Musculoskeletal Disorders Peds

Children have more

**cartilage and collagen** than adults.

Skin and Skeletal Traction

*Look at slide 43*

Risk factors of Rickets

-Limited sun exposure -•Strict vegetarian diet or lactose intolerance -exclusive breastfeed by mom w vit D deficit -Dark pigment skin -prematurity -Chronic renal disease -•Malabsorptive gastrointestinal disorder

Which nursing consideration regarding vital signs should be a priority when caring for a patient with osteogenesis imperfecta? a)Compare their apical pulse to their radial pulse for discrepancies b)Ask the health care provider prior to assessing blood pressure c)Assess oxygen saturation on both the upper right extremity and the lower left extremity

B) Ask the health care provider prior to assessing blood pressure Compression of a blood pressure cuff can be enough to cause a fracture in many children with OI. Collaborate with the healthcare provider before assessing blood pressure on children with OI.

A 12-year-old female client has been diagnosed with scoliosis with a curvature of 30 degrees. What type of treatment would the nurse anticipate being started on this client?

Bracing

nurse is caring for a child who fractured the arm in an accident. A cast has been applied to the child's right arm. Which action(s) should the nurse implement? Select all that apply.

Check capillary refill time in the both arms. Document any signs of pain. Monitor the color of the nail beds in the right hand.

The type of fracture often seen in young children is one in which there is not complete ossification of the bone, and the bone bends and just partially breaks. What type of fracture is this?

Greenstick

Assessing Musculoskeletal Function

History: •Chief complaint •COLDSPA •Medications •Birth history if needed •Developmental milestones Physical Exam: •Body alignment •Gait •ROM •Strength and tone •Bilateral vs unilateral •Other system considerations

nurse is caring for an 8-year-old child in traction. The client has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. The client is showing signs of regression with thumb sucking and pleas for the now tattered baby blanket. What would be the most helpful intervention?

Let's ask your parents to bring your friends for a visit.

nurse is caring for a child who had a cast on his lower leg placed two hours ago. When assessing the child's foot, the nurse notes that the toes are cool and the child reports extreme pain. What is the best action by the nurse?

Notify the health care provider of the findings immediately.

You are caring for a 4-year-old patient who is recovering from syndactyly surgery. Collaboration with which interdisciplinary professional do you anticipate working with during his recovery?

Occupational therapist Occupational therapists work with children needing assistance with upper extremity exercises and adaptations and activities of daily living.

Sprain Treatment

RICE technique: •Rest: Do not bear weight on the affected area for 48 to 72 hours. •Ice: Apply ice packs for 10 to 20 minutes at least 3 times a day. •Compression: Wrap the area with elastic bandage to reduce swelling. •Elevation: Elevate the area above the level of the heart while resting and applying ice to reduce swelling.

nurse is caring for a 10-year-old child in traction. After performing a skin assessment, she notices that the skin over the calcaneus appears slightly red and irritated. What should be the first intervention?

Reposition the child's foot on a pressure-reducing device.

child is admitted to the pediatric unit with osteomyelitis. The child is to be placed on antibiotics. The nurse expects antibiotic coverage to include which of the following as the most common cause of osteomyelitis?

Staph aureus

Treatment Polydactyly & Syndactyly

Surgical correction -*remove extra digits= polydactyly* -*separate fused digits= syndactyly* After surgery, may be casted or splinted.

Scoliosis Symptoms & Interventions

Symptoms: -truncal asymmetry, uneven shoulders, raised hips, and rib hump. -Bracing prevents further curving & must be worn 16 to 23 hours per day and be properly fitted. -Bracing is 80% effective when used properly -Avoid skin breakdown on patients wearing a brace. Surgical interventions: -spinal fusion, activity limitations postoperatively, and frequent neurovascular assessments

nurse is speaking with a parent of a child diagnosed with scoliosis. The parent states, "I hate to think about my child having to wear a huge brace to treat this disorder. My best friend growing up had to wear one and she hated it." What is the best response by the nurse?

The newer type of braces fit under the arms and are made to fit under clothing. They aren't nearly as big as they used to be."

