2: Musculoskeletal Disorders

Osteomalacia (Rickets)

*Softening* of bones due to lack of vitamin D or ability to absorb calcium. "Spaghetti legs" leads to *bone fractures, muscle weakness, widespread bone pain, & low Calcium* causes numbness, spasms in hands 👋 & feet. Diagnose with labs, bone X-rays, bone density tests, bone biopsy. Treat with *vitamin D, calcium & phosphorous supplements*. Prevent with sunlight & high vitamin D diet. Vitamin D reduced by little sunlight ☀️ exposure, dark skin, smog ☁️, winter, little milk intake. Will heal within *6 months* of treatment but symptoms may return if deficiency not corrected.

Pulses Pallor Paresthesias Paralysis Pain

5 P's

Fractures in babies less then 6 months Spiral fractures Multiple fractures of various ages Rib, sternal, vertebral fractures Depressed skull fracture

5 red flags for child abuse

Legg Calve Perthes Disease

Blood supply to the *femoral head* is disrupted causing *avascular necrosis* & osteonecrosis. Femoral head becomes *flattened due to weight & pressure*. Slowly revascularizes & replaced with new bone. More common in hyperactive, stalky boys. Caused by abnormal coagulation, abnormal venous drainage, arterial infections. Symptoms of *limping & decreased ROM, HIP pain, referred KNEE pain, unilateral, worsens with activity & improves with rest*. Diagnose with xray & perfusion MRI, disease of exclusion=history to R/O. Need to control pain with *NSAIDS* while revascularizing. Decrease activities, ROM, surgery if bone is deformed - muscle releases or osteotomies.

Osteomyelitis

Bone infection usually affecting long bones of arms & legs. Risk after surgery-especially splenectomy, diabetes, hemodialysis, & poor blood supply. Symptoms cause bone pain, fever, chills, diaphoresis, malaise, & localized swelling (general SxS of infection). Must treat infection to reduce by age to bone & surrounding tissues. Long term Antibiotics IV for 4-6 weeks. Surgery required to remove dead tissue if infection remains.

Abduction Brace

Brace for Developmental Dysplasia of the Hip (DDH) that must be *worn at all times (24 hours a day)*. Diapering done under brace- double diaper.

Pavlik Harness

Brace for Developmental Dysplasia of the Hip (DDH) used in *newborns less then 6 months*. Needs to be *worn at ALL times (24 hours a day*). Wear t-shirt underneath (must have something under brace). *Hips & knees flexed to 90 degrees*.

Juvenile Rheumatoid Arthritis

Chronic autoimmune disease causing joint pain & swelling. Onset before 16 years old with swelling of 1 or more joints for more then 6 weeks, *morning stiffness, decreased range of motion & limping, sudden high fever, rash with fever onset, risk of joint contractors & growth delay, appear sick, eye problems- red, vision changes & photophobia*. Treatment to control inflammation, relieve pain, prevent joint damage, maximize function. Medications include *NSAIDS, methotrexate (DMARD)* given inpatient, enbrel, remicade, humera, *Prednisolone*, Methylprednisolone, *aristospan*= joint injection. May need joint fusions & replacement in adulthood. RN must teach medication adherence, emotional support, low impact excercise, heat & warmth for pain, high calcium diet, warm shower in AM for stiffness. Risk of bone weakness from steroid therapy, decreased activity & weight bearing.

Compartment Syndrome

Complication from Increased pressure within a limited space (cast) that compromises circulation & tissue within the space. Risk of muscle, nerve & tissue necrosis. Pain unrelieved by opioiods is main symptom, cool & numbness in extremities. Official diagnosis with injection pressure measurments. Surgical emergency requiring fasciotomy & decompression!

1 finger 👇

Finger space between caste

Osteogenesis Imperfecta

Genetic defect that impairs the body's ability to form strong bones, *bones are brittle & fragile*. Symptoms *blue sclera, hypoplastic teeth that are blue/brown, TRIANGLE🔻face, bone deformities* (scoliosis & bowed legs). There is no cure, but treatment to improve quality of life, limit frequency of fractures, & encourage mobility/independence. *Biophosphonates* slow bone reabsorption. *Immobilization & bracing* used to heal fractures, Excercise with weight bearing *low impact activities* (swim/walk) after healed 🏊 Surgery may be required if severe. Understand *fractures can't be prevented & they will occur*. Teach family not to lift under armpits, don't pull on ankles when changing diaper, never pull or push on an extremity in an awkward position, *DONT TAKE BLOOD PRESSURES*, be aware of implications on child abuse. Also reclining car seat, padded with foam & large stroller recommended.

