Nursing Care of the Child with
Musculoskeletal Disorder
The Immobilized Child
 Immobilization was once thought to
be restorative for patients with illness
and injury
 We know now that immobilization has
serious consequences:
– Physical
– Social
– Psychologic
Physiologic Effects of Immobilization
• Muscular system:
– Decreased muscle strength and
endurance
– Atrophy
– Loss of joint mobility
– catabolism
• Skeletal system:
– Bone demineralization
– Weakened back and abdominal
muscles
– Negative calcium balance
Physiologic Effects of Immobilization
• Skeletal system:
– osteoporosis->fractures
– hypercalcemia->
– renal calculi
– negative calcium balance->
– electrolyte imbalance
• Metabolism:
– Decreased metabolic rate
– Decreased food intake -Negative
nitrogen balance
– Impaired healing
– Hypercalcemia
– Decreased production of stress
hormones
–  physical & emotional coping
• Cardiovascular system:
–  orthostatic neurovascular
reflexes &  vasopressor
mechanism = Diminished
vasopressor mechanism
– Dependent edema->tissue
breakdown & infection
– blood pooling- Venous stasis and
Dependent edema -venous
stasis->pulmonary emboli or
thrombi
– Altered distribution of blood
volume
–  cardiac workload & exercise
tolerance
–  efficiency of orthostatic
neurovascular reflexes
• Respiratory system:
–  need for oxygen
–  chest expansion & vital
capacity->diminished vital
capacity
– Poor abdominal tone and
distention
– Mechanical or biochemical
secretion retention
– Loss of respiratory muscle
strength
• poor abdominal tone & distention->
• alt. Diaphragmatic excursion
• mechanical or biochemical secretion
retention->bacterial & viral
pneumonia; atelectasis
• loss of respiratory muscle strength-
>dyspnea & acidosis
• URI
• Gastrointestinal system:
– Distention caused by poor
abdominal muscle tone
– Difficulty feeding in prone
position
– Gravitation effect on feces
– Anorexia
• Integumentary system:
– Decreased circulation and
pressure leading to decreased
healing capacity
• Urinary system:
– Alteration of gravitational force
– Difficulty voiding in supine
position
– Urinary retention
– Impaired ureteral peristalsis
->urinary retention, infection,
renal calculi
Psychologic Effects of Immobilization
• Diminished environmental stimuli
• Altered perception of self and
environment
• Increased feelings of frustration,
helplessness, anxiety
• Depression, anger, aggressive
behavior
• Developmental regression
• feelings: isolation & boredom,
forgotten by peers
• helpless, unwanted
•  communication skills
• ^fantasizing
• hallucinations & disorientation
• deprived of warmth & love feelings
• <3yrs: difficulty w/language
• revert to earlier developmental
behaviors (regression)
• active protest, anger, aggression
• crying outburst, temper tantrum
• quiet, passive, submissive
• sluggish intellectual & psychomotor
response
Effect on families with catastrophic
illness or disability
• Extended periods of immobilization:
– Logistical management of sick
child
– Need for family support and home
care assistance
• Coping skills
• Home management
• Rest periods
• Individual & group counseling
• Parent groups
• Long-term resources
Nursing care of immobilized child
• Frequent position changes
• Antiembolism stockings, ace wraps
• High protein, high calorie foods
• Hydration
• Discuss elimination needs
• Encourage participation & of others
• Passive ROM/PT
• Take outside of room
• Frequent visitors
• Clock, calendars, diversional therapy
• Play therapist, child-life specialist
• Resume school & hobbies
• Use dolls for teaching
• Choose roommates accordingly
Traumatic Injury
• Soft-tissue injury: injuries to muscles,
ligaments, and tendons
– Sports injuries
– Mishaps during play
Contusions
• Damage to soft tissue, subcutaneous
tissue, and muscle
• Escape of blood into tissues—
