MUSCULOSKELETAL (MS)

By

DR. Areefa Albahri (Alkasseh)

Assistant Prof. of MCH

Islamic University of Gaza

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DR. Areefa Albahri

• Musculoskeletal (MS)• The main organs and tissues that are part of the

musculoskeletal system in humans are• The cartilages• The bones• The muscles

• Main functions of MS are:• To support & protect vital organs (the brain, heart and lungs)• To keep structure and maintenance of the body spatial

conformation. • Allows the body to move (walking, standing, bending). Because

soft tissues are resilient in children, dislocations and sprains are less common than in adults

• Nutrient storage (glycogen in muscles, calcium and phosphorus in bones).

• Musculoskeletal: Physical Assessment• Inspect child undressed• Observe child walking• Spinal alignment• Range of Movement (ROM)• Muscle strength• Reflexes

Fracture

Fracture: Clinical Manifestations

• Swelling, pain or tenderness• Diminished functional use of the affected part; inability to bear

weight• Bruising, severe muscular rigidity• Sometimes crepitus• Less frequent neurological and vascular damage (ischemia), which

can be assessed using 5 Ps• Pain• Pallor• Pulselessness• Parasthesia• Paralysis

Fracture: Therapeutic Management

• Cast: fiberglass or plaster application to immobilize affected body part• Tractions :Is the direct application of force to produce equilibrium at the

fracture site• Distraction: involves the use of an external device to separate opposing

bones to encourage regeneration of new bone & used to immobilize fractures or correct defects when the bone is rotated or angled

• Fracture: Cast• Risk for altered tissue perfusion R/F pressure from

cast• Keep extremity elevated to decrease edema.• assess circulation Q 15 minutes after applying the cast then hourly• assess skin warmth and 5 Ps• Risk for impaired skin integrity R/F pressure from cast• Cast edges must smoothed/covered • Cast remains in place for 4-8 weeks• Discourage itching under the cast

• Possible concerns• Unusual odor under the cast• Drainage from cast• Tingling, numbness and swelling in the casted body part• Loose or cracked cast• Unexplained fever• Unusual irritability and pain• Discoloration of finger or toes

• Fracture: Traction

• traction refers to the practice of exerting a slow, gentle pull on a

fractured or dislocated body part. The purpose is to guide the part

back into place and to produce equilibrium at the fracture site

• . Traction may also be used to stretch the neck and prevent painful

muscle spasms.

• Manual traction: applied by hand is used during cast• Skin traction: pull applied directly to the skin surface and

indirectly to the skeletal structure• Skeletal traction: pull applied directly to the skeletal structure by

a pin, wire, or tongs

• Purposes of Traction:• To realign bone fragments & treat dislocation• To provide rest for an extremity & help prevent or improve

contracture deformity.• To allow preoperative or postoperative positioning and alignment.• To provide immobilization of affected body part• To reduce muscle spasm so that bones can be realigned

• Nursing Care of traction:• Regular assessment of 5 Ps • Skeletal traction is never released by the nurse (do not move the

weights)• Assess blood pressure • Skin care for the child’s back, elbows and heels

• Fracture Complications:

• Circulatory impairment: • Careful assessment of the pulses, skin color, and temperature is

crucial• Nerve compression syndromes (e.g., carpal tunnel syndrome,

tarsal tunnel syndrome)• Sensory testing with touch and pinprick • Evaluating motor strength by asking the child to move the

unaffected joint distal to the injury

•  

• Compartment syndromes• Is a tissue ischemia due to a compression of nerves, blood

vessels, and muscle inside a closed space (compartment) within the body due to increased pressure in that part

• The most frequent causes are: • Tight dressings or casts, hemorrhage, trauma, burns, and

surgery• Signs & symptoms include:• Motor weakness and pain that does not decrease with

medication • The muscle may feel tight or full • Burning sensation

• Epiphyseal damage: leads to unequal growth • Infection: osteomyelitis (potential problem in open fractures, from pressure ulcers, or when bone surgery)

• Pulmonary emboli: blood, air, or fat emboli may produce a life-threatening vascular obstruction and ischemia. • Primary symptom is shortness of breath and chest pain. • Interventions should include:

• Place patient in high fowlers• Administer O2 and check chest X-ray

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Sprained ankle

• A soft tissue injury• Management ( in the first 6 to 12 hours)

• Controlling the swelling and reducing muscle damage by “RICE” Rest, Ice, Compression, Elevation

Is an abnormally increased convex angulation in the curvature of the thoracic spine

It can occur secondary to disease process such as tuberculosis, chronic arthritis

Treatment Postural exercises

Bracing

(Milwaukee) for more marked deformity

        

Kyphosis

Is an accentuation of the lumbar curvature beyond physiologic limits

It may be a complication of a disease process, the result of trauma or idiopathic

Lordosis is a normal observation in toddlers

In older children is often seen in association with flexion contractures of the hip, obesity, congenital dislocated hip and slipped femoral capital epiphysis.

