Download Musculoskeletal Alterations

Musculoskeletal Alterations
NUR 264 – Pediatrics
Angela Jackson, RN, MSN
Differences between Children and
Adults
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Bones contain a large amount of cartilage, making
them more flexible and less likely to break
Periosteum is stronger and tougher
Bones heal more quickly because the bones are
still growing: The younger the child, the faster the
bone heals
Epiphyseal growth plate
Bone injury, especially at the growth plate, is more
common than sprains, because soft tissue
attachments are stronger in children
Types of Fractures
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Closed or Simple fracture: The skin over the broken bone
remains intact
Open or Compound fracture: The broken bone protrudes
through the skin
Transverse fracture: Occurs at a right angle to the long axis
of the bone
Oblique fracture: A slanting or diagonal break across the
bone
Spiral fracture: circular and twists around the bone shaft
Greenstick fracture: A break through the periosteum and
bone on one side while the other side only bends
Fractures
Salter-Harris Classification of
Epiphyseal injuries
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Type I: Separation of the epiphysis from the metaphysis.
Usually does not affect growth. No fracture of the bone.
Type II: Separation of the epiphyseal growth plate and
fracture of the metaphysis. Usually does not affect growth.
Type III: Fracture of the epiphysis extends into the joint. If
reduced properly, does not usually affect growth.
Type IV: Fracture of growth plate, epiphysis, and metaphysis.
Open reduction and internal fixation usually necessary to
prevent growth disturbance
Type V: Crushing injury of the epiphyseal growth plate.
Results in premature closure of the plate on one side with
growth arrest.
Salter-Harris Classification
Traction
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The application of pulling force to a body part
against a countertraction pull exerted in the
opposite direction
Used to treat a variety of injuries
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Spine
Long bones of the upper and lower extremities
pelvis
Traction
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Straight traction:
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Child’s body weight serves as the countertraction
Balanced Traction:
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the body part is suspended by a sling and the
countertraction as well as the primary traction is
provided by pulleys and weights. The angle of
the involved joint and the angle formed by the
placement of the pulleys on the bed determines
the direction of the pull or force
Primary Purposes of Traction
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Immobilizes the fracture
Decreases muscle spasms
Realigns and positions bone ends while
healing takes place
Prevents further soft tissue damage
Complications of Fractures
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malunion
compartment
syndrome
growth disturbances
Nursing Considerations
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Neurovascular status
Pain
Respiratory status
Cardiovascular status
Immobilization
Skin Integrity
Nutrition
Elimination
Nursing Management
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Monitor for appropriate alignment, and ensure that weights hang
freely
Perform Neurovascular checks every hour X 24 hrs, then q4-8hrs
Maintain skin integrity
Promote pulmonary hygiene
Promote adequate fluid and fiber intake to prevent constipation
Provide stimulation appropriate for developmental age to promote
growth and development
Encourage limited mobility as permitted
Encourage parents to hold child as permitted
Avoid pressure on the popliteal space to prevent nerve damage
Provide adequate pain relief
Infectious Disorders of the
Musculoskeletal System
Osteomyelitis
Osteomyelitis
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Infection of the bone caused by a microorganism
May be bacterial, viral or fungal
Bacteria may be introduced through the blood
stream from an infection in another part of the body
(endogenous spread) or directly into the bone via a
penetrating wound or open fracture (exogenous
spread)
More common in children between the ages of 3 and
12
Males are affect 2 to 4 times more often than
females
Osteomyelitis: Sources of Infection
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Sources of hematogenous
spread include
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Acute otitis media
Impetigo
URI’s
Abscessed teeth
Burn infections
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Causative Organisms
include
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Staphylococci aureus (80 –
90%)
Haemophilus influenzae
Streptococcus Pneumoniae
Escherichia Coli
Group B streptococci
gram-negative enteric
bacilli
Anaerobic bacteria
Osteomyelitis: Pathophysiology
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Bacteria travels to the small arteries at the end of the