ecchymosis—causing black and blue
discoloration
• Edema, pain with movement attempt,
disability
• Crush injuries
• Tx: cold application
Dislocations
• Occur when force of stress on
ligament is sufficient to displace
normal position of opposing bone
ends or bone ends to socket
• Pain increases with active or passive
movement of affected extremity
• More common in Down syndrome
• Hip dislocation: potential loss of blood
supply to head of femur
• elbow: “pulled or nursemaids elbow”
• tx: manipulation
• Hip: relocate within 60 min to prevent
femoral head damage
• shoulder: temporary restriction-
>medical help
• tx: reduced, simple traction & slight
flexion, immobilization 10-16 days-
>3 weeks
 Sprains
• Trauma to a joint from ligament
partially or completely torn or
stretched by force (ligament is
pulled off bony attachment)
• May have associated damage to
blood vessels, muscles, tendons,
and nerves
• Sx: joint laxity, c/o’s “feeling loose,
snap, pop, tear”, seldom pain,
rapid onset, selling, disability
reluctant to use
• Presence of joint laxity as indicator
of severity
• Rapid onset of swelling with
disability
Strains
• A microscopic tear to
musculotendinous unit
• Similar to sprain
• Swollen, painful to touch
• Generally incurred over time
Therapeutic Management of Soft-Tissue
Injuries
• RICE (rest, ice, compression, elevate)
and ICES (ice, compression,
elevate, support)
• Rest the injured part
• Ice immediately (maximum 30
minutes at a time)
• Wet elastic bandage for
compression
• Elevation of the extremity
• Immobilization and support (casts or
splints as appropriate to injury)
Fractures
• Common injury in children
• Bone yields to stress
• Methods of treatment are different
in pediatrics than in older adult
population
• Rare in infants, except with motor
vehicle crashes, physical abuse, or
osteogenesis imperfecta
• Clavicle is the most frequently
broken bone in childhood,
especially in those <10 years old
• School age: bike, sports injuries
Epiphyseal Injuries
• Weakest point of long bones is the
cartilage growth plate (epiphyseal
plate)
• Frequent site of damage during
trauma
• May affect future bone growth
• Treatment may include open
reduction and internal fixation to
prevent growth disturbances
Types of Fractures
• Complete: fragments are
separated
• or open: fractured bone
protrudes through the skin
• Complicated: bone fragments
have damaged other organs or
tissues
• Comminuted: small fragments of bone
are broken from fractured shaft and
lie in surrounding tissue
• Greenstick: compressed side of bone
bends, but tension side of bone
breaks, causing incomplete fracture
Pathologic fracture
• bones with tumors (bone cysts,
sarcomas, metastatic)
• Pathophysiology of fracture
– fracture->muscles contract to splint
area ->muscle tightness and
deformity
• Treatment: traction or complete
muscle relaxation
• children heal rapidly due to thickened
periosteum and generous blood
supply
Clinical Manifestations of Fracture
• Generalized swelling
• Pain or tenderness
• Diminished functional use
• May have bruising, severe muscular
rigidity, crepitus
Bone Healing and Remodeling
• Typically rapid healing in children
• Neonatal period: 2-3 weeks
• Early childhood: 4 weeks
• Later childhood: 6-8 weeks
• Adolescence: 8-12 weeks
Fractures (cont’d)
• History: may be difficult to get due to
age, misinterpretation, fear or child
abuse
• Radiography: after reduction or
during healing
• Diagnostic evaluation: x-ray is most
useful diagnostic tool
Therapeutic management goals
• Traction or closed manipulation
• Casting and immobilization
• Hospitalize: femur & supracondylar
humerus
Nursing care management
• Calm & reassure child & parents
• 6 P’s: pain, pulselessness, pallor,
paresthesia, paralysis,
poikilothermia
• How injured?
