Chapter 29: The Child with Musculoskeletal or Articular Dysfunction

treatment for lordosis

-Stretching tight hip flexors -Strengthening abdominals -wt loss -Postural training -Back bracing

treatment for kyphosis

1. postural training 2. strengthening 3. brace 4. anterior spinal release and posterior spinal fusion in severe cases

Clubfoot (Talipes Equinovarus)

A birth defect in which the foot is twisted out of shape or position.

What is osteogenesis imperfecta (OI)?

A group of heterogeneous inherited disorders of connective tissue Characterized by excessive fragility and bone defects Defective periosteal bone formation and reduced cortical thickness of bones Hyperextensibility of ligaments

What are the 3 degrees of DDH?

Acetabular dysplasia (preluxation) Mildest form; osseous hypoplasia of the acetabular roof *Femoral head remains in the acetabulum* Subluxation (incomplete dislocation of the hip) Dislocation (femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly; ligaments are elongated and taut)

Clinical manifestations of DDH in older children?

Affected leg is shorter than the unaffected leg Telescoping or piston mobility of the joint Trendelenburg sign Greater trochanter is prominent and appears above the line from the anterosuperior iliac spine to the tuberosity of the ischium Marked lordosis if bilateral dislocations Waddling gait if bilateral dislocations

What are some physiologic effects of immobilzation on the urinary system?

Alteration of gravitational force Difficulty voiding in the supine position Urinary retention Impaired ureteral peristalsis

What is teratologic clubfoot?

Associated with other congenital anomalies Usually requires surgical correction and has a high incidence of recurrence

What are some physiologic effects of immobilization on the skeletal system?

Bone demineralization Negative calcium balance

What are complicated fractures?

Bone fragments have damaged other organs or tissues

What is Congenital idiopathic or true clubfoot?

Bony abnormality almost always requiring surgical intervention

Pathophysiology of Legg-Calve-Perthes Disease?

Cause is unknown but involves disturbed circulation to the femoral head with ischemic aseptic necrosis

What is the most common fracture?

Clavicle is the most frequently broken bone in childhood, especially in those younger than 10 years old Rare in infants, except with motor vehicle crashes Or non-accidental trauma, or Osteogensis Imperfecta

What are greenstick fractures?

Compressed side of the bone bends but the tension side of the bone breaks, causing an incomplete fracture

What is Developmental dysplasia of the hip (DDH)?

Congenital dislocation of the hip

Rehab is directed toward preventing?

Contractures and deformities Muscle weakness and osteoporosis Malalignment of lower extremity joints

What are contusions?

Contusion (bruise) is damage to soft tissue, subcutaneous tissue, and muscle Causes swelling, pain, and disability

What is an osteomy?

Cutting of a bone or removal of a piece of bone. Rare, seldom used in the acute setting

What are some physiologic effects of immobilization on the integumentary system?

Decreased circulation and pressure leading to decreased healing capacity

What are some physiologic effects of immobilization on the cardiovascular system?

Decreased efficiency of orthostatic neurovascular reflexes Diminished vasopressor mechanism Altered distribution of blood volume Venous stasis Dependent edema

What are some physiologic effects of immobilization on metabolisim?

Decreased metabolic rate Negative nitrogen balance Hypercalcemia Decreased production of stress hormones

What are some physiologic effects of immobilization on the muscular system?

Decreased muscle strength and endurance Atrophy Contractures and loss of joint mobility

What are some physiologic effects of immobilization on the respiratory system?

Decreased need for oxygen Diminished vital capacity Poor abdominal tone and distention Mechanical or biochemical secretion retention Loss of respiratory muscle strength

What are cogneital defects?

Defects you are born with.

Therapeutic management for DDH 6 -24 months?

Dislocation is unrecognized until the child begins to stand and walk; use traction and cast immobilization (spica)

What are some physiologic effects of immobilization on the GI system?

Distention caused by poor abdominal muscle tone Difficulty feeding in the prone position Gravitation effect on feces Anorexia

What are compound/open fractures?

Fractured bone protrudes through the skin

Clinical manifestations of fracture?

Generalized swelling Pain or tenderness Deformity Diminished functional use May have bruising, severe muscular rigidity, and crepitus

How long does it take for bones to heal in: Neonatal period? Early childhood? Later childhood? Adolescence?

In neonatal period, 2 to 3 weeks In early childhood, 4 weeks In later childhood, 6 to 8 weeks In adolescence, 8 to 12 weeks

Clinical manifestation of Legg-Calvé-Perthes Disease?

Insidious onset; may have a history of a limp, soreness or stiffness, or limited range of motion; vague history of trauma

Nursing Management of developmental dysplasia of the hip

Inspect skin three x a day in harness -gently massage skin under straps once daily -place diaper under straps -maintain cleanliness of diaper area -no lotions or powders -Patents should be instructed not to adjust Pavlik harness -can still hold baby

What is OI Type I?

It is the most common -mildest form -most fractures occur before puberty

What is OI Type II?

It is the most severe -considered lethal in infancy -multiply fx at in birth -autosomal recessive inheritance

What is mild/postural clubfoot?

May correct spontaneously or require passive exercise or serial casting

What are strains?

Microscopic tears to a musculoTENDINOUS unit Similar to a sprain Swollen and painful to the touch Generally incurred over time

What is OI Type III?

Multiple fx present at birth -short stature -severe bone deformity -disability -short life expectancy

What are myositis ossificans?