Lordosis

Scoliosis

Is a spinal deformity which may involve lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis.

It is the most common spinal deformity.

It can be congenital, or it can develop during infancy or childhood, but it is most common during adolescence (peaks between 8-15 years)

It may be genetic and transmitted as an autosomal dominant trait

It may be multifactorial

Scoliosis: Types Non-surgical management aimed to :

Promoting self-esteem and positive body image Maintain spinal stability Prevent further progression of deformity until bone growth is complete and surgical repair can be performed

Mild cases (less than 20%), observation and exercises- swimming is advised & Long-term monitoring.Moderate (20-40%), exercises, traction, bracing. Bracing (Milwaukee brace) is successful in halting or slowing the progression of curvatures Severe (more than 40%), bracing until the skeletal system mature and then surgical intervention

Surgery includes realignment and straightening of the spine with internal fixation

Developmental/congenital hip dysplasia/dislocation (DDH/CHD)

• Improper formation and function of the hip socket. • Cause of DDH is unknown, but there are predisposing

factors such as:• Genetic factors & birth order• Physiologic factors: maternal hormone• Mechanical factors: intrauterine position (breech),

oligohydraminos, twining and fetus size, delivery type, postnatal positioning

• DDH occurs more commonly in females.

Acetabular dysplasia  (or preluxation)

Subluxation_Accounts for the largest percentage of DDH. It implies incomplete dislocation. The femoral head remains in contact with the acetabulum, but a stretched capsule and the head of the femur

to be partially displaced. Dislocation Femoral head loses contact with the

acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim

DDH/CHD: Degree:

• Acetabular dysplasia (or preluxation)• The mildest form • The femoral head remains in the acetabulum

DDH/CHD: diagnosis Ortolani test

Abduction of the thighs with external rotation.

If the femoral head can be felt to slip forward into the acetabulum on pressure from behind, it is dislocated (positive Ortolani sign)

Sometimes an audible “clunk” can be heard. Barlow test

Pressure from the front If the femoral head is felt to slip out over the

posterior lip of the acetabulum and immediately slips back in place when pressure is released, there is dislocation or “unstable” (positive Barlow sign)

Other signs of DDH are:

Shortening of the limb on the affected side (limping and toe walking

Positive Trendelenburg sign or gait)Asymmetric thigh and gluteal foldsBroadening of the perineum(in bilateral dislocation)

Ultrasounds

DDH/CHD: Management• Newborn to six months

• Pavlik harness• The harness is used to maintain

the infant’s hips in flexion and abduction and external rotation

• Pavlik harness device is to be worn continuously.

• The child in a Pavlik harness needs special attention to skin care because the infant’s skin is sensitive and the harness may cause irritation.

DDH/CHD: Managementsix months to 8 months

• Gradual reduction by traction is used for approximately 3 weeks.

• If the hip is not reducible, an open operative reduction is performed. Following reduction the child is placed in a hip spica cast for 2-4 months

• Older child: • Operative reduction• After cast removal and before

weight bearing is permitted, range-of-motion exercises & rehabilitative measures

• The former practice of double-or triple-diaper for DDH is not recommended because it promotes hip extension, thus worsening proper hip development

• Pavlik harness can be used from birth up to 5 or 6 months of age.

• It is anon-invasive device for keeping hips in a continually abducted position, which

• allows for the femoral head to remain in contact with the acetabulum.

• ■■ Infants will wear the harness continuously for 3 to 5 months, until the hip is determined, by radiograph, to be stable. Frequent follow-ups will be needed for strap adjustment.

