Care of Children with Musculoskeletal Disorders (The final lecture) PDF

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Care of Children with Musculoskeletal Disorders (The final lecture)...

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Care of Children with Musculoskeletal Disorders Differences in Child’s MSK System  Long bones increase in diameter by addition of new bone tissue around bone shaf  Long bones increase in length by proliferation of cartilage at the growth plates (epiphyses)  Ligaments are stronger than bone until adolescence  Rapid growth in Tanner stage 3 results in decreased strength and greater potential for injury Immobilization  Once thought to be beneficial – but we now know that immobilization has serious developmental effects: o Physiological Effects on Bone, Muscles, Respiration, Abdominal, urinary o Psychological implication o Socially unacceptable Immobilization Physiologic Effects  Decreased metabolic rate  Negative nitrogen balance  Hypercalcemia – calcium leaks out to blood  Decreased production of stress hormones

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Diminished vasopressor mechanism Altered distribution of blood volume Venous stasis – deep vein thrombosus Dependent edema

Nursing Care to Lessen Physiological Effects of Immobilization  Range of Motion exercises  Nutrition  Play Therapy

Immobilization Psychological/Social Effects  Decreased environmental stimulus  Altered perception of self  Frustration, anxiety  Depression  Developmental regression  Delayed school progression  Isolation from friends/siblings

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Need for family support Logistics of family with sick child

Nursing Care to Lessen Psychological/Social Effects  Allow appropriate expression of anger  Help parents understand behavior may be a release of tension  Encourage active involvement in care

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Involve Child Life/School teachers Encourage visits by peers, siblings Provide alternate environment if possible (trips to the playroom, etc)

Trauma  Leading cause of death in children > 1 year of age o Has been decreasing  Childhood Characteristics o Head larger in proportion to body – they’re top heavy o Neck muscles weak – causes neck to be displaced, not as ofen – neck/spinal cord injury may not be able to see on xray o Rib cage is flexible with thinner chest wall – no rib fracture but can get lungs and heart contusions & other organs o Poor impulse control – ex. running into the streets afer a ball  When trauma occurs o ALWAYS EVALUATE ABC’S FIRST – HOLD THEIR HEAD STILL!!! o Consider cervical spine injury Types of Traumatic Injuries  Contusions – BRUISES! – Bleeding under the skin o Damage to sof tissue, muscle, resulting in inflammatory response, hemorrhage, edema, and pain o Escape of blood into tissue – black/blue/yellow discoloration o Treat with cold compress for no more than 20 min o Don’t put a date to a bruise!!! 

Dislocations o Occurs when force of stress on ligament is sufficient to displace the normal position of the opposing bone ends or the bone ends to its socket o Common in Down syndrome o Hip dislocation: potential loss of blood supply to head of femur (necrosis)

Common Dislocation  “Nursemaids Elbow”- Subluxation of the radial head o Subluxation- partial dislocation o Once it’s happened, it can happen again – teach parents to Not swing childs arms

Types of Traumatic Injuries – use RICE!!!

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Sprains o Trauma to a joint from ligament tear  Grades I, II, III o Associated injuries to blood vessels, muscles, tendons, and nerves o Presence of joint laxity as indicator of severity o Rapid onset of swelling with disability

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Strains – less common in children o A microscopic tear to musculotendinous unit - tendon o Similar to sprain o Swelling, ecchymosis, difficulty weight bearing o Swollen, painful to touch o Generally incurred over time o Uncommon in children

Treatment of Strains and Sprains – RICE causes deep tissue vasocompression!  

Rest the injured part Ice immediately – for no more than 20 minutes at a time. Produces deep tissue vasodilatation without increased metabolism

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Compression bandage (ACE) Elevate affected extremity

Bone Injuries  Long bone fractures o Common in children due to high speed, high impact activities  Epiphyseal injuries o Growth plate at end of long bones o 18-30% of pediatric fractures o More common in adolescents – peak 11-12 years of age o Most occur in upper limbs o Epiphyseal is the weakest part of the bone Epiphyseal Injuries - Usually require surgery!  Weakest point of long bones is the cartilage growth plate (Epiphyseal plate)  Frequent site of damage during trauma  Injury may affect future bone growth  Treatment may include open reduction and internal fixation to prevent growth disturbances  Salter 1-5 fractures

Types of Fractures  Closed  Compound or open: o Fractured bone protrudes through the skin  Displaced  Nondisplaced 

Comminuted o Fracture with several bone fragments o May require pins, screws, plates for reunion

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Greenstick: o Compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture o (Imagine snapping a pencil. Now imagine an arm) o Only children gets it – it bends but doesn’t completely break!

