Transcript Musculoskeletal

Musculoskeletal
Common MS disorders in Children
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Developmental hip dysplasia
Clubfoot
Fractures
Scoliosis
Osteogenesis Imperfecta
Osgood-Schlatter Disease
Osteomyelitis
Muscular Dystrophy
JRA
DISORDERS OF THE LOWER
EXTREMITIES
Developmental hip
dysplasia
• Hereditary disorder, more common
in girls, unilateral
• Improper formation and function
of hip socket
• Head of femur is dislocated
• Flat acetabulum of pelvis (prevents
femur from remaining in the
acetabulum and rotating
adequately)
Congenital hip dysplasia
Symptoms
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Limited abduction of the affected hip
Asymmetry of the gluteal and thigh fat folds
Affected leg may appear shorter
Positive “Ortolani click”
Uneven gait in older children
Diagnosis
 Early
detection is key for success
 Treatment
diagnosis
depends on age at
Management for infants
under 3 months of age
Pavlik harness:
keeps hips and knees flexed, the hips
abducted, and the femoral head in the
acetabulum
worn continuously for 3 to 6 months
effective 90% of time
Management
for infants >3 months age
Hip spica cast:
maintains abduction (frog-like position) 3-18
months age
Worn for 1 year
Must be changed as child grows
ORIF (surgical insertion of pin)
For child >18mos
Successful reduction is difficult after age 4
Nursing Considerations
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Skin care
Hygiene
Feeding
Handling
Immobility
• Elimination
• Growth and
Development
• Clothing
• Transportation
Clubfoot (equinusvarus)
• Congenital deformity of the foot
• Three areas of deformity:
– The midfoot is directed downward (equinus),
– the hindfoot turns inward (varus),
– the forefoot curls toward the heel (adduction) and
turns upward in partial supination.
Clubfoot
Can affect one or both feet
Portions of foot and ankle are twisted out
of normal position
Varying degrees of severity &
combinations of abnormal positions
Assessment:
Early detection is critical
Part of newborn assessment
Move foot to midline
Can range from mild to severe
• Treatment:
Begins soon after birth, before
discharge
Manipulation with serial casting for
8-12 weeks (due to rapid growth)
Cast extends above infant’s knee to
ensure correction
• Surgical correction btw 4-12 mos, realignment
of bones, pin insertion, cast for 6-12 weeks
• Denis Browne Splints: shoes attached to metal
bar to maintain correction
Fractures
• Break in bone from stress
• Frequent in children- bones are not as dense
and more porous
• Usually occur from
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Falls
Sports
MVA
Bone disease
Fractures
• Symptoms:
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Pain
Abnormal limb positioning
Decreased ROM
Edema
Ecchymosis
Crepitus
Refusal to play with extremity, guarding
Management
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Cast
Surgery
Pins and external devices
Traction- used to align bone
– Skin
• Pull is applied to the skin and muscle
– Skeletal
• Pull is applied to the bone pins
Nursing Considerations: New Cast
• Inspect skin
– observe for swelling, pain, discoloration, odor
– keep cast free of foreign objects
• Monitor Neurovascular Status
– keep extremity elevated for 1st day
– observe for loss of distal pulse, discoloration, loss of
movement
Watch for Compartment Syndrome
• Clinical manifestations begin about 30 minutes after tissue
ischemia starts.