Congenital Musculoskeletal Disorders

born with genetic disorder -Pectus Exacavatum -Polydactyly & Syndactyly •Congenital Clubfoot

Kids who are symptomatic

may need surgery=place bar in chest to maintain structure & relieve pressure (in for 2 yrs) -Post-op: teach splinting when coughing or sneezing, practice deep breathing exercises, >education on their limitations such as lifting (1 mo) or contact sports (6 mo)

Treatment DDH

oBefore 6 months of age: bracing **Pavlik harness** 90% successful - places the hips in alignment with the joint in an abducted position, worn 24/7 for 3-4 months o6 to 24 months: closed-reduction surgery oAfter 24 months: open-reduction surgery -Spica casting postoperatively to allow maintain alignment while the tissue repairs. Monitor skin for breakdown with cast or brace. -edu on hygiene

nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to:

prevent edema

physical therapy for kids

work with children needing assistance with lower extremity exercises and adaptations.

Assessment Made Before Casting

•Color (note cyanosis or other discoloration) •Movement (note inability to move fingers or toes) •Sensation (note whether loss of sensation is present) -Edema -Quality of Pulses

Developmental Musculoskeletal Disorders

•DDH •Blount disease •Osteogenesis Imperfecta

Osteomyelitis Symptoms

•fever, chills, malaise, fatigue, sharp bone pain, warm to touch, edema, difficulty with movement or bearing weight

Osteomyelitis Treatment

•limitation on weight bearing, immobilization, short administration of IV antibiotic followed by oral antibiotic

(Ortolani/Barlow test), and limping gait. **O/B test: R. hip adduction>>CLICK>>hip abduction>>CLICK**

**O/B test: 1. both hips start abducted (open) 2. L leg is adducted & see if hip pops out of socket (-= no CLICK)=Barlow 3. L. leg abducted & lift on trochanter to pop hip back into socket (-=no CLICK)= Ortolani 4. R. hip adduction>>CLICK= + Barlow 5. R. hip abduction>>CLICK= +Ortolani

**Ligaments & tendons** are

**stronger than bones in children** until they reach puberty.

Your patient is a 12-year-old fresh post-op spinal fusion due to scoliosis. Select which of the following post-operative care interventions are a priority for this patient? (select all that apply) a)Assess neurovascular status frequently b)Early and frequent ambulation c)Logrolling position changes every 2 hours d)Oral pain medications prn

*a)Assess neurovascular status frequently* *b)Early and frequent ambulation* *c)Logrolling position changes every 2 hours* Not d) Oral pain medications prn - why not?? A spinal surgery patient needs strong and frequent pain medication. May have an epidural, PCA, or scheduled IVP medications.

Osteogenesis Imperfecta

-AKA Brittle Bone Disease. -Congenital disorder -Tendency for bones to fracture easily=*poor collagen formation.* -8 types, Type I is the mildest form & most common. -*constant protection from trauma.* -require casting of fractures & lots of education= how to prevent future fractures. -Families may be initially suspected of child abuse before diagnosis is known due to multiple fractures in different stages of healing. -Conduct a thorough history and physical.

Assess Musculoskeletal Function: Dx tests

-Bone scan = nuclear radiology to identify areas of *physical & chemical changes in bone* -Electromyography = the recording of the electrical activity of muscle tissue through electrodes attached to skin or inserted into the muscle -Arthroscopy: *diagnosing and treating joint problems* -muscle/bone biopsy -radiography

Genu Varum (bowlegs) & Genu Valgum (knock knees)

-Bowlegs: normal occurrence in toddlers, straighten naturally by **2 years old** -*if alignment not straight by 3 years= Blount disease suspected* -Blount disease (tibia vara): inward turning of the lower leg that worsens over time >result from disorder of tibial growth plate -Blount disease r/t *obesity, early walking, vitamin D deficiency, & genetic component* -Blount disease: risk for joint degeneration & may need correction surgery & casting/external frame after surgery

Developmental Dysplasia of the Hip (DDH)

-Hip socket does not adequately cover the ball of the femur of the hip joint or easy dislocation of the ball from the hip socket. -Found during newborn exam. -Often result **breech fetal position.** -Symptoms: limited hip abduction, differing leg lengths, uneven thigh skin folds, palpable and audible click as femoral head moves (Ortolani/Barlow test), and limping gait. **O/B test: R. hip adduction>>CLICK>>hip abduction>>CLICK**

Emergency Management Fractures

-Immobilize the body part -Splinting: joints distal and proximal to the suspected fracture site must be supported and immobilized -Assess neurovascular status before and after splinting -Open fracture: cover with sterile dressing to prevent contamination -Do not attempt to reduce the fracture

A&P Differences Peds v. Adults

-Infants start with 300 bones at birth -> after fusion and ossification occurs -206 bones as adults. -Growth plates on children's bones are open until child stops growing >Girls: 13 - 15 years >Boys: 15 - 17 years -Kids bones: more porous & elastic >means kid bones move more before breaking >>> buckling & compression or bulging instead of breaks. -Fractures not as easily seen on x-ray.