bone
Inflammation with increased blood flow and swelling
occurs
The infectious process leads to bone destruction and
abscess formation
Increasing pressure as exudate collects and is
confined within the bone results in vascular
occlusion, ischemia and eventually bone necrosis
Osteomyelitis: Clinical Manifestations
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Infants
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Irritability
Poor feeding
Failure to move affected
limb
Permanently arrested
bone growth
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Children
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Constant bone pain
Restricted movement
Swelling
Heat in the affected area
Redness
Fever
Signs and symptoms of
systemic infection
Osteomyelitis: Diagnosis
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Lab tests
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CBC
C-reactive protein
Sed rate (ESR)
Blood cultures
Wound cultures
Culture of bone aspirate
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X-Rays
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Routine x-ray of affected
area
Bone scan
X-ray examination of the
affected area will detect
bone necrosis ten to
fourteen days after
appearance of clinical
manifestations
Osteomyelitis: Potential Complications
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Abscess
Joint or bone damage, especially damage to
epiphyseal growth plate
Complications affecting the hepatic, renal
and hematological systems (related to high
dosages of antibiotics)
Amputation of affected extremity
Interference with growth
Osteomyelitis: Treatment
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IV broad-spectrum antibiotics for 3 – 6 weeks
(may switch to po after adequate response is
achieved)
Splinting
Surgical drainage and debridement
Osteomyelitis: Nursing Management
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Monitor for potential complications
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Perform neurovascular checks at least q8hrs
Maintain proper alignment and move the limb cautiously to avoid
further injury to the bone
Administer antibiotics as scheduled
Assess the site of infection; monitor for edema, redness,
warmth or drainage every 4 hours
Monitor white blood cell count and therapeutic medication
levels
Maintain splinting if present
Use sterile technique for dressing changes
Assess for pain, and administer analgesics as prescribed
Muscular Disorders
Muscular Dystrophy
Muscular Dystrophy
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A group of inherited diseases affecting the muscle,
leading to progressive muscular wasting and
degeneration of muscle fibers
It is the largest group of muscle diseases affecting
children, and it is genetically acquired
Duchenne’s Muscular Dystrophy is the most
common childhood form (x-linked recessive)
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Affects all races and ethnic groups
Affects males almost exclusively
Females may be carriers and pass the defect to their male
children
Muscular Dystrophy: Pathophysiology
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Absence of the muscle protein dystrophin,
which plays a role in supporting the structure
of muscle fibers
Results in degeneration of skeletal muscles
that control movement
Fat and connective tissue replace the
degenerated muscle fibers
Muscular Dystrophy: Clinical
Manifestations
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Generalized muscular
weakness and muscle
wasting – usually appears
during the third year of life
Difficulty running and
climbing stairs
Tires easily when walking
Waddling gait
(Trendelenburg gait)
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Lordosis
Frequent falls
Gower’s sign
As disease progresses,
calves, thighs, and upper
arms become larger as a
result of fatty infiltration
(pseudohypertrophy)
Mental retardation is
common
Gower’s Sign
Muscular Dystrophy: Diagnosis
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Muscle biopsy (identifies presence of fatty
tissue)
DNA testing
Electromyography (detects decreased
electrical impulses)
Elevated serum creatine kinase (enzymes
leak from deteriorating muscles)
History and physical findings
Muscular Dystrophy: Treatment
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There is no cure for muscular dystrophy.
Treatment is supportive and includes:
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PT/OT
Braces, wheelchairs
Surgery
Muscular Dystrophy: Potential
Complications
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Atrophy may develop as a result of immobility
Contracture deformities may develop as a result of
immobility and disease
Obesity may result from bed rest and immobility
Cardiac complications occur lat in disease and may
require a pacemaker
Infections, especially respiratory, secondary to weak
muscles of respiration, occur. Even minor infections
require prompt treatment to avoid complications or
death.