• Paresthesia (tingling, burning, loss of two-point discrimination)
• Pain (unrelieved by medication, characterized by crying in the
young child)
• Pressure (skin is tense or discolored, cast appears tight)
• Pallor distal to cast (pale, gray, or white skin tone)
• Paralysis (weakness or inability to move extremity)
• Pulselessness distal to cast (weak or absent pulse)
Cast Care in Children
– Promote Mobility
• Crutches
• Wheelchair
• Wheeled Carts (hip spica casts)
– Promote Growth and Development
promote body image
provide diversional activity
cast becomes part of body, fear removal
DISORDERS OF THE SPINE
Scoliosis
• Most common type of spinal deformity,
girls 5:1 ratio
• Lateral curvature of spine
• Can be congenital or develop in infancy
or childhood
Dx: by observation, non painful at first
• All children screened in 5th grade
• Ill fitting clothes
• Uneven shoulders, scapulae, hips
• Scoliometer: degree of curvature
Treatment
• Treatment will not correct the curve, but
prevent it from worsening
• Mild Scoliosis
– Life Long monitoring
• Moderate Scoliosis
– Bracing
– Exercises to improve posture and flexibility
– Electrical Stimulation to back muscles
Treatment for Severe
Scoliosis
• Surgical correction: spinal realignment & straightening
(Harrington Rod)
• Followed by Milwaukee Brace . Worn 23 hr day
Nursing Considerations
• Screen and identify children
• Refer to ortho for eval and treatment
• Assess respiratory, neurological,
cardiovascular as rib cage deformity can affect
• Promote understanding and compliance of
treatment
• Promote good body image and self esteem
DISORDERS OF THE BONES
Osteogenesis Imperfecta
• Connective tissue disorder,
leads to fragile bone formation
• “Brittle Bone Disease”
• Causes recurrent pathological
fractures
• Will not have normal growth in
height
Clinical manifestations
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Multiple and frequent fractures
Thin, soft skin
Increased joint flexibility
Weak muscles
Soft, pliable, brittle bones
Short stature
Nursing Management
• Goal: protect from trauma and reduce
the number of fractures
• Early intervention
– Splints, Braces, Surgical Rods
– Childproof home
Nursing Management
• Handle child gently.
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Support trunk and extremities as child is moved.
Bathing and diapering may cause fractures
Use blanket for additional support when lifting
Never pull legs upward when changing a diaper
gently slip a hand under the hips to raise
Nursing Management
• Encourage well-balanced diet
– additional vitamin C, vitamin D, and calcium to
encourage healing and bone growth.
• Limit calories to maintain weight
– immobility can lead to overweight
Nursing Management
• Support normal growth and development
– Socialization
– Swimming improves muscle tone
– Wheelchairs and adaptive equipment
Osgood-Schlatter Disease
• Thickening & enlargement of tibial tuberosity
• Results from microtrauma (sports-related)
• Bilateral knee pain exacerbated by running,
jumping, climbing stairs
Nursing Management
• Self-limiting condition
– rest, ice, heat, NSAIDs
• Immobilization of limb may be
necessary
• Support other methods of exercise,
sports
Osteomyelitis
• Bacterial infection of bone
• Common in children age 1-12 years
• Can follow open fractures, burns, skin
abscess, foreign body
• Infecting organism spreads through the
bloodstream from the penetrating injury to
the bone
Signs and Symptoms
• Pain, warmth, tenderness,
limited ROM localized to the
area of infection
• Usually in the extremities
• In younger child- more subtle
symptoms, irritability
Osteomyelitis
• Diagnosis:
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Increased WBC’s
Increased sed rate
Increased C-reactive protein
Positive blood culture
MRI shows bone purulence and edema
Treatment
• 4-6 weeks of Antibiotics (PICC line)
• Limit weight bearing on extremity
• Aggressive therapy is needed to prevent
– Disruption of the growth plate, interrupt growth
– Septic arthritis and joint damage
– Recurrent infection
Nursing Considerations
• Administer IV antibiotics
• Teach care of PICC line
• Strict aseptic technique and transmissionbased precautions during all dressing
changes.
• Good hygiene
• Teach signs of spread of infection
– increasing pain, difficulty breathing, increased
pulse rate, fever
Nursing Considerations
• Promote Development
– Provide suggestions for the family if the child will
be immobilized at home.