Clinical Manifestations of Fracture  Swelling  Pain or tenderness  Diminished functional use  May have bruising, severe muscular rigidity, crepitus  Goal of traction is to relax the muscle so bone will come/stay in alignment Fractures  Diagnostic Evaluation o Radiograph of effected limb – joint above and below  Therapeutic management goals o Reduction o Immobilization o Restore function o Prevent further injury  Nursing considerations o 5 P’s = pain, pulse, pallor, paresthesia, paralysis o Control pain, spasms o Ensure alignment o Preserve function Assessment of Fractures the 5 P’s  Pain and point of tenderness  Pulse – distal to the fracture site  Pallor  Paresthesia – sensation distal to the fracture site

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Paralysis – movement distal to the fracture site Last 3 P’s are late & ominous signs

Bone Healing – the younger you are the faster your bone heals!  Typically, rapid healing in children o Neonatal period – 2-3 weeks o Early childhood - 4 weeks o Late childhood - 6-8 weeks o Adolescence - 8-12 weeks  A child's bones heal faster than an adult's because a thicker, stronger, and more active dense fibrous membrane (periosteum) covers the surface of their bones. The periosteum has blood vessels that supply oxygen and nutrition to the bone cells.  Question for class. Why do neonates heal quicker than adolescents?  My guess, Neonate bones are sofer and haven’t fully developed leading to quick recovery Treatment for Fractures  Splint at first – to allow swelling  Casts: o Cast application  Preparation  Drying  Nursing considerations o Neurovascular assessment o “Hot spots” on cast may indicate infection under cast  Discolor the cast at the infected spot – area gets warm and hot  Bring them back if they have a hot spot  Cast care at home o Itching – hair drier…, coat hanger, pencil o Skin care – brusing o Teach the parents & child to know when the cast is too tight o Allow cast to dry completely Spica Cast  Hip and ligament injuries (DDH)  Special considerations o Elimination – difficult to keep clean, bc hard to poop & pee o Positioning o Itching o Cleaning cast o Traveling

o Removal – can be scary for child The Child in Traction – good skin care!!  May be used o To provide rest for extremity o To help prevent deformity o To correct deformity o To allow position and alignment o To provide immobilization o To reduce muscle spasm  Nursing Considerations o Maintain traction o Maintain corrective alignment o Neurovascular checks o Skin integrity o Immobilization risks Other Immobilization Devices  Braces/Splints o Brace be careful about skin irritation  External Fixation Device o Pin Care Braces  Redness is a sign of skin irritation – brace needs to be adjusted  Do not apply lotion to irritated areas  Padding of irritated areas may alter the alignment of the brace – NO PADDING Infections of Bones and Joints  Osteomyelitis o Types:  Exogenous – bone is communicating with the outside,how bacteria get in  Infectious agent invades the bone following penetrating wound, open fracture, contamination in surgery, or from abscess  Hematogenous  Preexisting infection spreads to bone  Source may be skin infections, URI, abscessed teeth, Pyelonephritis, etc.  Any organism can be cause – staph aureus most frequent o S/S may begin abruptly, resemble symptoms of arthritis (inflammation of the joints) o Marked leukocytosis

o Bone cultures obtained by bone biopsy o Bone scans o Elevated WBC’s, sed rate, positive blood cultures  Severe pain, fever, irritability, tenderness – does not want to move affected limb – give pain meds!!  Clindamycin, Nafcillin common treatments  Need for long term IV access – need IV antibiotics & pain meds!  Monitor hematologic renal, hepatic responses to treatment o Nursing Considerations  Bed rest and immobility of limb  Pain management  Nutritional considerations  Psychosocial needs

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Congenital Skeletal Defects Developmental Dysplasia of the Hip (DDH) Club Foot (talipes equinovarus)

Formally called: “congenital hip dysplasia” or “congenital dislocation of the hip.” Reflects variety of hip abnormalities Shallow acetabulum (not deep enough to fit femoral head) Subluxation (head of femur slightly outside of acetabulum) – flat, anterior (more common) or posterior Dislocations (head of femur completely out of acetabulum

Clinical Manifestations of DDH Infant  Shortened limb on affected side  Restricted abduction of hip on affected side  Unequal gluteal folds when infant prone – bend the knees & they should be aligned  Positive Ortonlani test  Positive Barlow test Ortolani maneuver Barlow maneuver

Ortalani’s- Abduction and pushing head interior for relocation into the acetabulum

