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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