flexed to prevent weight baring. Casting typically continues for 6-12 weeks. May require
corrective shoes or brace

7. Serial Casting Cast applied to hold foot in desired position.
Changed every 1-2 weeks until maximum correction is achieved.
Nursing Care:
Cast care
Skin Care
Education of parents

8. Neurovascular Assessment
Circulation S
Sensory M
Motion
What is included in a neurovascular assessment?

9. Cast Care – Assessment Unusual odor beneath the cast
Tingling, burning, numbness of toes
Drainage through cast
Swelling or inability to move toes
Toes that are cold, blue or white
Sudden unexplained fever
Pain that is not relieved by comfort measures

10. Cast Care Teaching “Petaling” the edges of the cast Drying of the cast
Prevention of swelling
Protecting the cast
When to call the doctor

11. Try this
A infant has a cast applied for treatment of club foot. Which of the following symptoms requires immediate attention and should be reported to the health care provider?
A. Capillary refill of 4 seconds in the affected toes.
B. Edema in the affected toes that improves with
elevation.
C. Numbness of the toes on the affected foot.
D. Skin distal to the cast is warm
C – feeling asleep is numbness. This and a tingling sensation indicates something is wrong with neuro supply.

12. Splinting is used after casts are removed to maintain the correction.
Dennis Brown Splint
Straight-last shoes separated by a metal bar keep the calcaneus in valgus, the forefoot in abduction and the ankle dorsiflexed - all in an attempt to straighten out the child with Club Foot.
Splinting is used after casts are removed to maintain the correction.

13. Care of a child in a splint
Braces should fit snugly but should not interfere with neurovascular function.
 Before wearing the brace, check the skin for any areas of redness or breakdown.
Give parents guidelines for braces.
If redness develops, arrange to have the fit of the brace evaluated and modified.
Bar between legs is not a handle.
Teach appropriate positioning for safety to prevent falls, and allow mobility and "tummy-time“
What are specific measures related to care of the child with a Dennis-Browne splint?

14. Parent Support
Parents are trained and become active participants in the physical therapy treatments and child’s stretching program
Nurses need to help the parents understand the time commitment involved
Assess the parents’ ability to monitor the child adequately for complications and confirm they understand the signs and symptoms of the
complications
What is parent’s role in treatment and how can the nurse assist the parents in this role?

15. Question
The parents of an infant with clubfoot ask how it is treated. Which of the following treatments should the nurse discuss with the parents?
Weekly cast changes with manipulation
Probably surgery on the affected
Abduction device to keep the extremity in alignment
Use of a Dennis-Browne splint to achieve correction.

16. Hip Dysplasia
The head of the femur is improperly seated in the acetabulum of the pelvis
What is the pathology related to a congenital hip dislocation?

17. Developmental Dysplasia of Hip Clinical Manifestations
Limited abduction of the affected hip during Ortolani maneuver. May hear a click upon movement.
Asymmetry of gluteal and thigh fat folds when lying with legs extended.
Telescoping of thigh
Limp and abnormal gait in older
child
Ortolani maneuver
What are the classic signs and symptoms of congenital hip dislocation?
What is Ortolani sign – how performed?
Asymmetry of gluteal folds

18. Treatment and Nursing care of a child with Dysplasia of the Hip:
Pavlik harness
Ensures hip flexion and abduction and does not allow hip extension or adduction.
It maintains correct position of the femoral head in the acetabulum.
How does the Pavlik harness assist to correct this anomaly?

19. Nursing Care
Teach parents/caregivers to remove and apply harness appropriately –only remove for bathing and skin checks.
Teach skin assessment
Encourage cuddling infant to promote cognitive development and infant/caregiver bonding
What is the nursing care for the child while wearing this harness?  

20. Ask Yourself ?
A parent asks why the infant must wear a Pavlik harness. What is the nurse's best response? This treatment is to:
provide comfort and support.
shorten the limb on the affected side.
maintain the femur within the acetabulum.
provide outward displacement of the femoral head.
Maintain the femur within the acetabulum

21. Treatment and Nursing care of a child with Dysplasia of the Hip:
Spica cast
Covers lower half of
body except perineal area
Nursing Care
Elimination/ protection of cast
Positioning
Neurovascular assessment
Skin care
Hygiene
Discuss care of the child in a spica cast related to hygiene, feeding, cast care, and elimination.
To prevent complications:
assess breathing patterns and lung sounds frequently
perform skin and neurovascular assessments every 2 hours
provide padding and skin wrapping to avoid pressure on popliteal space (pressure can lead to nerve damage)
change child's position every 2-3 hours while awake to increase respiratory status, circulation, and decrease pressure. Place either prone or supine on side
Prevent skin irritating and breakdown. Use moleskin to protect from rough edges of cast (flute edges with soft tape- petaling )
Increase fiber and fluids to maintain bowel status
release from traction for meals and daily hygiene (should not release more than one hour per day)

22. Fractures

23. Causes of Fractures Increased mobility and immature motor skills
Trauma
Bone diseases

24. Manifestations of Fracture
Pain or tenderness at site
Immobility or decreased ROM
Deformity of extremity
Edema
Other signs – crepitus, ecchymosis, muscle spasm and inability to bear weight
What are the signs and symptoms of a fracture?