Barlow’s- adduction and posteriorly directed force (is it subluxable/ relocatable?) DDH in Older Infant and Child  Affected leg shorter than other  Telescoping or piston mobility of joint  Trendelenburg sign (standing on one leg, pelvis drops) o Ex. Imagine your index and middle finger as your legs. Now imagine how that would look.  Greater trochanter is prominent and appears above a line from anterior superior lilac spine to tuberosity of ischum  Marked lordosis and waddling gait if bilateral  Use a spica cast Therapeutic Management of DDH  Early intervention  NB – 6 months: Pavlik harness for abduction of hip  Age 6-18 months: Dislocation unrecognized until child begins to stand and walk. Spica cast  Older child: May require surgical intervention Congenital Club Foo [Talipes Equinovarus] – feet are turn in internally  Positional o Due to intrauterine crowding o Treated with stretching/casting  Syndromic o Associated with other abnormalities o Ofen resistant to treatment  Congenital or true o Most common o Wide range of rigidity and prognosis  

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Diagnostic evaluation o Orthopedic and Neurological exam Therapeutic Management o Correction of deformity o Casting Nursing considerations o Special shoes - turning the foot

Leg Alterations Genu Varum- Lateral bowing of the tibia **normal for 2-3yrs to be bow legged – will grow out of it … nothing you can do afer age 4-5yr (abn)

Genu Valgum- Knees close together, but feet spread apart (Like gum knees stick

Hip Joint Dysfunction  Legg-Calve-Perthes

Slipped Femoral Epiphysis

Legg-Calve-Perthes Disease  Pathophysiology – cause unknown, self limiting, idiopathic, occurs in juveniles ages 3-12, more common in males age 4-8  Avascular necrosis of femoral head – femoral head not getting enough blood supple o Circulation to femur epiphysis is more tenuous in middle childhood  10-15% of cases have bilateral hip involvement  Delayed bone growth  Disease may last 18 months – several years – can last for a long time Legg-Calve-Perthes Disease  Clinical Manifestations o Insidious onset, may have history of limp, soreness, or stiffness, limited ROM, vague history of trauma o Pain and limp more pronounced on arising and at end of activity  More Pain in the morning right when they get up o Diagnosed by radiograph – xray & bone scan 

Therapeutic Management o Treatment goal: Keep head of femur in acetabulum

o Containment with various appliances and devices vs. no treatment  Abduction casts, braces, leg casts – more casting than braces o Children under age of 4 do better o Children over 10 – may have degenerative arthritis o Rest, no weight bearing initially o Home traction in some cases o Surgery in some cases – requires pinning to keep aligned 

Nursing Care Management o Activity as tolerated afer initial bed rest o Encourage school activities, visits with friends o Develop activities that require less physical activity – such as models, board games, etc. o Long-term care – Parent fatigue

Slipped Femoral Capital Epiphysis  Spontaneous displacement of the proximal femoral epiphysis in a posterior and inferior direction  Occurs shortly before or during accelerated growth periods or puberty  Usually idiopathic, multifactorial o Obesity, puberty hormone changes, bone changes – more in rapid growth & overweight Slipped Femoral Capital Epiphysis  Clinical Manifestations o Episode of trauma with acute displacement o Gradual displacement without definite injury o Intermittent displacement  Therapeutic management o Goal: Prevent further slippage and restore function o Complete non-weight bearing – immobilized initially o Surgical pinning o Crutches afer surgery for 4-6 weeks  Nursing considerations o Same as for patients in cast or traction Spine: Scoliosis  The most common spinal deformity  Complex spinal deformity in three planes

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o Lateral curvature o Spinal rotation causing rib asymmetry, thoracic hypokhyposis o May be congenital or develop during childhood Diagnostic evaluation o Asymmetry of shoulder height, scapular or flank shape, or hip height o Ofen have a primary curve and a compensatory curve to align head with gluteal clef Therapeutic Management o Bracing o Exercise o Surgical intervention for severe curvature Nursing considerations o Concerns with body image o Concerns of prolonged treatment of condition o Pre and post-op care o Family issues

Osteogenesis Imperfecta (OI)  Heterogeneous inherited disorders of connective tissue o An autosomal dominant disorder  Characterized by excessive fragility and bone defects  Defective periosteal bone formation and reduced cortical thickness of bones  Hyperextensibility of ligaments  Multiple bone fractures and bone deformities  Blue sclera – seeing blood behind sclera  Bone Marrow transplant beneficial – NO  Can get fracture by just being picked up or diaper changed – easily fractured 

If you used a black and white printer you won’t see it, but blue sclera is a sign of OI

Nursing Considerations o Primarily supportive care o Lightweight braces o Physical therapy o Cautious handling of patient to prevent fractures o Genetic counseling – usually die real young o May initially think patient is victim of abuse

