1. Musculoskeletal Alterations NUR 264 – Pediatrics Angela Jackson, RN, MSN

2. Differences between Children and Adults Bones contain a large amount of cartilage, making them more flexible and less likely to break Periosteum is stronger and tougher Bones heal more quickly because the bones are still growing: The younger the child, the faster the bone heals Epiphyseal growth plate Bone injury, especially at the growth plate, is more common than sprains, because soft tissue attachments are stronger in children

3. Types of Fractures Closed or Simple fracture: The skin over the broken bone remains intact Open or Compound fracture: The broken bone protrudes through the skin Transverse fracture: Occurs at a right angle to the long axis of the bone Oblique fracture: A slanting or diagonal break across the bone Spiral fracture: circular and twists around the bone shaft Greenstick fracture: A break through the periosteum and bone on one side while the other side only bends

4. Fractures

5. Salter-Harris Classification of Epiphyseal injuries Type I: Separation of the epiphysis from the metaphysis. Usually does not affect growth. No fracture of the bone. Type II: Separation of the epiphyseal growth plate and fracture of the metaphysis. Usually does not affect growth. Type III: Fracture of the epiphysis extends into the joint. If reduced properly, does not usually affect growth. Type IV: Fracture of growth plate, epiphysis, and metaphysis. Open reduction and internal fixation usually necessary to prevent growth disturbance Type V: Crushing injury of the epiphyseal growth plate. Results in premature closure of the plate on one side with growth arrest.

6. Salter-Harris Classification

7. Traction The application of pulling force to a body part against a countertraction pull exerted in the opposite direction Used to treat a variety of injuries – Spine – Long bones of the upper and lower extremities – pelvis

8. Traction Straight traction: – Child’s body weight serves as the countertraction Balanced Traction: – the body part is suspended by a sling and the countertraction as well as the primary traction is provided by pulleys and weights. The angle of the involved joint and the angle formed by the placement of the pulleys on the bed determines the direction of the pull or force

9. Primary Purposes of Traction Immobilizes the fracture Decreases muscle spasms Realigns and positions bone ends while healing takes place Prevents further soft tissue damage

10. Complications of Fractures malunion compartment syndrome growth disturbances

11. Nursing Considerations Neurovascular status Pain Respiratory status Cardiovascular status Immobilization Skin Integrity Nutrition Elimination

12. Nursing Management Monitor for appropriate alignment, and ensure that weights hang freely Perform Neurovascular checks every hour X 24 hrs, then q4-8hrs Maintain skin integrity Promote pulmonary hygiene Promote adequate fluid and fiber intake to prevent constipation Provide stimulation appropriate for developmental age to promote growth and development Encourage limited mobility as permitted Encourage parents to hold child as permitted Avoid pressure on the popliteal space to prevent nerve damage Provide adequate pain relief

13. Infectious Disorders of the Musculoskeletal System Osteomyelitis

14. Infection of the bone caused by a microorganism May be bacterial, viral or fungal Bacteria may be introduced through the blood stream from an infection in another part of the body (endogenous spread) or directly into the bone via a penetrating wound or open fracture (exogenous spread) More common in children between the ages of 3 and 12 Males are affect 2 to 4 times more often than females

15. Osteomyelitis: Sources of Infection Sources of hematogenous spread include – Acute otitis media – Impetigo – URI’s – Abscessed teeth – Burn infections Causative Organisms include – Staphylococci aureus (80 – 90%) – Haemophilus influenzae – Streptococcus Pneumoniae – Escherichia Coli – Group B streptococci – gram-negative enteric bacilli – Anaerobic bacteria

16. Osteomyelitis: Pathophysiology Bacteria travels to the small arteries at the end of the bone Inflammation with increased blood flow and swelling occurs The infectious process leads to bone destruction and abscess formation Increasing pressure as exudate collects and is confined within the bone results in vascular occlusion, ischemia and eventually bone necrosis

17. Osteomyelitis: Clinical Manifestations Infants – Irritability – Poor feeding – Failure to move affected limb – Permanently arrested bone growth Children – Constant bone pain – Restricted movement – Swelling – Heat in the affected area – Redness – Fever – Signs and symptoms of systemic infection

18. Osteomyelitis: Diagnosis Lab tests – CBC – C-reactive protein – Sed rate (ESR) – Blood cultures – Wound cultures – Culture of bone aspirate X-Rays – Routine x-ray of affected area – Bone scan – X-ray examination of the affected area will detect bone necrosis ten to fourteen days after appearance of clinical manifestations

19. Osteomyelitis: Potential Complications Abscess Joint or bone damage, especially damage to epiphyseal growth plate Complications affecting the hepatic, renal and hematological systems (related to high dosages of antibiotics) Amputation of affected extremity Interference with growth

20. Osteomyelitis: Treatment IV broad-spectrum antibiotics for 3 – 6 weeks (may switch to po after adequate response is achieved) Splinting Surgical drainage and debridement

21. Osteomyelitis: Nursing Management Monitor for potential complications – Perform neurovascular checks at least q8hrs – Maintain proper alignment and move the limb cautiously to avoid further injury to the bone Administer antibiotics as scheduled Assess the site of infection; monitor for edema, redness, warmth or drainage every 4 hours Monitor white blood cell count and therapeutic medication levels Maintain splinting if present Use sterile technique for dressing changes Assess for pain, and administer analgesics as prescribed

