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Musculoskeletal Alterations

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									Musculoskeletal Alterations



             NUR 264 – Pediatrics
             Angela Jackson, RN, MSN
Differences between Children and
Adults

     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

   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

   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

   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
    –   Spine
    –   Long bones of the upper and lower extremities
    –   pelvis
Traction

   Straight traction:
    –   Child’s body weight serves as the countertraction
   Balanced Traction:
    –   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

   Immobilizes the fracture
   Decreases muscle spasms
   Realigns and positions bone ends while
    healing takes place
   Prevents further soft tissue damage
Complications of Fractures

   malunion
   compartment
    syndrome
   growth disturbances
Nursing Considerations

   Neurovascular status
   Pain
   Respiratory status
   Cardiovascular status
   Immobilization
   Skin Integrity
   Nutrition
   Elimination
Nursing Management
   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

   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

   Sources of hematogenous      Causative Organisms
    spread include                include
    –   Acute otitis media        –   Staphylococci aureus (80 –
    –   Impetigo                      90%)
    –   URI’s                     –   Haemophilus influenzae
    –   Abscessed teeth           –   Streptococcus Pneumoniae
    –   Burn infections           –   Escherichia Coli
                                  –   Group B streptococci
                                  –   gram-negative enteric
                                      bacilli
                                  –   Anaerobic bacteria
Osteomyelitis: Pathophysiology

   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

   Infants                           Children
    –   Irritability                   –   Constant bone pain
    –   Poor feeding                   –   Restricted movement
    –   Failure to move affected       –   Swelling
        limb                           –   Heat in the affected area
    –   Permanently arrested           –   Redness
        bone growth                    –   Fever
                                       –   Signs and symptoms of
                                           systemic infection
Osteomyelitis: Diagnosis

   Lab tests                         X-Rays
    –   CBC                            –   Routine x-ray of affected
    –   C-reactive protein                 area
    –   Sed rate (ESR)                 –   Bone scan
    –   Blood cultures                 –   X-ray examination of the
    –   Wound cultures                     affected area will detect
                                           bone necrosis ten to
    –   Culture of bone aspirate           fourteen days after
                                           appearance of clinical
                                           manifestations
Osteomyelitis: Potential Complications

   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

   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

   Monitor for potential complications
     –   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

   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)
    –   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

   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

   Generalized muscular               Lordosis
    weakness and muscle                Frequent falls
    wasting – usually appears          Gower’s sign
    during the third year of life
                                       As disease progresses,
   Difficulty running and              calves, thighs, and upper
    climbing stairs                     arms become larger as a
   Tires easily when walking           result of fatty infiltration
   Waddling gait                       (pseudohypertrophy)
    (Trendelenburg gait)               Mental retardation is
                                        common
Gower’s Sign
Muscular Dystrophy: Diagnosis

   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

   There is no cure for muscular dystrophy.
    Treatment is supportive and includes:
    –   PT/OT
    –   Braces, wheelchairs
    –   Surgery
Muscular Dystrophy: Potential
Complications

   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

   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

   Temporary loss of blood supply to the femoral capital
    epiphysis, results in avascular necrosis of the
    femoral head
   Unknown cause
   Occurs in four stages:
    –   Incipient stage
    –   Necrotic stage
    –   Regenerative stage
    –   Residual stage
Legg-Calve-Perthes: Clinical
Manifestations

   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

   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

                   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:
                    –   Traction
                    –   Braces
                    –   Leg casts
                    –   Surgery
Legg-Calve-Perthes: Diagnosis

   Diagnosed and classified by X-ray
   Bone scan
Osteogenesis Imperfecta (OI)

   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

   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

   Multiple and frequent            Weak muscles
    fractures, some of which         Short stature
    may be present at birth          Conductive hearing loss
   Limb and spinal column           May have dentinogenesis
    deformities related to            imperfecta: hypoplastic teeth
    multiple breaks                   with opalescent blue or
   Blue sclera                       brown discoloration
   Thin, soft skin with easy
    bruising
   Increased joint flexibility
OI: Diagnosis

   Collagen studies
   Prenatally, may be detected by level II ultrasound if
    disease is severe
OI: Treatment

   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

   Maintain a non-judgmental and supportive attitude
   Handle child gently and teach family to handle child
    gently:
    –   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???

								
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