• Don’t move part, immobilize with
splint
• Cover open wounds
• Assess neurovascular
• Traction if circulatory compromise
• Elevate, Cold
• EMS or transport
Assessment of Fractures: The 6 Ps
• Pain and point of tenderness
• Pulselessness–distal to the fracture
site
• Pallor
• Paresthesia–sensation distal to the
fracture site
• Paralysis–movement distal to the
fracture site
• Poikilothermia-inability to regulate
core body temperature
The Child in a Cast Cast application
techniques
• Plaster of paris
– Molds close to body
part
– Dries 10-72 hrs
– Smooth exterior
– Inexpensive
• Synthetic (Fiberglass)
– Light, durable, easy to clean
– Water resistant: Gore-Tex liner-
>waterproof
– Dries 5-30 min
– Water resistant
– Different colors & designs
Nursing considerations
Applying & caring for cast
• Prior:
• Check skin for skin alterations, remove
anything that may cause constriction
w/swelling
• Set up materials & hold extremity
Caring for cast
• Post: keep uncovered
• Turn Q2
• Fan or cool-air hair dryer
• Elevate
• Handle with palms
• Assess & report “hot spots”
• Surgical reduction: post-surgery:
circumscribe blood-stained area &
time
• Report: pain, swelling, discoloration,
lack of pulses & warmth, inability to
move, cast is loose
 • Caring for client in cast (Box p. 1215)
• Car seats and restraints
• Cleanliness: disposable diapers
• Feeding: supine w/head ^, cuddle,
“football” hold, lap facing caregiver,
prone by table
• Voiding: bedpans, diapers
• Baths: is immersable
Cast removal
• Explain procedure
• Demonstrate on doll
• Will feel tickly sensation and heat
• Reassure
• Use analogies: cutting hair or nails
• Soak in tub for desquamated skin
removal for several days
• Comfort: Olive oil or lotion
• No scrubbing
The Child in Traction
• Traction: extended pulling force may
be used:
– To provide rest for an extremity
– To help prevent or improve
contracture deformity
– To correct deformity
– To treat dislocation
– To allow position and alignment
– To provide immobilization
– To reduce muscle spasms (rare in
children)
Bone Alignment
FIG. 31-5 Application of traction to maintain
bone alignment.
Traction: 3 Essential Components
• Traction: forward force produced by
attaching weight to distal bone
fragment
– Adjust by adding or
subtracting weights
• Countertraction: backward force
provided by body weight
– Increase by elevating foot of
bed
• Frictional force: provided by patient’s
contact with the bed
Types of Traction
• Manual traction: applied to body part
by the hand placed distally to
fracture site
• Skin traction: pulling mechanisms are
attached to skin with adhesive
material or elastic bandage
• Skeletal traction: applied directly to
skeletal structure by pin, wire, or
tongs inserted into or through
diameter of bone distal to fracture
Traction
• Adjusting equilibrium:
• Add or subtract weight
• Elevate foot of bed
• Bed board under mattress
• All or none law = complete relaxation
Dunlop Upper extremity traction
• Fractures of humerus
• Overhead suspension
• Bent arm suspended vertically by skin
or skeletal attachment & traction
• Dunlop traction
• Arm suspended horizontally with skin
or skeletal attachment
Lower extremity traction (femur)
• Bryant traction: skin, one direction,
not recommended  • Ensure bed is correct size, in lowest
• Buck extension: skin, legs extend, turn
side to side
• Russell traction: skin on lower leg &
padded sling under knee, keep at
prescribed angle
• 90-degree-90-degree traction: most
common, boot cast or calf sling &
pin or wire on femur
• Balance suspension traction:
suspends in desired flexed position
to relax hip & hamstring; does not
exert traction
• Thomas splint & pearson attachment
• Check splints & ropes periodically
Cervical traction
• Cervical soft or hard collar
• Cervical skin traction
• Halter & weight
• Crutchfield or Barton tongs
• Crutchfield or Barton tongs
• Inserted through burr holes in skull
with weights attached to the
hyperextended head
• As neck muscles fatigue, vertebral
bodies gradually separate so the