22. Muscular Disorders Muscular Dystrophy

23. A group of inherited diseases affecting the muscle, leading to progressive muscular wasting and degeneration of muscle fibers It is the largest group of muscle diseases affecting children, and it is genetically acquired Duchenne’s Muscular Dystrophy is the most common childhood form (x-linked recessive) – Affects all races and ethnic groups – Affects males almost exclusively – Females may be carriers and pass the defect to their male children

24. Muscular Dystrophy: Pathophysiology Absence of the muscle protein dystrophin, which plays a role in supporting the structure of muscle fibers Results in degeneration of skeletal muscles that control movement Fat and connective tissue replace the degenerated muscle fibers

25. Muscular Dystrophy: Clinical Manifestations Generalized muscular weakness and muscle wasting – usually appears during the third year of life Difficulty running and climbing stairs Tires easily when walking Waddling gait (Trendelenburg gait) Lordosis Frequent falls Gower’s sign As disease progresses, calves, thighs, and upper arms become larger as a result of fatty infiltration (pseudohypertrophy) Mental retardation is common

26. Gower’s Sign

27. Muscular Dystrophy: Diagnosis Muscle biopsy (identifies presence of fatty tissue) DNA testing Electromyography (detects decreased electrical impulses) Elevated serum creatine kinase (enzymes leak from deteriorating muscles) History and physical findings

28. Muscular Dystrophy: Treatment There is no cure for muscular dystrophy. Treatment is supportive and includes: – PT/OT – Braces, wheelchairs – Surgery

29. Muscular Dystrophy: Potential Complications Atrophy may develop as a result of immobility Contracture deformities may develop as a result of immobility and disease Obesity may result from bed rest and immobility Cardiac complications occur lat in disease and may require a pacemaker Infections, especially respiratory, secondary to weak muscles of respiration, occur. Even minor infections require prompt treatment to avoid complications or death.

30. Muscular Dystrophy: Nursing Management Participation with the interdisciplinary team Respiratory care: teach deep breathing and coughing exercises Maintenance of optimal nutrition Prevention of skin breakdown Maintenance of optimal bowel and bladder function Teach signs and symptoms of infection Encourage independence as long as child is capable. Powered wheelchairs, special eating utensils, and other assistive equipment is available Encourage genetic counseling Assist family and child in coping with a fatal disease Teach proper body mechanics and range-of-motion exercises

31. Musculoskeletal Disorders Legg-Calve Perthes Osteogenesis Imperfecta

32. Legg-Calve-Perthes: Pathophysiology Temporary loss of blood supply to the femoral capital epiphysis, results in avascular necrosis of the femoral head Unknown cause Occurs in four stages: – Incipient stage – Necrotic stage – Regenerative stage – Residual stage

33. Legg-Calve-Perthes: Clinical Manifestations Intermittent appearance of limp on affected side Mild pain in hip exacerbated by increased activity and relieved by rest Joint dysfunction and limited range of motion, especially abduction and internal rotation Stiffness varying from intermittent to constant Limb-length inequality Pain, soreness, and aching; usually worse on rising or at the end of the day; may be in groin, hip or knee area Tenderness over hip capsule External hip rotation (late sign) Deterioration of the femoral head on x-ray

34. Legg-Calve-Perthes: Nursing Management Monitor neurovascular status Encourage meticulous skin care Teach signs of muscle atrophy Teach crutch Walking Encourage non-weight bearing activities Teach safety measures

35. Legg-Calve-Perthes: Treatment The main goals of treatment are to keep the head of the femur contained in the acetabulum, to promote healing, and to prevent deformity. This may be achieved through: – Traction – Braces – Leg casts – Surgery

36. Legg-Calve-Perthes: Diagnosis Diagnosed and classified by X-ray Bone scan

37. Osteogenesis Imperfecta (OI) Known as brittle bone disease Connective tissue disorder. Occurs in several forms with variable degree of severity Fractures may result form trauma, but also from simple walking or pressure of birth Affects boys and girls equally A child with this diagnosis should not be confused with the child with fractures because of abuse

38. OI: Pathophysiology Characterized by disturbed formation of periosteal bone, resulting in formation of pathologic fractures Normal calcium and phosphorus levels, and abnormal precollagen type I, which prevents the formation of collagen, the major component of connective tissue Bones consist of large areas of osseous tissue and increased numbers of osteoblasts

39. OI: Clinical Manifestations Multiple and frequent fractures, some of which may be present at birth Limb and spinal column deformities related to multiple breaks Blue sclera Thin, soft skin with easy bruising Increased joint flexibility Weak muscles Short stature Conductive hearing loss May have dentinogenesis imperfecta: hypoplastic teeth with opalescent blue or brown discoloration

40. OI: Diagnosis Collagen studies Prenatally, may be detected by level II ultrasound if disease is severe

41. OI: Treatment Early intervention of fractures Prevention of deformities using splints, braces, casts and surgery Rod insertion Adequate nutrition including calcium, magnesium and vitamins

42. OI: Nursing Management Maintain a non-judgmental and supportive attitude Handle child gently and teach family to handle child gently: – Avoid lifting by a single arm or leg – Use a blanket for extra support when lifting and moving – Never hold by ankles when diapering. Gently lift by slipping a hand under the buttocks Encourage activities the promote growth and development while maintaining a safe environment Encourage exercise, such as swimming, to improve muscle tone and prevent obesity Encourage realistic occupational planning Suggest genetic counseling

43. Any Questions???