Growing Pain

-Know differences btw normal growing pains & other musculoskeletal disorders -Growing pains: **muscle**, never joints. -Common in preschool & school-age, GIRLS more -Often occur: late afternoon/night -May r/t running, climbing, or jumping during the day. -No specific treatment necessary, but comfort measures recommended >*Massage, heating pad, stretching, ibuprofen or acetaminophen* "my legs hurt"

Polydactyly & Syndactyly

-Most common congenital hand and foot anomalies. -*Polydactyly: extra digits* on hands and/or feet. -*Syndactyly: digits fail to separate and fuse/webbed look* -Both conditions can occur alone or in combination -In both conditions, the digits can have skin, soft tissue, bone, joints, or any combo -Syndactyly often involves *nerves and muscles.* Treatment involves surgical correction consisting of removal of extra digits with polydactyly or separation of fused digits with syndactyly. After surgery, they may be casted or splinted.

Priority Care Traction

-Principles of traction care is what we will focus on today. -Positioning - supine and maintaining straight alignment. -Countertraction - keeping the bed flat with no more than 20-degree elevation. -Friction - through gravity and weight of the traction, the child can slide down in bed, needing frequent positioning. Protecting any at-sick bony prominences should be a priority, especially the heels. Often use sheepskin or another barrier inside splits or boots. The weights must always be "free hanging" and not touching the floor, bed, or patient. -Maintain traction 24/7 unless ordered otherwise. -Frequent neurovascular checks - ROM as appropriate, movement, color, pulses, edema, temp, cap refill, tactile sensations, tingling/numbness.

Traction

-Skin traction: pull applied to skin that indirectly pulls traction on bone & muscle. -Skeletal traction: pull applied directly to bone w surgically placed pins through the bone. •Nursing Priorities: considerations for traction-related care

Strain vs Sprain

-Strain: *stretched or torn muscle or tendon.* Heal strain=REST -Sprain: injury to a ligament caused by force exceeding ligament's strength. (NSAIDs): provide analgesia & reduce swelling. -Severe sprain: enough to prohibit ambulation, healthcare professional needed=immobilize the area for 10 to 14days. -brace, splint, or walking shoe may be used

Compartment Syndrome

-The muscle groups in the body are divided into sections; each section is kept in place by tight bands called fascia, which do not stretch. -trauma or other conditions cause swelling and pressure inside one of those muscle group sections (compartments). -Without the ability to expand, circulation to the tissue inside that section (compartment) is impaired and can become necrotic (or die). -occur after casting an injured extremity because (a) cast too tight when dries & (b) healing process causes edema & WBC flood area to facilitate healing. -Mostly in *long bones; forearm injuries* are the second most common.

Medical Management of Fracture

-Treatment: reduction of fracture (putting the bone back in place) and immobilization. -Reduction may be done closed (without surgery) or open (surgically), depending on the severity of the injury. -Protection against infection is important with an open fracture. -Immobilization after fracture reduction may be accomplished with a splint, a cast, internal or external fixation, and/or traction.

Toddler Fractures

-accidental *twisting injury* (nondisplaced spiral fracture), typically to the *lower extremities in ambulating toddlers during normal activities* (e.g., sliding down a slide and getting the leg caught). -Twisting injuries in non-ambulating children= possible child abuse.

Rickets

-growing bone kids &teens- young bone fails to calcify. -classic type is caused by *Vitamin D deficiency* + *lack of sunlight.* -US rickets incidence: very low bc infant formulas & milks *fortified with vitamin D.* -Teach parents about diet options for their child that contain vitamin D and safe exposure to sunlight

Kids Bone Structure

-growth plate: rapid growth occurs along the long bones. -During growth periods: cartilage cells in the epiphysis (the end of the long bones) are ossified by osteoblasts (immature bone cells) which lengthens the bone -this process continues until early 20s, when the growth plate completely ossifies. -GROWTH PLATES allow for rapid growth=quickens healing process -injuries involving growth plate of long bones: concerning =adversely affect growth& remodeling of the bone.