spinal cord is no longer pinched
between vertebrae
• Assess neuro to prevent further injury
• Halo traction can be applied in some
cases
Nursing Care Management for Traction
Traction Care P. 1162 Box
• Assessing patient in traction
• Understand therapy: purpose &
function
• Maintain traction & alignment: assess
bandages, ropes, pulleys, weights,
bed position; when moving,
restraints if needed, check angles
Nursing Care Management for Traction
• Skin care issues
– Skin & skeletal traction: assess
bandages, replace if needed
maintaining traction, check pins
(clean, tightness)
– Prevent skin breakdown: turn Q2,
wash QD, foam, assess
• Traction care
• Pain management and comfort
• Prevent complications: NV assess,
drsg, restraints, Deep breathing,
passive/active exercises, footdrop,
contractures
• Pin Care
• Analgesics (opioids)
• Muscle relaxants
Focus on Safety: Falls
• Use Pediatric Fall Risk tool to
determine fall risk
position, with wheels locked
• Ensure side rails of bed are up
• Child’s clothes should be well-fitted
• Skid-proof footwear should be worn
by the patient
• All IV tubes, drains, and catheters
need to be secured
• Ensure spills and clutter are cleaned
up
• Hourly rounds to check on the child
• Do not allow child out of bed without
assistance
• Utilize patient care sitters
• Remove all unnecessary equipment
and furniture from room
• Determine need for consults: PT, OT,
psychiatry, social work
• Child-life specialist
• Indicate risk for fall with door sign and
special wristband
Distraction
• Process of separating opposing bone
to encourage regeneration of new
bone in created space
• Can be used when limbs are unequal
in length and new bone is needed to
elongate shorter limb
Ilizarov external fixator (IEF) by manual
distraction
• Lengthening correct angular or
rotational defects
• 15 cm length (6 inches)
• Appearance of how it works
• Activities
• pin care, observe for infection &
loosening of pins
 • Children participate actively in care
IEF nursing
• Psych: prepare for reactions of others,
camouflaging device w/apparel
• Partial wt bearing w/crutches; full wt
bearing when distraction is
completed & bone consolidation has
occurred
• Removed surgically p bone has
consolidated
• crutches or cast 4-6 wks after removal
Amputation
• Surgical amputation
– Stump shaping & elevation
– Exercise upper body
• Surgical repair of severed limb
• Saving an amputated body part:
– wrap lightly in clean cloth/gauze
saturated in N & plastic bag; avoid
ice & label
• Prosthetics
– Teach Stump hygiene &
assessment
– Teach Phantom limb sensation
– Report ^limb pain w/ambulation
– Pain management, “phantom
limb” pain
CONGENTIAL DEFECTS
• Developmental Dysplasia of the Hip
(DDH) or CDH
• Congenital Clubfoot
• Metatarsus Adductus (Varus)
• Skeletal Limb Deficiency
• Osteogenesis Imperfecta (OI)
• Developmental dysplasia of the hip
(DDH)
• Formerly called congenital hip
dysplasia or congenital dislocation of
the hip
• DDH reflects variety of hip
abnormalities:
• Shallow acetabulum
• Subluxation
• Dislocations
Three Degrees of DDH
• Acetabular dysplasia (preluxation)
– Mildest form; osseous hypoplasia
of acetabular roof
– Femoral head remains in the
acetabulum
• Subluxation: incomplete dislocation of
hip
• Dislocation: femoral head loses
contact with acetabulum and is
displaced posteriorly and superiorly;
ligaments elongated and taut
DDH Factors
• Maternal hormone: estrogen
• Mechanical factors
• Intrauterine posture: breech & C- Therapeutic Management of DDH
section • Importance of early intervention
• Twins • Newborn to age 6 months: Pavlik
• Large infant size harness for abduction of hip (3-5
• Tightly wrapped or swaddled, months)
strapped to cradle boards • Age 6-18 months: dislocation
unrecognized until child begins to
stand and walk; use traction and
cast immobilization (spica)
• Older child: operative reduction,
tenotomy, osteotomy; difficult after
4 years
FIG. 31-10 Configuration and relationship of • Skin traction
structures in developmental dysplasia of the • Hip spica cast
hip.