• Nursing Actions• ☐☐ Check skin integrity frequently.• ☐☐ Ensure proper positioning at all times.• ☐☐ Determine the family’s ability to adjust the harness.• Client Education• ☐☐ Instruct families to keep the harness on continuously,

except during bathing, if prescribed.• ☐☐ Instruct families to return for follow-up visits.• ☐☐ Reinforce teaching about skin care. • Encourage application of a cotton shirt and cotton socks

under the harness to prevent irritation and the avoidance• of powders and lotions.

Congenital clubfoot (Talipes)• Deformity of the ankle and foot• Categories of Talipes

• Positional clubfoot (transitional, mild or postural), • may occur from intrauterine crowding • responds to simple stretching and

casting.• Syndromic (tetralogic ) clubfoot

• associated with other congenital abnormalities such as myelomeningocele,

• more severe form of clubfoot that is often resistant to treatment.

Congenital clubfoot (idiopathic )

• has a wide range of rigidity and prognosis

• Congenital clubfoot: Management• Goal of management: is Correction of the deformity & Maintenance

of the correction until normal muscle is gained • Management:

• Casts: • Begin immediately or shortly after birth and continue until

marked overcorrection is reached. • Weekly manipulation and cast changes proceed for the first 6 to

12 weeks of life.• Surgery:

• If casting and manipulation are not successful• Followed by brace and cast

• Nursing Care:• Observation of skin and circulation (particularly important in young infants because of their normally rapid growth rate): swelling in the toes, foot temperature

• Parents need to understand the diagnosis, the overall treatment program, the importance of regular cast changes

•  

Juvenile Rheumatoid Arthritis (JRA)

• Is an inflammatory disease of the body joints and sometimes affects blood vessels and connective tissue

• Unknown cause but a slight tendency to occur in families• Peak ages: 2 – 5 years and between 9 - 12 years of age• JRA is similar to the adult disease with some

distinguishing features • Onset before puberty• A negative rheumatoid factor (RF).

Pauciarticular Polyarticular Systemic

Juvenile Rheumatoid Arthritis (JRA): Courses

• Juvenile Rheumatoid Arthritis (JRA): Pauciarticular • 4 or fewer joints are affected• The most common form of JRA; about half of all children with JRA have this

type • Affects large joints, such as the knees• Girls under age 8 are most likely to develop this type of JRA.• Some children have special kinds of antibodies in the blood.

• Antinuclear antibody (ANA) • Rheumatoid factor

•Eye disease: • affects about 20 to 30% of children with pauciarticular

JRA• Up to 80% of those with eye disease also test positive

for ANA• The disease tends to develop at a particularly early age

in these children• Regular examinations by an ophthalmologist are

necessary to prevent serious eye problems such as iritis or uveitis

• Juvenile Rheumatoid Arthritis (JRA): Polyarticular • 30% of all children with JRA have polyarticular disease• 5 or more joints are affected. The small joints (hands and

feet) are most commonly involved, though large joints may be affected

• Symmetrical; that is, it affects the same joint on both sides of the body

• Some children have an antibody in their blood called IgM rheumatoid factor (RF)

• These children often have a more severe form of the disease

• Juvenile Rheumatoid Arthritis (JRA): Systemic (Still’s disease)

• Joint swelling, & fever and a light skin rash• May also affect internal organs such as the heart, liver,

spleen, and lymph nodes• Almost all children with this type of JRA test negative for

both RF and ANA• Affects 20% of all children with JRA. A small percentage

of these children develop arthritis in many joints and can have severe arthritis that continues into adulthood.

• Juvenile Rheumatoid Arthritis (JRA): Clinical Manifestations

• Joint swelling:• Stiffness is worse in the morning or after a nap• Pain may limit/loss movement of the affected joint • Commonly affects the knees and joints in the hands and feet• One of the earliest signs of JRA may be limping in the

morning because of an affected knee. • Besides joint symptoms, children with systemic JRA have

• A high fever and a light skin rash. The rash and fever may appear and disappear very quickly.

• Swelling in the lymph nodes located in the neck and other parts of the body

• In some cases (< 50%), internal organs (heart and, very rarely, the lungs) may be involved.

• Eye inflammation: • Sometimes occurs in children with pauciarticular JRA. • Not present until sometime after a child first develops

JRA• Typically, there are periods when the symptoms of JRA

are better or disappear (remissions) and times when symptoms are worse (flare-ups).

