Download Musculoskeletal Dysfunction

Musculoskeletal Dysfunction
M. Rubolino-Gallego
Nursing 355
Musculoskeletal
Affects muscles, bones, joints and tendons
Rapid growth of the skeletal system
Most musculoskeletal problems are short-term
Bones
A surface for the attachment of muscles, tendons, and ligaments
206 bones
Long bone consists of a shaft with an epiphysis
Wide portion of the bone responsible for growth
Periosteum covers the bone
Joints/Articular System
Connective tissue and cartilage
Connect bones to one another
Immovable vs. slightly movable vs. Freely movable
Ligament binds one bone firmly to another
Muscle
Elongated fibers
3 types of muscles
Cartilage
Dense connective tissue
The skeleton of an embryo is mostly cartilage
Musculoskeletal History
_______________ is leading cause of death in children over age 1 year
Fractures in children under 1 year are uncommon
Depends on developmental stage of the child in the injury and the physiologic response
Leading causes of morbidity in children are medical problems resulting from injury at
home
Musculoskeletal
Skull is not rigid/fixed during infancy
Sutures fuse ____________ months of age
Soft tissues are resilient in children
Fractures
Occur in children from:
Increased mobility
Immature motor and cognitive skills
Trauma (falls, MVAs, child abuse, sports injuries)
Ages 5-9 more likely to have Fx
Dx: X-ray
Etiology of a Fracture
In infancy more often result ________________________________________
Any investigation of fx in infants should include r/o osteogenesis imperfecta
Fx of forearm common childhood injuries
Clavicle bone is most frequently broken bone in children
Hip fx are rare
Children fall from heights
Pathophysiology
Adult bones – are strong, require a violent traumatic force to fx, injuring the soft tissue
Children – bones are more easily injured, fx may result from falls or twists
Types of Fractures
Complete – fracture fragments are separated
Incomplete – fracture fragments remain attached
Transverse
Oblique
Spiral
Simple
Compound
Comminuted
Greenstick
Buckle
Bends
Types of Fractures
Greenstick Fractures
_______________________________________
But only bows or buckles on the other side
Greenstick Fracture
Oblique Fracture
Diagonal break that occurs between the horizontal and perpendicular planes of the bone
Oblique Fracture
Comminuted Fracture
Bone is splintered into pieces
Comminuted Fracture
Salter-Harris Classification System
Assessment
ABC’s
Assess extent of injury – 5 “Ps”
Pain and point of tenderness
Pulselessness
Pallor
Paralysis
Paresthesia
Determine mechanism of injury
History
Observe for bruising, lacerations, swelling
Diagnostic Criteria
Infants and toddlers are unable to clearly communicate the details
Older children may not be reliable informants
X-ray – most useful
Treatment – Casts/Traction
Emergency -Move injured part as little as possible
Immobilize limb
Elevate limb if possible
Apply cold to affected area
Cover open wound with sterile or clean dressing
Call EMS
Casts
Provides support and maintains position
Plaster of Paris is not water resistant, heavier, molds easily, takes 24+ hours to dry
Synthetic casts more expensive, dry quickly, lighter weight, water resistant
Traction
Force exerted on one part of the body
Skin _______________________________________________________________
Counter-traction must be provided at the same time usually with the child’s weight
Mattress should be firm
Attached with adhesive material
Limits of weight
Skin breakdown may occur
Skeletal Traction
Pull applied directly to the skeletal structure by a pin, wire, or tongs
Greater force than skin traction
Tolerated for longer periods of time
Complication: Osteomyelitis
__________________________________
Inserted into the diameter of the bone
Stress placed on the bone
External Fixation Device
Pins or wires inserted through the skin, soft tissue, and bone and secured on the outer
limb surface to a metal frame
Child is ________________________
More common now
Pin care is needed to avoid infection
Nursing Considerations
Understand purpose of traction
Maintain traction
Maintain alignment
Neuro status – every ___________ hours for the first 48 hours
Care for skin traction
Prevent skin breakdown
Prevent complications
Consequences of Immobility
Integumentary : red, irritated skin, ulceration or drainage
Respiratory: Decreased or altered respirations, SOB, lying supine for prolonged
periods, decreased breath sounds, pulmonary embolism
GI: decreased # of bowel mvmts
GU: Decreased UO, foul smelling urine
Musculoskeletal: reduced strength, loss of muscle tone, muscle atrophy, limited ROM
Limb Defects
Common in children
Often resulting from birth anomalies and sometimes trauma
Syndactyly (webbing)
Polydactyly (extra digits)
Genu Valgum (knock knees)
Genu Varum (bow leg)
Club Foot
Webbing
Polydactyly
Knock knees
Bow leg
Club Foot
Club Foot
Malformation of the lower extremities
Genetic
1.2 in every 1000 births in the US
Boys more than girls
Treatment started soon after birth
Serial manipulation and casting for 3-6 months
Surgery if casting fails
Even with treatment, foot is often not completely normal
Lifelong atrophy of the calf is common
Hip Dysplasia
Head of the femur is improperly seated in the acetabulum of the pelvis
Can be present at birth
May develop after birth
Genetic
African American and Asian less common
More common in girls
Hip Dysplasia
Infants beyond newborn exhibit asymmetry of the gluteal skinfolds when lying down
Limited ROM of the affected hip
Asymmetric abduction when child is supine with knees and hips flexed