Juvenile Rheumatoid Arthritis (AKA Juvenile Idiopathic Arthritis)  Inflammatory disease affecting joints and tissues  Female predominance 1-3 years , 8-10 years  Symptoms: o Stiffness, swelling o Loss of mobility in affected joints o Warm, tender to touch, may have erythema o Growth retardation 

Diagnostic evaluation o No definitive diagnostic tests o Elevated sed rate in some cases o Antinuclear antibodies common, but not specific for JIA o Leukocytosis during exacerbations o Diagnosis based on criteria of American College of Rheumatology  Age on onset < 16 years  One or more affected joints  Duration of arthritis > 6 weeks  Exclusion of other forms of arthritis

Juvenile Idiopathic Arthritis  No specific cure  Goals of therapy: preserve function, prevent deformities, and relieve symptoms o Painful in the morning  Iridocyclitis/uveitis (hallmark difference between adults) o Inflammation of iris and cillary body o Unique to JRA o Requires treatment by ophthalmologist q6 months o When exposed to light Iris starts constriction – causing severe pain!!!!    

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Pharmacology o NSAID’s SAARD’s (Slower acting anti-rheumatic drugs)- slower acting antirheumatic drugs o Methotrexate, sulfasalazine,and hydroxychloroquine Corticosteroids – used for irretraceable flare-ups Biological – o Etanercept (autoimmune medicaiton reduces inflammation activity o May have long term side effects such as increased risk for infection Cytotoxic agents- When all else fails (CHEMOTHEARAPY!!!) o Cyclophosphamide, axathioprine, chlorambucil o Toxicity risk, potential benefits not well defined

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JIA Management o Therapy individualized to child o OT/PT o Nutrition, lots of exercise o Splinting devices o Pain management w/o sedation o Prognosis – will have arthritis for the rest of their life! o Nursing Considerations

Cerebral Palsy (CP)  Characterized by early onset and impaired movement and posture  Incidence 1.5 to 3 per 1000 live births  Most common permanent physical disability in childhood CP: Etiology  Intrauterine hypoxia/asphyxia o Intrapartum asphyxia o 12% to 23% of CP occurs in term infants with intrapartum asphyxia o Postnatal – occasionally o Ofen no identifiable immediate cause CP: Etiology (cont.)  Preterm birth of ELBW and VLBW is single most important determinant of CP  Anoxia—most common cause of brain damage whenever it occurs Types of CP  Spastic- uncontrollable stiff movements, tightness and jerky, Hypertonic or increased muscle tone – MOST COMMON!!  Athetoid/ dyskinetic—Slow wormlike movements of extremities, trunk, face, tongue o Drooling, speech problems o Lead to chorea—jerky involuntary movements worsen w/ emotional stress  Ataxic—rapid repetitive movements; wide gait, unable to hold on to objects  Mixed/dystonic—combination or spastic and athetosis 

Spastic o Most common clinical type o Presents as hypotonia most ofen

Types of Spastic CP  Quadriparesis (tetraparesis) o Four extremities involved/severe disability o Speech and swallowing difficulties o Tongue protrusion (incomplete)

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o Labile emotions in some patients Diplegia Monoplegia Triplegia Paraplegia

Possible Motor Signs of CP  Poor head control afer age 3 months  Stiff or rigid limbs  Arching back/pushing away  Floppy tone – bc spastic  Unable to sit without support at age 8 months  Clenched fists after age 3 months Possible Behavioral Signs of CP  Excessive irritability  No smiling by age 3 months  Feeding difficulties o Persistent tongue thrusting o Frequent gagging or choking with feeds Therapeutic Management for CP  General concepts  Mobilization  Surgical interventions (Like?)  Medications (Like?)  Technical aids o You gonna have to read the book Cerebral Palsy and IQ  Wide variation  70% of CP patients have normal IQ  Difficult to assess  Rigid, atonic, and quadriparetic CP have highest incidence of profound impairment Therapeutic Management: Therapies, Education, Recreation  PT  Functional and adaptive training (OT)  Speech therapy  Recreation  Normalization  Family support  Manual Jaw movement for eating – bc they’re so spastic

Muscular Dystrophies (MDs)  Largest group of muscular diseases in children  All have genetic origin with gradual degeneration of muscle fibers, progressive weakness, and wasting of skeletal muscles  All have increasing disability and deformity with loss of strength  Die at an early age due to respiratory difficulties/depression – pneumonia Duchenne Muscular Dystrophy (DMD)  Also called pseudohypertrophic muscular dystrophy  Most severe and most common of the MDs in childhood  X-linked inheritance pattern; one third ar...