Pediatric Musculoskeletal Disorders Pediatric by nikeborome


									______________________________________Pediatric Musculoskeletal Disorders                               1

Pediatric Musculoskeletal Disorders
Key Concepts
    •   Few facts about the pediatric musculoskeletal system:
           – Bones and muscles grow and develop throughout childhood.
           – Bone lengthening occurs in the epiphyseal plates at the ends of bones; when the
               epiphyses close, growth stops.
           – Bone healing occurs much faster in the child than in the adult because the child's bones
               are still growing.• The younger the child, the faster the bone heals.
           – Bone healing takes approximately 1 week for every year of life up to age 10.

    •   Fractured logic
    •   The most common fractures in the child are
            – Clavicular fractures
                    • Clavicular fractures may occur during vaginal birth because the shoulders are the
                        widest part of the body.
            – Greenstick fractures
                    • of the long bones are related to the increased flexibility of the young child's
    •   Clubfoot (talipes),
    •   Developmental hip dysplasia (dislocated hip),
    •   Duchenne's muscular dystrophy,
    •   Fractures,
    •   Juvenile rheumatoid arthritis,
    •   Scoliosis.

    •   Clubfoot, also known as talipes, is a congenital disorder in which the foot and ankle are twisted
        and can't be manipulated into correct position.
    •   Clubfoot occurs in these five forms:
            – equinovarus:
                     • combination of positions
            – talipes calcaneus:
                     • dorsiflexion, as if walking on one's heels
            – talipes equinus:
                     • plantar flexion, as if pointing one's toes
            – talipes varus:
                     • inversion of the ankles, with the soles of the feet facing each other.
            – talipes valgus:
                     • eversion of the ankles, with the feet turning out
    •   CAUSES
            – Arrested development during the 9th and 10th weeks of embryonic life, when the feet are
            – Deformed talus and shortened Achilles tendon
            – Possible genetic predisposition

           – Deformity usually obvious at birth
           – Inability to be corrected manually (distinguishes true clubfoot from apparent clubfoot)

______________________________________________________________________ ”Do you 1
know that you are the temple of God and the Spirit of God dwells in you?”    1Corinthians 2:16
______________________________________Pediatric Musculoskeletal Disorders                                 2

            –   X-rays show superimposition of the talus and calcaneus and a ladderlike appearance of
                :he metatarsals.

          – Delayed growth and development
          – Impaired physical mobility
          – Risk for peripheral neurovascular dysfunction

           – Treatment is administered in three stages:
                 • correcting the deformity either with a series of casts to gradually stretch and
                     realign the angle of the foot
                 • after cast removal, application of Denis Browne splint at night until age 1 or
                     surgical correction
           – maintaining the correction until the foot gains normal muscle balance
           – observing the foot closely for several years to prevent the deformity from recurring.

           – Assess neurovascular status to ensure circulation to foot with cast in place.
           – Ensure that shoes fit correctly to promote comfort and prevent skin breakdown.
           – Prepare for surgery, if necessary, to maintain or promote healing process and to decrease

    •   Teaching topics
           – Using a blow-dryer on the cool setting to provide relief of itching
           – Importance of placing nothing inside the cast
           – Keeping corrective devices on as much as possible
           – Walking as exercise after surgical repair

Developmental hip dysplasia
    •   Developmental hip dysplasia (dislocated hip) results from an abnormal development of the hip
    •   It occurs when the head of the femur is still cartilaginous and the acetabulum (socket) is shallow;
        as a result, the head of the femur comes out of the hip socket.
    •   It can affect one or both hips and occurs in varying degrees of dislocation, from partial
        (subluxation) to complete.

    •   CAUSES
          • Breech delivery
          • Fetal position in utero
          • Genetic predisposition
          • Laxity of the ligaments

           • On the affected side, an increased number of folds on the posterior thigh when the child
             is supine with knees bent
           • Appearance of a shortened limb on the affected side
           • Restricted abduction of the hips

           • Barlow's sign is present:

______________________________________________________________________ ”Do you 2
know that you are the temple of God and the Spirit of God dwells in you?”      1Corinthians 2:16
______________________________________Pediatric Musculoskeletal Disorders                                 3

                    •   A click is felt when the infant is placed supine with hips flexed 90 degrees, knees
                        fully flexed, and the hip brought into midabduction.

            •   Ortolani's click is present.
                    • It can be felt by the fingers at the hip area as the femur head snaps out of and
                        back into the acetabulum.
                    • It's also palpable during examination with the child's legs flexed and abducted.

            •   Sonography and MRI may be used to assess reduction.