– Assist the family in planning for completion of
school tasks
DISORDERS OF THE MUSCLE
Muscular Dystrophy
• Inherited disease with progressive
deterioration of muscle cells
• Causes progressive muscle weakness and
atrophy
• Several different types
• All differ by age of onset and severity
• The most common form of childhood
muscular dystrophy is Duchenne muscular
dystrophy
Duchenne’s Muscular Dystrophy
• X-linked recessive disorder
• Affects boys, symptoms by age 3
• Will meet early motor milestones, but later at
age 3 see:
– waddling gait, difficulty climbing stairs,
frequent falls; easily tired, when walking
and running
– toe walking, hypertrophied calves, lordosis
Gower’s Sign: press hands against
ankles, knees & thighs to stand up
Duchenne’s Muscular Dystrophy
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Speech & swallowing become impaired
More pronounced muscle weakness (scoliosis)
Wheelchair by junior high
Tachycardia
Pneumonia
Heart failure age 20
Nursing Considerations
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Maintain ambulation as long as possible
Physical Therapy, Adaptive equipment
Braces to prevent contractures
Promote independence
Prevention of injury
Prevention of infection
DISORDERS OF THE SOFT
TISSUE
Juvenile Rheumatoid Arthritis
• Chronic inflammation of synovium
with eventual erosion of articular
cartilage
• Cause is autoimmune
+ ANA (antinuclear antibodies)
+ RF (rheumatoid factor)
• Peak: 1-3 years or 8-12 years, girls
affected more
Follows one of three clinical
courses
• Systemic: elevated temperature, rash, any #
of joints affected
• Pauciarticular: involves 4 or less joints,
usually large joints
• Polyarticular: involves 5 or more joints,
smaller joints or weight bearing joints
Symptoms
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Stiffness in AM
Swelling
Tenderness
Painful to touch
Warm to touch,
seldom red
• Loss of motion
• Increased WBC’s &
sed rate
Juvenile Rheumatoid Arthritis
Goals of care:
1. Maintain joint fx (splints, ROM)
2. Prevent physical deformities
3. Relieve symptoms (pain &
inflammation)
• NSAID’s (aspirin, ibuprofen, naproxen)
• SAARD’s Slower Acting Antirheumatic
Drugs(gold, D-penicllamine)
Nursing Care
• Facilitate medication compliance
• Encourage child to be as independent as
possible
• Moist heat (bath or whirlpool) especially in
morning
• Prevention of injury
• Promote functioning
• Most common complication
severe hip involvement with loss of function
Practice Questions!
A 3-year-old child is suspected of having Duchenne’s
muscular dystrophy. Which of the following
assessment findings by the nurse would support
this diagnosis?
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A history of delayed crawling
Outward rotation of the hips
Difficulty climbing stairs
Wasted muscle appearance
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A child is admitted to the hospital suspecting
osteomyelitis. Which of the following serum
laboratory values noted by the nurse
supports this diagnosis? (Select all that
apply)
Positive Blood Cultures
+ ANA
WBC 15,000
Sed Rate 5
Decreased C-Reactive Protein
An adolescent diagnosed with moderate
scoliosis describes all of the following
symptoms. Which one would the nurse
conclude is not associated with the initial
diagnosis?
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Back pain
Skirts that hang unevenly
Unequal shoulder heights
Uneven waist angles
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A 4-year-old child with osteogenesis
imperfecta is admitted to the hospital unit.
Which of the child’s nursing diagnosis has
the highest priority?
Impaired skin integrity related to cast
Pain related to fractures
Risk for injury related to disease state
Disturbed body image related to short
stature
• Which item should the nurse remove from the
bedside table of a 4-year-old child who has
just been placed in bilateral long leg casts?
1. Legos
2. Etch-a-sketch
3. Fireman’s hat
4. Coloring book
The nurse is assessing a child in a newly applied
cast to the lower leg for a tibia fracture. The
nurse medicates the child for pain, which is
ineffective. The nurse should further assess:
1. Color of toes.
2. Apical pulse.
3. Skin temperature.
4. Blood pressure
A 14-year-old states her fingers and wrists are
stiff in the morning, hurt, and are swollen. The
nurse suspects this adolescent will be tested for:
1. Osteomyelitis
2. Osgood-Schlatter Disease
3. Rheumatoid Arthritis
4. Fractures