25. Repositioning of the bone fragments into normal alignment
Treatment
Reduction
Repositioning of the bone fragments into normal alignment
Application of a device or mechanism that maintains alignment until healing occurs
What are reduction and retention related to treatment of a fracture?
Retention

26. Retention Application of Cast Traction
What are reduction and retention related to treatment of a fracture? How are these accomplished?
Pull or force exerted on one part of the body

27. Question
Which of the following nursing interventions takes highest priority when caring for a child in skeletal traction?
Assessing bowel sounds every shift
Providing adequate nutrition
Assessing temperature every 4 hours
Providing age-appropriate activities

28. Complications associated with Orthopedic Trauma/ Fractures
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

29. Orthopedic Trauma / Fracture Complications
Compartment syndrome (very serious)
Paresthesia
Pain
Pallor
Paralysis
Pulselessness

30. 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.
What legal and ethical implications must the nurse include when caring for a child with a fracture?

31. Progressive degeneration of
Muscular Dystrophy
Progressive degeneration of
Muscle fibers

32. Manifestations of Muscular Dystrophy
Delayed walking – (first sign)
Progressive, symmetric muscle wasting
Frequent falls
Easily tired when walking, running, or climbing stairs
Hypertrophied calves muscle
Waddling wide-based gait
Uses Gower’s maneuver to rise from floor
Unable to walk independently by
age 9 – 12.
What clinical manifestations would a parent or care giver report first? What are additional signs
and symptoms?

33. Diagnostic findings:
Muscle biopsy – reveal fatty fibrous tissue that gradually replaces muscles (the protein dystrophin is low in the muscles of these patients)
Elevated serum enzyme CK (creatine kinase)
What specific diagnostic findings confirm muscular dystrophy?

34. Maintain ambulation and independence for as long as possible.
Goal of Care
Maintain ambulation and independence for as long as possible.

35. Nursing Care Coordinate a variety of health care services
Maintain activity and self-care functions
Skin care
Maintain bladder and bowel functioning
Protect from respiratory infections
Teach dietary modifications to decrease obesity
What is the nursing care for this child/family?

36. Question Which of the following interventions is
INAPPROPRIATE to incorporate in the care for a
child with muscular dystrophy hospitalized with a
respiratory infection?
Physical therapy
Aggressive antibiotic therapy
Passive range of motion exercises
Complete Bedrest

37. Lateral S curvature of the spine
Scoliosis
Lateral S curvature of the spine

38. Scoliosis Assessment findings: Lateral curvature of spine
Truncal asymmetry
Uneven shoulders
Prominent scapula – uneven height
Rib-hump
uneven hips
What are the classic manifestations of scoliosis?

39. Braces used in Treatment of Scoliosis
What types of braces are used in treating scoliosis?

40. Quick Question:
What is the priority psychosocial nursing diagnosis for the adolescent diagnosed with scoliosis?
What psychosocial implications do the adolescent experience with this treatment? **At risk for Disturbed Body Image related to deformity and brace wear

41. Treatment and Nursing Care for Scoliosis Spinal Fusion
Pre-operative teaching
Demonstrate incentive spirometer and C&DB
Discuss all potential equipment (chest tubes, IV, O2 masks & nasal canula, Foley catheter)
Teach use of pumps for PCA or epidural block.
Demonstrate log rolling and assist out of bed.
What is the pre-operative teaching for spinal fusion?
What is post-op care

42. Nursing Care for spinal fusion
Post-operative Care
Maintain airway
Neurovascular Assessment of lower extremities
Teach passive and active ROM exercises
Encourage independence in ADL’s
Provide with resources / information on scoliosis support groups

43. Post operative care of an adolescent following a
spinal fusion for scoliosis includes: (select ALL
that apply)
Oral analgesics for pain
Logrolling every 2 hours
Nasogastric intubation
Bilateral Neurovascular checks of lower extremities
Use of incentive spirometer q 2 hours
Assess skin on bony prominences
bdef

44. The End