            •   Trendelenburg's test is positive.
                   • When the child stands on the affected leg, the opposite pelvis dips to maintain
                       erect posture.

            •   Ultrasonography shows the involved cartilage and acetabulum.
            •   X-rays show the location of the femur head and a shallow acetabulum; X-rays can also be
                used to monitor progression of the disorder

          • Delayed growth and development
          • Impaired physical mobility
          • Risk for impaired skin integrity

           • Hip-spica cast or corrective surgery (for older children)
           • Bryant's traction, if the acetabulum doesn't deepen
           • Casting or a Pavlik harness to keep the hips and knees flexed and the hips abducted for at
             least 3 months

           – Assess circulation before application of cast or traction; after application, have the child
             wiggle toes to detect signs of impaired circulation. The nurse should be able to place one
             finger between the child's skin and cast.
           – Provide skin care to prevent skin breakdown.
           – Give reassurance that early, prompt will probably result in complete correction to
             decrease anxiety.
           – Assure the parents that the child will adjust to restricted movement and return to normal
             sleeping, eating, and play in a few days to ease anxiety.
           – Inspect skin, especially around bony prominences, to detect cast complications and skin

    •   Teaching topics
           – Correctly splinting or bracing the hips
           – Receiving frequent checkups
           – Coping with restricted movement
           – Removing braces and splints while bathing the child and replacing them immediately
           – Stressing good hygiene

Duchennes muscular dystrophy
    •   A genetic disorder that occurs only in males,

______________________________________________________________________ ”Do you 3
know that you are the temple of God and the Spirit of God dwells in you?”     1Corinthians 2:16
______________________________________Pediatric Musculoskeletal Disorders                                     4

    •   Duchenne's muscular dystrophy (also called pseudohypertrophic dystrophy) is marked by
        muscular deterioration that progresses throughout childhood.
    •   It generally results in death from cardiac or respiratory failure in the late teens or early 20s due to
        a defect on the X chromosome, resulting in a lack of production of dystrophin.
    •   The absence of dystrophin results in breakdown of muscle fibers. Muscle fibers are replaced with
        fatty deposits and collagen in muscles.
    •   There's no known cure.

    •   CAUSE
          – Sex-linked recessive trait

           – Begins with pelvic girdle weakness, indicated by waddling gait and falling
           – Cardiac or pulmonary failure
           – Decreased ability to perform self-care activities
           – Delayed motor development
           – Eventual contractures and muscle hypertrophy
           – Eventual muscle weakness and wasting
           – Gowers' sign (use of hands to push self up from floor)
           – Toe-walking
           – Electromyography typically demonstrates short, weak bursts of electrical activity in
             affected muscles.
           – Muscle biopsy shows variations in the size of muscle fibers and, in later stages, shows fat
             and connective tissue deposits, with no dystrophin.

          – Impaired gas exchange
          – Impaired physical mobility
          – Impaired walking

           – Gene therapy (under investigation to prevent muscle degeneration)
           – High-fiber, high-protein, low-calorie diet
           – Physical therapy
           – Surgery to correct contractures
           – Use of devices such as splints, braces, trapeze bars, overhead slings, and a wheel-chair to
             help preserve mobility

           – Perform range-of-motion (ROM) exercises to promote joint mobility.
           – Provide emotional support to the child and parents to decrease anxiety and promote
             coping mechanisms.
           – Initiate genetic counseling to inform the child and family about passing the disorder on to
             future children.
           – If respiratory involvement occurs, encourage coughing, deep-breathing exercises, and
             diaphragmatic breathing to maintain a patent airway and mobilize secretions to prevent
             complications associated with retained secretions.
           – Encourage use of a footboard or high-topped sneakers and a foot cradle to increase
             comfort and prevent footdrop.
           – Encourage adequate fluid intake, increase dietary fiber, and obtain an order for a stool
             softener to prevent constipation associated with inactivity.
______________________________________________________________________ ”Do you 4
know that you are the temple of God and the Spirit of God dwells in you?”         1Corinthians 2:16
______________________________________Pediatric Musculoskeletal Disorders                                  5

    •   Teaching topics
           – Recognizing early signs of respiratory complications
           – Avoiding long periods of bed rest and inactivity; if necessary, by limiting television
               viewing and other sedentary activities
           – Planning a low-calorie, high-protein, high-fiber diet (because child is prone to obesity
               due to reduced physical activity)
           – Helping the child maintain peer relationships and realize his intellectual potential
               (encourage parents to keep child in regular school as long as possible)