• Growth problems:• Depending on the severity of the disease and the joints

involved, it may cause joints to grow unevenly or to one side causing one leg or arm to be longer than the other.

• Overall growth may also be slowed.

• Juvenile Rheumatoid Arthritis (JRA): Diagnosis

• Diagnosis of JRA is based on:• onset• Laboratory tests-- Blood may be taken to test for RF ,

and Sedimentation Rate (ESR).• Positive RF is detected in just 10% of the cases. The RF test

helps the doctor tell the difference among the three types of JRA.

• ANA is found in the blood more often than RF, and both (ANA & RF) are found in only a small portion of JRA patients.

• ESR indicates inflammation in the body. Not all children with active joint inflammation have an elevated ESR.

• Lab. tests may include elevated WBCs

Juvenile Rheumatoid Arthritis (JRA): Therapeutic Management

• Disease-modifying anti-rheumatic drugs (DMARDs) such as (Cytoxan, Methotrexate…): most given in combination with NSAIDs to slow the progression of JRA.

• Corticosteroids: to control severe symptoms; can interfere with a child's normal growth, a round face, weakened bones, and increased susceptibility to infections.

• Biologic agents: Etanercept (Enbrel) blocks the actions of tumor necrosis factor, a naturally occurring protein in the body that helps cause inflammation.

• Physical therapy: Exercise to maintain muscle tone and preserve and recover the range of motion of the joints; rest of affect body part and heat application.

• Bleeding.• Stomach upset.• Liver problems

• Reye’s Syndrome: • Is sudden (acute) brain damage (encephalopathy) & liver function

problems.• Abnormal accumulations of fat begin to develop in the liver and other

organs of the body, along with a severe increase of pressure in the brain.

• Without proper treatment, death is common within a few days.• During painful episodes of the disease:

• Proper positioning is important to support and protect affected joints. Isometric exercises and passive range-of-motion exercises will prevent contractures and deformities. Swimming in warm water provides strengthening and range-of-motion exercises while protecting the joints.

• Cerebral palsy (CP)• It is a group of non-progressive disorders (meaning the brain damage does

not worsen, but secondary orthopedic difficulties are common) of motor neuron impairment that result in • Motor dysfunction• May be accompanied by perceptual problems, language deficits, and

intellectual involvement.• The disabilities usually result from injury to the cerebellum, basal ganglia,

or motor cortex.• The exact cause is unknown; it may results from injury to the brain before,

during, or shortly after birth• Risk factors include:

• Prematurity• LBW• Asphyxia• Infections (meningitis, encephalitis)• Head injuries• Metabolic problems such as hyperbilirubinemia and hypoglycemia• Sever dehydration

• Types of Cerebral Palsy: • Spastic : (most common type)

• May involve one or both sides• Hypertonicity with poor control of posture, balance, • Impairment of fine and gross motor skills

• Dyskinetic/ athetoid:• Abnormal involuntary movement• Slow, wormlike, writhing (rolling & twisting) movements that usually

involve the extremities, trunk, neck, facial muscles, and tongue.• Involvement of the pharyngeal, laryngeal, and oral muscles causes

drooling and dysarthria (imperfect speech articulation)• Involuntary irregular jerking movements

• Ataxic• Rapid, repetitive movements performed poorly.• Disintegration of movements of the upper extremities when the child

reaches for objects• Mixed type/dystonic:

• Combination of spasticity and athetosis.

• Cerebral Palsy Clinical Manifestations: • Delayed gross motor development.• Alteration in muscle tone: increased or decreased

resistance to passive movements. • Abnormal posture :opisthotonic postures (exaggerated

arching of the back) and may feel stiff on handling or dressing.

• Reflex abnormalities: persistence of primitive infantile reflexes is one of the earliest clues to CP.

• Possible Associated disabilities and problems: • Convulsion/seizure• Visual and hearing impairments• Communication and speech difficulties• Some may have varying levels of mental retardation.

•Cerebral Palsy Treatments: •Goals of Treatment:

• Establish locomotion, communication and self-help.• Gain optimum appearance and integration of motor functions.• Correct associated defects.• Adaptation.

• Management:• Provide safe environment to prevent injury.• Prevent physical deformities by using braces and provide ROM

exercises.• Appropriate motor activities.• Medications such as sedatives, muscle relaxants, anticonvulsants.• Encourage ADLs.• Occupational to improve small muscles development• Speech therapy