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					    Musculoskeletal

Elisa Mancuso, RNC-NIC, MS, FNS
       Professor of Nursing
    Anatomic Differences
• Child's skeleton contains growth cartilage
• √ Injury = widening of growth plate
• Physis = growth plate.
  – cartilaginous disq btwn epiphysis and metaphysis
• Growth plate FX need ↑ follow-up
  – Growth disturbances
  – Non-union
  – Deformity if not healed properly
      Pediatric Fractures
• Seldom complete breaks
• Buckle or bend RT flexibility of bones
  – ↑ thicker periosteum
  – ↑ amounts of immature bone
• Fractures RT direct force to bone
• FX <1 year are always suspicious
  – R/O Intentional (Child Abuse) vs.
    Accidental
Fracture -Clinical Signs
•       Pain @ site with guarding
•       Tenderness
•       Edema
•       Ecchymosis
•       Impaired ROM
•       Deformity
•       Crepitus
•       Neurovascular status impaired
    –     Distal to site RT compression
  Neurovascular Check
“Five P’s”
1.Pain
2.Pallor
3.Pulselessness
4.Paresthesia
5.Paralysis
          Diagnosis
• X-ray
  – √ R & L extremities
  – Comparison
  – Oblique FX→
• CT scan
• Bone Scan
• MRI
  – √ ligament damage
                 Therapy
RICE
•  Rest
•  Ice
•  Compression
•  Elevation

Surgery- ORIF
   Open Reduction Internal Fixation

Casting- Closed Reduction
   – Fiber glass
   – Plaster
•          Neurovascular √’s
•               Pain medication
          Complications
Compartment Syndrome
• Surgical Emergency!
• ↑ Pressure to FX site
• ↓ Circulation
• ↑ Risk for infection
• ↑ Pain
• Tenseness with palpation
• Motor weakness
•        ↓ ROM
             Traction
• Immobilize fracture
• Realign bone fragments
• ↓ Muscle spasms and pain
• Applies pull in 1 direction
   – Against counter pull in opposite
     direction
• Body wt is counter traction
•       External fixation = ↑ mobility
          Skin Traction
• Buck’s
  – Leg extended.
  – 1 line of horizontal - pull.
• Russel’s
  – Leg extended & knee flexed.
  – 2 lines of pull;
  – 1 horizontal & 1 vertical.
• Bryant’s
  –    Hips flexed @ 90 degrees
  –    Buttocks off bed
  – Both legs extended vertically
       Skeletal Traction
• Pin or wire directly inserted into bone.
• For complicated fx of femurs >6 years

• Complications
  – Osteomyelitis.
    Immobility Complications
•    Skin integrity
•    Atelectasis
•    Renal calculi
•    Constipation
•    Infections
•    Osteoporosis-bone demineralization
•    Fat Embolism
     – Female adolescents in 1st 24 hours (Femur Fx)
     – Sudden chest pain
     –     SOB
     –         Impending doom!
     –      Tx like PE!
  Nursing Interventions
• √ lab values-
  – ↑ Ca+, ↑BUN, & ↓ H and H
  – √ bleeding
• ↑ Hydration (2-3 L/day)
  – Prevent hypercalcemia & renal calculi
• ↑ Nutrition & Protein
  – Small frequent meals
• Exercise to help prevent osteoporosis
          Osteomyelitis
• Infection –
  – Bacteria invading metaphysis
  – Forming abscess and local bone destruction
• Males at ↑ risk at 5-14 years
• Causes:
  – Trauma or penetration injury
  – Invasion during surgical procedure
  – Systemic infection
         Clinical Signs
• ↑ Temp
• Erythema and warmth
• Pain
   – Abrupt onset with ↑ intensity
• Non-weight bearing
• ↓ ROM
• Irritability
• Septicemia
             Diagnosis
•   CBC ↑ WBC with shift
•   BC
•   ↑ ESR
•   X-ray maybe negative at first
•   Bone scan
    – Show ↑ uptake @ site of infection
• Bone Biopsy
    – Identify organism and degree of damage
            Therapy
IV antibiotics
• Long term 4 – 6 weeks
   – PICC line
• Meningitic dose
• Surgery I & D
• Nutrition
   – ↑ calories, ↑ protein and ↑ fluids
 Osteogenisis Imperfecta OI
• Congenital connective tissue disorder
  – Defect in synthesis of collagen
  – Incomplete development of :
     • bones, teeth, ligaments and sclera
• Brittle bones and ↑ risk for fractures
• Autosomal Dominant-mild-Type I
• Autosomal Recessive-severe-Type II
•         Intrauterine fx and death
            Clinical Signs
•   Depends on type of OI
•   Short stature
•   Fractures from minimal trauma “brittle bones”
•   Progressive bone deformities and bowing of
    lower limbs
•   Blue, purple or gray sclera.
•   Hearing loss by 20-30 years
•   Thin skin
•   Bruise easily
•   Hypoplastic teeth
     – Yellow or grayish blue
     –      W shaped
     – ↑ dental = more severe skeletal deformities
            Therapy
• Prevent fractures-
   – Lift gently and avoid jarring
     movements
   – Provide padded and soft environment
• Encourage walking
• No contact sports, and no strenuous
  activity
• Preventative dental caries
• Diet ↑ Calcium, ↑ Vit D and ↑C
•         Maintain healthy weight
   Muscular Dystrophy
       Duchenne’s
• Duchenne muscular dystrophy (DMD)
  – X-linked recessive disorder,
  – DMD occurs in 1 in 3000 male infants.