Juvenile rheumatoid arthritis
    •   Juvenile rheumatoid arthritis (JRA) is an autoimmune disease of the connective tissue.
    •   It's characterized by chronic inflammation of the synovia and possible joint destruction.
    •   Episodes recur with remissions and exacerbations.
    •   The three main forms of JRA are:
             • pauciarticular JRA
                     • asymmetrical involvement of less than five joints, usually affecting large joints
                          such as the knees, ankles, and elbows.
             • polyarticular JRA
                     • symmetrical involvement of five or more joints, especially hands and weight-
                          bearing joints such as hips, knees, and feet.
                     • Involvement of the temporomandibular joint may cause earache; involvement of
                          the sternoclavicular joint may cause chest pain.
             • systemic disease with polyarthritis
                     • involves the lining of the heart and lungs, blood cells, and abdominal organs.
                     • Exacerbations may last for months.
                     • Fever, rash, and lymphadenopathy may occur.

    •   CAUSES
          • Autoimmune response
          • Genetic predisposition

           • Inflammation around the joints
           • Stiffness, pain, and guarding of the affected joints

           • Hemalology reveals an elevated erythrocyte sedimentation rate, a positive antinuclear
             antibody test. and the presence of rheumatoid factor
           • Slit-lamp evaluation may show iridocyclitis
                  • (inflammation of the iris and the ciliary body).

           • Disturbed body image
           • Impaired physical mobility
           • Chronic pain
           • Heat therapy: warm compresses, baths
           • Splint application

    •   Drug therapy
           • Low-dose corticosteroids
______________________________________________________________________ ”Do you 5
know that you are the temple of God and the Spirit of God dwells in you?”    1Corinthians 2:16
______________________________________Pediatric Musculoskeletal Disorders                                  6

            •   Low-dose methotrexate (Rheumatrex)
                   • (used as a second-line medication)
            •   Nonsteroidal anti-inflammatory drugs
                   • (NSAIDs): naproxen (Naprosyn), ibuprofen (Motrin)

           • Monitor joints for deformity to assess for early changes as a complication of this disease
           • Administer medications, as prescribed, and note effectiveness to relieve pain and prevent
             further joint damage.
           • Assist with exercise and ROM activities to maintain joint mobility.
           • Apply warm compresses or encourage the child to take a warm bath in the morning to
             promote comfort and increase mobility.
           • Apply splints to maintain position of function and prevent contractures.
           • Provide assistive devices, if necessary, to encourage the normal performance of daily

    •   Teaching topics
           • Understanding how stress and climate can influence exacerbations
           • Practicing preventive eye care

    •   Scoliosis is a lateral curvature of the spine, especially among females.
    •   It's commonly identfied at puberty and throughout adolescence.
    •   Scoliosis stops progressing when bone growth stops.

           • Nonstructural scoliosis:
                 • When the child bends at the waist to touch the toes, the curve in the spinal
                     column disappears.
           • Structural scoliosis:
                 • When the child bends forward with the knees straight and the arms hanging down
                     toward the feet, the spinal curve fails to straighten; the hips, ribs, shoulders, and
                     shoulder blades are asymmetrical.

           • X-rays may aid the diagnosis.

          • Delayed growth and development
          • Disturbed body image
          • Impaired physical mobility

    •   Nonstructural scoliosis
           • Corrective lenses if the problem is associated with poor vision that results in a head tilt
           • Postural exercises
           • Shoe lifts

    •   Structural scoliosis
            • Electrical stimulation for mild to moderate curvatures

______________________________________________________________________ ”Do you 6
know that you are the temple of God and the Spirit of God dwells in you?”          1Corinthians 2:16
______________________________________Pediatric Musculoskeletal Disorders                                7

            •   Harrington, Luque, or Cotrel-Dubousset rods for curves greater than 40 degrees (to
                realign the spine or when curves fail to respond to orthotic treatment)
            •   Possible prolonged bracing (Milwaukee or Boston brace)
            •   Skin traction or halo femoral traction
            •   Spinal fusion with bone from the iliac crest

    •   After spinal fusion and insertion of rods
            – Monitor vital signs and intake and output to prevent fluid volume deficit.
            – Turn the child only by logrolling to prevent injury.
            – Maintain correct body alignment to promote joint mobility and prevent injury.
            – Maintain the bed in a flat position to prevent injury and complications.
            – Help the child adjust to the increase in height and altered self-perception to promote self-
                esteem and decrease anxiety.

    •   Teaching topics
           – Performing stretching exercises for the spine
           – Helping the child maintain self-esteem

______________________________________________________________________ ”Do you 7
know that you are the temple of God and the Spirit of God dwells in you?”     1Corinthians 2:16

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