MusculoskeletalMusculoskeletal Elisa Mancuso, RNC-NIC, MS, FNS Professor of Nursing.
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Transcript of MusculoskeletalMusculoskeletal Elisa Mancuso, RNC-NIC, MS, FNS Professor of Nursing.
MusculoskeletalMusculoskeletalMusculoskeletalMusculoskeletal
Elisa Mancuso, RNC-NIC, MS, FNSElisa Mancuso, RNC-NIC, MS, FNS
Professor of NursingProfessor 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.Pain2.Pallor3.Pulselessness4.Paresthesia5.Paralysis
Diagnosis• X-ray
– √ R & L extremities– Comparison– Oblique FX→
• CT scan• Bone Scan• MRI
– √ ligament damage
TherapyRICE• Rest• Ice• Compression• Elevation
Surgery- ORIFOpen 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
TherapyIV 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 DystrophyDuchenne’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.
DiagnosisMuscle 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 stages1-Onset-
Epiphysis begins to show ischemia & necrosis
2-Necrosis-Bone weakens and diesCollapse 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