Breastfed babies northwest & cold regions

Have higher risk of Osteomalacia (Rickets)

Developmental Dysplasia of the Hip (DDH)

Hip disorder that may be caused from Breech in utero, birth order -affects first born, female, postnatal positioning. Diagnosis done by doctor with Barlow & Ortolani signs causing a *hip click, limited hip abduction, leg length discrepency, excessive lordosis*, ultrasound for babies (cartilage), use *xray if over 3 months*. Treatment uses *pavlik harness, abduction brace, Bryant's traction*.

Scoliosis

Lateral curve of spine that measures greater then *10 degrees* in xray. May be congenital, neuromuscular or idiopathic. Types may be ASF which is anterior & higher on body or PSF which is posterior lower curve. Diagnosed by screenings at school, if visualized with *uneven hips or shoulders* then further physical testing with height & weight, xray with *Cobb angle*, menarche status (no surgery until fully developed) & *rissler sign* for bone aging & grading. If angle *less then 10-25* degrees, observe & screen again later. If *25-45* degrees *brace* required, if *greater then 50* it is severe & *surgery* is required. Treatment uses brace, *halo traction*, & surgery. Post op manage pain, *logrolling* & *flat for 6 hours*

In situ pinning

Less invasive Treatment for *stable* Slipper Capital Femoral Epiphysis (SCFE) that uses only 1-2 screws in thigh bone to prevent further slipping. *Limited weight bearing for 6-12 weeks. Use crutches*

Slipper Capital Femoral Epiphysis (SCFE)

Medical emergency where *Capital epiphysis (ball of femur) slips off the growth plate*- further slippage will cause deformity or necrosis! R/t Obesity. It may be stable & slow or unstable, *sudden severe pain with inability to walk*! Emergency! Stop walking, use wheelchair to carry them to bed! *Strict Bedrest!* Cause unknown but related to weakness in bone from hormone abnormalities especially hypothyroidism, obesity, familial history of hip conditions. Symptoms *limping, thigh or knee pain, 1 leg SHORTER*. Treat with in situ pinning if stable or Open reduction used if unstable to align bone & prevent loss of blood flow. Manage pain! Can resume activities after *3 months*.

Elevate above Heart ❤️

Position of caste to help with perfusion & swelling

Halo Traction

Preoperative treatment to loosen soft structures supporting the spine. Pin care & Neuro checks

Open reduction

Treatment for *unstable* Slipper Capital Femoral Epiphysis (SCFE) to align bone & prevent loss of blood flow. *NO weight bearing for 12 weeks. Can resume athletic activities after 3 months*

Bryant's Traction

Treatment for Developmental Dysplasia of the Hip (DDH) that is worn *23 hours a day* & only removed bathing. *Legs must be 90 degrees & buttocks off bed*.

Pat or cool blow dryer

Treatment for itchiness under cast

Neuromuscular

Type of scoliosis from being not strong enough to keep spine straight which is associated with CP, spinal bifida, SCI, & muscular dystrophy

Congenital

Type of scoliosis from failure of formation & segmentation. Check Heart ❤️, kidneys, & ears 👂

Surgery

Used to partially straighten the curve & stop the curve from progressing & decrease rib prominence if scoliosis is severe (*>50*). Also to correct the cosmetic appearance associated with severe curves & neuromuscular complications

SPICA Cast

Worn post op for Developmental Dysplasia of the Hip (DDH) surgery. Avoid boats & planes. Use cast care (CPETC). Risk of skin breakdown. Careful with toys. Nothing in caste (No toys, lotion ect). Pad any sharp edges with tape or moleskin

Rissler Sign

bone aging & grading - done prior to back surgery for scoliosis

25-45

scoliosis curve indicating a brace

>45-50

severe scoliosis curve indicating surgery

Bracing

used to halt progression of spinal curve during growth. Must still be growing to be effective- not indicated after growth spurt. Must *wear 23 hours a day!* Take off only to shower! Non-compliance in teenagers