Myositis ossificans is deep contusions to the biceps or quadriceps muscles

How to diagnose fractures?

Obtain information from the person who observed the injury X-ray is the most useful diagnostic tool

What are dislocations?

Occur when force of stress on a ligament is sufficient to displace the normal position of opposing bone ends or bone ends to socket

What are some clinical manifestation SCFE?

Often seen in obese children (BMI>95%) Limp on affected side Inability to bear weight due to pain Pain in groin, thigh, or knee External rotation of affected leg Increasing severity causes loss of abduction and internal rotation Shortening of lower extremity

Therapeutic management for DDH in older children?

Operative reduction, tenotomy, osteotomy; difficult after 4 years

How to assess fractures (5 p's)?

Pain and point of tenderness Pulselessness (distal to the fracture site) Pallor Paresthesia ("pins and needles" sensation distal to the fracture site) Paralysis (movement distal to the fracture site)

Major symptom of dislocation?

Pain is the predominant symptom Increases with active or passive movement of the affected extremity

Therapeutic management for DDH for newborns?

Pavlik harness for abduction of the hip

What is a hip arthroscopy?

Performed before pinning in situ can be effective in decreasing hip pain and allowing early hip movement in some children w/ SCFE

Issues with hip dislocation?

Potential loss of blood supply to the head of the femur Common in elderly, loss of blood flow= necrosis

What is an indicator of sprain severity?

Presence of joint laxity as an indicator of severity

Therapeutic Management of Soft Tissue Injuries?

Rest, ice, compression, and elevation (RICE) Rest the injured part Ice immediately (maximum 30 minutes at a time) Wet elastic bandage for compression Elevation of the extremity Immobilization and support (casts or splints as appropriate to the injury)

What is Legg-Calvé-Perthes Disease?

Self-limiting, idiopathic, occurs in juveniles age 3 to 12 years, more common in males age 4 to 8 years Avascular necrosis of the femoral head

Clinical manifestations of DDH in infants?

Shortened limb on the affected side Restricted abduction of hip on the affected side Unequal gluteal folds when the infant is prone Positive Ortolani test Positive Barlow test

What are comminuted fractures?

Small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue

What is Slipped Capital Femoral Epiphysis (SCFE)?

Spontaneous displacement of the proximal femoral epiphysis in a posterior and inferior direction Most cases are idiopathic but it can be associated with endocrine disorders Dx: Imaging (xray) shows a change in position of the proximal femoral epiphysis Fermur progressively slips out of place.

Idiopathic scoliosis

Structural lateral spinal curvature for which no cause has been established

What is nursemaid's elbow

Subluxation or partial dislocation of the radial head

What are some treatments to treat SCFE?

Surgery may be done within 24 hours of acute symptoms Possible procedures: Pinning in situ, Osteotomy, Hip arthroscopy

What are complete fractures?

The bone is completely separate.

therapeutic management of clubfoot

Three Stages: Correction of the deformity Maintenance of the correction until normal muscle balance is regained. Follow-up to avert possible recurrence. Ponseti method (serial casting): Soon after birth Weekly gentle manipulation and serial long leg casts allow for gradual repositioning of the foot. The extremity is casted until maximum correction is achieved (6-10 weeks).

What is a sprain?

Trauma to a joint from a LIGAMENT partially or completely torn or stretched by force May have associated damage to blood vessels, muscles, tendons, and nerves Rapid onset of swelling with disability

How to diagnose Legg-Calve-Perthes Disease?

X-ray MRI

lordosis

abnormal anterior curvature (concave) of the lumbar spine (sway-back condition)

treatment for scoliosis

aimed at correcting the curvature, curves between 20 and 45 degrees require a brace; severe scoliosis greater than 45 degree requires surgery for correction

diagnosis of idiopathic scoliosis

aysymmetry of shoulder ht, scapular or flank shape, hip ht or pelvic obliquity -when child bends and hips and head, hips are not aligned

Nursing Management of OI

careful handling to prevent fx -even diaper change can cause fx -never be held by ankles, instead gently lift by buttocks and support with pillows

kyphosis

excessive outward curvature (convex) of the spine, causing hunching of the back.

nursing management of clubfoot

observation of skin/circulation cast/brace care and education

What is teratologic DDH?

occur before birth genetic or neuromuscular disorders

What is pinning in situ?

placement of a single or multiple pins and screws through femoral neck to prevent further slippage

nursing management

preop- explanation that PCA to manage pain, urinary catheter, how to log roll, may have chest tube, recommend bringing favorite games toys post op- change postions to prevent spine damage, brace/cast used, pressure relieving mattress, prompt recognition of neuro impairment, hypotention, infection, blood loss, respiratiory complication. Maintain f/e, skin integrity. Want them walking asap, begin ROM, self care with washing, eating.

nursing management

preparing child/family for pre/post op surgical care

therapeutic management of legg-calve perthes disease

rest or activity restrictions limited wt bearing NSAIDS to decrease inflammation ROM exercises/ PT abduction braces/ traction surgery

nursing management

teach family the care required -emphasize the need to continue to attend school -adapt school activities to child needs

What is idiopathic DDH?

without any known cause

Treatment

• Biphosphonates: inhibit bone resorption by inactivating osteoclasts • Use in OI: improved bone mass initially, decreased bone resorption, increased bone formation (? Sustained effects) • Intravenous therapy has been shown to be useful in severe OI -maybe surgery