S/sx Musculoskeletal Illness

-limp/other changes in gait -recent trauma -recent strenuous exercise -fever -weakness -changes in muscle tone -areas of redness/swelling

Clinical Presentation Fractures

-pain -deformity -crepitus -Dx by s/sx & radiology -loss of function -shortening of extremity -local swelling/discoloration -report injury to area

Scoliosis

-progressive condition of lateral curvature of the spine greater than 10° with rotation of the vertebrae=spine have S-shaped appearance -classified by location of the curvature (thoracic or lumbar) & by cause: congenital, neuromuscular (secondary to neuro disease of CNS or muscles - most progressive), or idiopathic (unknown) -80% of scoliosis cases are idiopathic and occur in teens

Pectus Excavatum

-ribs & sternum to grow abnormally such that the breastbone (sternum) goes inward, making *concave appearance* -Familial, BOYS more -Assess: chest deformities, s/sx *cardiopulmonary difficulties* -Symptoms: fatigue, exercise intolerance, chest pain, coughing, wheezing, frequent respiratory infections & palpitations.

Congenital Clubfoot

-talipes equinovarus: foot is twisted. -Cause unknown, familial. -BOYS > girls. -1/2 all kids with this disorder affected bilaterally (both legs) -Without treatment, kids difficulty wearing shoes & walking (pain w walk) -Early treatment=successful, -95% success with the *Ponzi method of serial casting (4-8 weeks)*, surgery to lengthen the tendon, casting for another 3 weeks, and then a brace for 2-4 years.

Antibiotics used to Treat Osteomyelitis

1. Cefazolin (Cephalosporin): IV monitor intermittent infusion over 30-60min, against gram + cocci, monitor for rash 2. Nafcillin (Penecillinase resistant Penicillin): *same as cefazolin* 3. Clindamycin (anti-infective): IV & PO, Monitor for GI upset (diarrhea & cramps), intermittent infuse over 30 min 4. Vancomycin (anti-infective): IV & PO, admin IV over 60 minutes -Monitor irritation @ IV site, s/sx anaphylaxis, kidney function (I&O) & hearing (ototoxic)

Types of Fractures

•Closed: A fracture in which the bone does not break through the skin •Open: A fracture in which the bone breaks through the skin •Nondisplaced (hairline): A fracture in which the bone cracks rather than breaking into two separate pieces •Displaced: A complete fracture in which the bone breaks into two or more pieces and changes position such that the ends of the bone are not in alignment •Complete (transverse): A break across the entire section of bone at a 90° angle •Oblique: A break across the entire section of bone at a diagonal angle •Spiral: A twisting break across a bone •Comminuted: A fracture involving the bone breaking into several fragments •Avulsed: A small chunk of bone attached to a tendon/ligament is pulled away •Segmental: Two fracture lines that isolate a segment of bone •Impacted: Occurs when the two broken ends of the bone and jammed together by the force of the injury •Buckle (torus): An incomplete fracture in which one side of the bone is compressed because of an impact, causing the other side of the bone to bend away from the growth plate •Greenstick: An incomplete fracture in which the bone bends and only breaks on the convex side

5 P's Compartment Syndrome: Neuro-vasc Compromise

•Pain: out of proportion to the injury or unrelieved by opioids *Earliest &Cardinal Sign* •Pallor: pale or blue color •Pulselessness: decreased pulse strength (or absence of pulse) •Paresthesia: numbness or tingling •Paralysis: inability to move areas distal to the cast *LAST SIGN*

Acquired Musculoskeletal Disorders

•Rickets •Slipped Capital Femoral Epiphysis (read in txtbook) •Legg-Calvé-Perthes disease (read in txtbook) •Osteomyelitis •Scoliosis a result of *nutritional deficiency, infection, or unknown cause.*

whole milk is okay starting at

1 years old

Cartilage & Collagen are stronger than bones in children until they reach puberty? T or F

FALSE **ligaments and tendons are stronger than bones until puberty**

nurse is assessing a child with suspected osteomyelitis. Which finding would help support this suspicion?

swelling and point tenderness

Fractures Assessment

•Get the story - what happened? •Does the story match the injury? •Most common childhood fractures occur from falls •Rule out child maltreatment in all unintentional injuries

Cast Care

•Handle a wet cast with open palms •Elevate the cast above the level of the heart and ice to prevent swelling •Assess for bleeding and signs of infection (foul odor, drainage, fever, warmth, redness) •Assess for skin breakdown and pressure points •Keep the cast clean and dry •Never put anything inside the cast •Prepare patients and caregivers before cast removal -Casts can remain wet for 12-24 hours after application

Musculoskeletal Injuries

•Strains and Sprains •Fractures •Overuse syndromes