• Absence or deficiency of dystrophin
     a skeletal protein product
• Onset @ the fourth year
• Often causes death by age 20.
     Signs and Symptoms
• Delay in motor development:
   – Waddling gait, prolonged lordosis and ↑ falls
• Gower’s sign
   – Hands push self up from floor when rising
     from sitting or supine position
• Proximal limb weakness
• Pseudohypertrophy of the calves.
• Myocardium is affected
• Severely disabled by the age of 10.
              Diagnosis
Muscle biopsy identifies type of dystrophy
• Absence or deficiency of dystrophin
• Degeneration of muscle fibers
• Fibrosis and fat present (Pseudohypertrophy)

• ↑↑ CPK
• ↑↑SGPT &↑↑SGOT
• EMG (electromyography)-
   – ↓↓ Electrical activity in muscles
               Therapy
• Genetic counseling
• Maintain function in unaffected muscles as
  long as possible
  – ROM, Braces,
  – ↑ top sneakers to prevent foot drop
• ✔ Respiratory function-
  – Mobilize secretions, CDB, PD & C
• Promote independence
• ↑ Fluids and fiber to prevent constipation
• Anticipatory grieving
  – (cardiomyopathy is main cause of death)
  –     Make will & funeral arrangements
 Congenital Hip Dysplasia
Head of femur improperly seated in acetabulum
• Shallow acetabulum
  – Mildest form
• Subluxation
  – Incomplete dislocation.
  – Displaced laterally.
• Dislocation
  – Femoral head out of acetabulum.
  – Displaced posteriorly
         Etiology
• ↑↑ Maternal estrogen
  = ↑ relaxation of joints
• Positive family history
• Breech presentation
• Females 6x > males
• Bilateral 20%
            Clinical signs
• Asymmetry of gluteal folds
• Unequal limb length
• Trendelenburg sign
Ortolani test
• Flex hips @ 90 degree angle
• Adduct hips and apply gentle pressure with thumbs.
• Feel “Click” from femoral head moving out of
  acetabulum
Barlow’s
• Abduct hips and feel “clunk” of dislocated femoral
•          head moving back into acetabulum
•        Sonogram or x-rays confirm diagnoses
        Interventions
• Pavlik Harness
   – Newborn to 6 months
   – Skin care
   – Must remain on 24 h/day

• Hip Spica Cast
  – 6-18 months
  – Change q 4-6 weeks for growth

•     Skeletal Traction
     Congenital Clubfoot
     Talipes Equinovarus
• Most common congenital foot deformity
• Boys 2x > girl
• Unilateral more common

• Abnormal intrauterine position
• Oligohydramminos
• Muscular atrophy or dystrophies

• Inversion and lateral border convexity
• Plantar flexion-toes lower than heels
•       Medial adduction of toes and fore foot
      3 Stage Therapy
• Correction of deformity
  – Manipulation and casting

• Maintenance of correction
  – Until normal balance is regained
  – Follow-up observation

• Surgery by 3-6 months
  – Manipulation is ineffective with casting
  – Unable to maintain position
             Prognosis
• Variable
• Correct foot maybe ½ size smaller
   – Need 2 different shoe sizes
• Calf is 10% smaller

• Observe the foot closely for several years
  – Prevent deformity from recurring
Legg-Calve-Perthes Disease
•   Avascular necrosis of femoral head
•   Causes ↓ circulation to femoral epiphysis
•   Ischemia and necrosis to femoral head
•   Painful limp that is ↑ by activity
•   Self-limiting
•   Idiopathic
•   Trauma
•   Inflammatory
•         Boys 4-8 years @ ↑ risk
•             White 10X > blacks
              5 stages
1-Onset-
  Epiphysis begins to show ischemia & necrosis
2-Necrosis-
  Bone weakens and dies
  Collapse of femoral head
3-Fragmentation-
  Avascular bone is reabsorbed & healing
  occurs
4-Reossification-
  Femoral head and neck re-form
5-Reconstitution-
          Final healing occurs
             Treatment
• Containment of femoral head in acetabulum
  – Prevent further stress and damage
  – 1-2 year healing process
• Blood supply takes long time to reestablish.
• Immobilization-
  – Casting or brace for 1 ½ years!!
• No Weight Bearing!
• Surgery- Latest approach!
  – Minimizes immobilization time.
  –       Cast for six weeks
  –            Wheelchair additional 4 weeks

				
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posted:12/2/2011
language:English
pages:34