Muscular Dystrophy: Nursing
Management
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Participation with the interdisciplinary team
Respiratory care: teach deep breathing and coughing exercises
Maintenance of optimal nutrition
Prevention of skin breakdown
Maintenance of optimal bowel and bladder function
Teach signs and symptoms of infection
Encourage independence as long as child is capable. Powered
wheelchairs, special eating utensils, and other assistive
equipment is available
Encourage genetic counseling
Assist family and child in coping with a fatal disease
Teach proper body mechanics and range-of-motion exercises
Musculoskeletal Disorders
Legg-Calve Perthes
Osteogenesis Imperfecta
Legg-Calve-Perthes: Pathophysiology
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Temporary loss of blood supply to the femoral capital
epiphysis, results in avascular necrosis of the
femoral head
Unknown cause
Occurs in four stages:
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Incipient stage
Necrotic stage
Regenerative stage
Residual stage
Legg-Calve-Perthes: Clinical
Manifestations
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Intermittent appearance of limp on affected side
Mild pain in hip exacerbated by increased activity and relieved
by rest
Joint dysfunction and limited range of motion, especially
abduction and internal rotation
Stiffness varying from intermittent to constant
Limb-length inequality
Pain, soreness, and aching; usually worse on rising or at the
end of the day; may be in groin, hip or knee area
Tenderness over hip capsule
External hip rotation (late sign)
Deterioration of the femoral head on x-ray
Legg-Calve-Perthes: Nursing
Management
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Monitor neurovascular status
Encourage meticulous skin care
Teach signs of muscle atrophy
Teach crutch Walking
Encourage non-weight bearing activities
Teach safety measures
Legg-Calve-Perthes: Treatment
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The main goals of treatment
are to keep the head of the
femur contained in the
acetabulum, to promote
healing, and to prevent
deformity. This may be
achieved through:
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Traction
Braces
Leg casts
Surgery
Legg-Calve-Perthes: Diagnosis
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Diagnosed and classified by X-ray
Bone scan
Osteogenesis Imperfecta (OI)
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Known as brittle bone disease
Connective tissue disorder. Occurs in several forms
with variable degree of severity
Fractures may result form trauma, but also from
simple walking or pressure of birth
Affects boys and girls equally
A child with this diagnosis should not be
confused with the child with fractures because of
abuse
OI: Pathophysiology
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Characterized by disturbed formation of
periosteal bone, resulting in formation of
pathologic fractures
Normal calcium and phosphorus levels, and
abnormal precollagen type I, which prevents
the formation of collagen, the major
component of connective tissue
Bones consist of large areas of osseous
tissue and increased numbers of osteoblasts
OI: Clinical Manifestations
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Multiple and frequent
fractures, some of which
may be present at birth
Limb and spinal column
deformities related to
multiple breaks
Blue sclera
Thin, soft skin with easy
bruising
Increased joint flexibility
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Weak muscles
Short stature
Conductive hearing loss
May have dentinogenesis
imperfecta: hypoplastic teeth
with opalescent blue or
brown discoloration
OI: Diagnosis
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Collagen studies
Prenatally, may be detected by level II ultrasound if
disease is severe
OI: Treatment
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Early intervention of fractures
Prevention of deformities using splints,
braces, casts and surgery
Rod insertion
Adequate nutrition including calcium,
magnesium and vitamins
OI: Nursing Management
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Maintain a non-judgmental and supportive attitude
Handle child gently and teach family to handle child
gently:
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Avoid lifting by a single arm or leg
Use a blanket for extra support when lifting and moving
Never hold by ankles when diapering. Gently lift by slipping a
hand under the buttocks
Encourage activities the promote growth and
development while maintaining a safe environment
Encourage exercise, such as swimming, to improve
muscle tone and prevent obesity
Encourage realistic occupational planning
Suggest genetic counseling
Any Questions???