Dx: exam, ultrasound, CT, MRI
Tx: depends on age and severity
Newborn: splinting the hips with a Pavlik harness
After newborn period: traction or surgery
Osteogenesis Imperfecta
Most common osteoporosis in children, brittle bone disease
Inherited syndrome: FX and bone deformity
Clinical features: bone fragility, deformity, fracture, blue sclerae, hearing loss,
discolored teeth, skin transparent, frequent fractures
Dx: X-rays, genetic testing
TX: supportive, prevention of more fractures
Patho: biochemical defect in the synthesis of collagen
Abnormal collagen results in incomplete development of bones, teeth, ligaments and
sclerae
Osteomyelitis
Bacterial Infection of the bone involving the cortex or marrow
Acute vs. chronic (longer than 1 month)
Occurs more in children 10 years of age or younger
_________________________ #1 causitive agent, B strep (newborns), E. coli
Results from a blood borne bacteria causing an infection in the bone
Causes: large amount of organisms, foreign body, bone injury, immunosupression,
malnutrition
Bacteria adheres to bone
1 in 500 children younger than 13 years old
Infants: blood vessels cross the growth plate into the epiphysis and joint space, allowing
infection to spread into the joint
Children: infection is contained by the growth plate, joint infection is less likely
S/Sxs: severe pain, fever, irritability, tenderness, without local signs of infection, tender
extremity
Dx: organism ID, cultures from blood, joint fluid, and infected skin, bone changes may
not be evident on x-ray until 10 days after onset
Tx: IV antibiotics – clindamycin, or vanco for at least 4 weeks, surgery
Nursing: affected limb will cause discomfort to the child
Child positioned comfortably with limb supported
Poor appetite leading to vomiting, high calorie liquid foods encouraged
Juvenile Arthritis
Autoimmune, inflammatory disease
No known cause
May or may not have a + rheumatoid factor
Chronic disease, is the leading cause of blindness and disability in children
Unknown etiology: infection, trauma, emotional stress cited as triggers
Juvenile Arthritis
1 in 1000 children in the US
Before 16 years of age
Sxs: intermittent joint pain lasting longer than 6 weeks in more than 1 joint
Joint may appear stiff, swollen, warm, limited ROM
Dx: History, rheumatoid factor, ANA, elevated ESR, + C-reactive protein
Juvenile Arthritis
Tx: supportive, NSAIDs, steroids, gold salts, methotrexate
PT/OT treatment
Scoliosis
Complex spinal deformity in three planes
Most common spinal deformity
Lateral curvature of the spine
Affects 10% of the population
congenital or develop during infancy or childhood
May be genetic or multifactorial
Rarely apparent before age 10
Rarely has discomfort and few outward signs in the beginning
Dx: standing child, wearing only underwear, viewed from behind
X-ray
Screening is controversial
Tx: observation, bracing, spinal fusion surgery, based on magnitude, location and type
of curve
Must promote self-esteem
Lordosis
Accentuation of the lumbar curvature beyond physiologic limits
Idiopathic, trauma, secondary complication
Normal in toddlers
Teens: more in girls, in obese children; the wt. of the abdominal girth alters the center
of gravity
Pain
Tx: manage predisposing cause, postural exercises
Kyphosis
Abnormally increased convex angulation in the curvature of the thoracic spine
Can occur secondary to diseases
Postural kyphosis in 4% of healthy adolescents
Dx: visual exam
Tx: postural exercises, sports
Muscular Dystrophy
Inherited disease
Duchenne’s MD recessive disorder affects only males – females are carriers and pass the
defect onto their male children
Muscle fibers degenerate and are replaced by fat and connective tissue causing weakness
and atrophy
1 in 3000 male children
Increasing disability/deformity
Usually 3-7 years old, must use Gowers maneuver to rise from floor (child puts hands on
knees and moves the hands up legs until standing erect)
Labs: Serum Creatine Kinase - CK levels elevated in early stages
TX: maintain ambulation and independence
Cardiopulmonary complications most common cause of death
Goals: Prompt attention to infection
- Respiratory
-Obesity prevention
Legg-Calve-Perthes
Self-limited disorder
Avascular necrosis of the femoral head
Disorder of growth
1 in 20,000, more in boys
Affects boys 4-8 years, average onset 6 years
Cause unknown
S/Sxs: intermittent, painful limp, hip soreness, ache or stiffness, pain along hip or entire
thigh, limited ROM
Tx: keep head of femur contained in the acetabulum as it regenerates, and reduce the
risk of permanent stiffness, surgery, adductor brace for 18 months
Slipped Capital Femoral Epiphysis
Affects the upper femoral growth plate
Hip disorder, during rapid growth ie. Adolescence
Cause: Unknown
2 per 100,000, average age 12 years for girls and 13.5 years for boys
Usually exceed the 90th percentile for height and weight
Slipped Capital Femoral Epiphysis
Sxs: limp, pain (groin, thigh, knee), abnormal gait
Dx: History, x-rays
Tx: pin or screw inserted into the growth plate securing the femur head, with diagnosis,
leads to admission to the hospital and bed rest
Osgood-Schlatter Disease
Related to repetitive stress from sports-related injuries, combined with overuse of
immature muscles and tendons over an extended period of time
Exacerbated by exercising
Occurs between ages 8-16 yrs, knee pain
Inflammation of the tibial tubercle
Without tx, tubercle enlarges and can cause functional and cosmetic problems
Dx: x-ray, clinical picture
Tx: avoid exercising x 6 weeks, wrapping the knee, PT, ice, heat, NSAIDs