Radiography confirmation
DDH diagnostics
• Open reduction->spica cast-
• Newborn period
>abduction splint
• Ortolani click test
• Older child:
• Barlow test
– Operative reduction
• Infancy: ultrasonography
– Preop traction,tenotomy/osteotomy
• >4 mos: radiography
->cast->ROM->rehab
Clinical Manifestations of DDH
Teach parents
• Infant:
• Pavlik harness: skin care (sponge
– Shortened limb on affected side
bath)
– Restricted abduction of hip on
• Do not remove
affected side
• Avoid powders/lotions
– Unequal gluteal folds when infant
• Casts & orthotics
prone
• Involve in activities
– Positive Ortolani test
• Toys, avoid confinement, encourage
– Positive Barlow test
mobility
DDH in Older Infant and Child
Clubfoot
• Affected leg shorter than the other
 Common foot deformity diagnosed in
• Telescoping or piston mobility of joint
newborns
• Trendelenburg sign
 Signs and symptoms
• Greater trochanter is prominent and
 The foot:
appears above line from
anterosuperior iliac spine to  Is plantar-flexed
 Has an inverted heel
tuberosity of ischium
 Has an adducted forefoot
• Marked lordosis if bilateral
 Is rigid and cannot be manipulated
dislocations
into a neutral position
• Waddling gait if bilateral dislocations
 Diagnosis
 Made by visualization during
Signs of DDH
newborn nursing assessment
 Nursing care
 Treated with serial casting
 Browne splint used after final cast
has been removed
 Severe cases of clubfoot may
require surgery when infant is 9 to
12 months old
 After surgery
o Observe for swelling in ankle
FIG. 31-11 Signs of developmental dysplasia of and foot
the hip. A, Asymmetry of gluteal and thigh folds
o Elevate ankle and foot
with shortening of the thigh (Galeazzi sign). B, o Assess for drainage from cast
Limited hip abduction, as seen in flexion
as well as for signs of infection
(Ortolani test). C, Apparent shortening of the
femur, as indicated by the level of the knees in o Provide pain management
flexion (Allis sign). D, Ortolani test with femoral
head moving in and out of acetabulum (in
infants 1 to 2 months old). E, Positive
Trendelenburg sign with lordosis (if child is
weight bearing).
Congenital Clubfoot
• Diagnostic evaluation At birth
• Ultrasound
• X-ray: confirms alignment
• Therapeutic management
– Serial casting begun shortly after
birth before discharge from
nursery. Successive casts allow for
gradual stretching of skin and tight
structures on the medial side of
the foot. Manipulation and casting
of the leg are repeated frequently
(every week) to accommodate the
rapid growth of early infancy.
Clubfoot (cont’d)
 Education/discharge instructions:
 Instruct family to keep cast clean
 Use double diapering; change diaper
frequently
 Give sponge bath
 Provide emotional support
 Use distraction techniques and age-
appropriate toys to meet
developmental milestones
Metatarsus Adductus
• AKA metatarsus varus
• Most common congenital foot
deformity
• Often results from abnormal position
in uterus; usually evident at birth
• Angulation at tarsometatarsal joint
• “Pigeon toed” gait
• Treatment: physical therapy, orthotics
• Mgt: reliable, passive stretching of
foot X6weeks->straight shoes (pre-
walkers)
• Casts &/or orthoses if no response
Skeletal Limb Deficiency
• AKA reduction malformations
underdevelopment of skeletal
elements of extremities
• Wide range of severity
• Most are primary defects of
development
• May have prenatal destruction of limb
from constriction of amniotic band
Types of Limb Deformities
• Amelia: absence of entire extremity
• Meromelia: partial absence of
extremity
• Phocomelia: deficiency of long bones
with relatively good development of
hands and feet attached at or near
shoulder or hip (“seal limbs”)
Therapeutic Management of Limb
Deficiencies
• Prosthetics as early as possible
• Early prosthetics encourage maximum
exploration and development in
infancy
• Phocomelic digits may be surgically
modified, preserved, and reattached
for use with prosthetics
Osteogenesis Imperfecta (OI)
• A group of heterogeneous inherited
disorders of connective tissue
• Characterized by excessive fragility
and bone defects
• Defective periosteal bone formation
and reduced cortical thickness of
bones
• Hyperextensibility of ligaments
Classification of OI: Type I
• Type I-A: mild bone fragility, blue
sclera, normal teeth, presenile
deafness
• Type I-B: same as A except with
abnormal dentition
• Type I-C: same as B but no bone
fragility
• Two thirds of all cases are Type I
Classification of OI: Type II
• Lethal; stillborn or die in early infancy
• Severe bone fragility with multiple
fractures at birth
• Autosomal recessive inheritance
Classification of OI: Type III
• Severe bone fragility leads to severe
progressive deformities
• Normal sclera, marked growth failure
• Most are autosomal recessive, but
some are autosomal dominant
inheritance
Classification of OI: Type IV
• Type IV-A: mild to moderate bone
fragility, normal sclera, short
stature, variable deformity,
autosomal dominant
• Type IV-B: same as A except abnormal
dentition (dentinogenesis
imperfecta)
– Approximately 6% of OI cases
are type IV-B
• Other sx: thin skin, hyperextensibility
of ligaments, recurrent epistaxis,
^diaphoresis, bruising, hyperpyrexia
• Fx’s decrease @ puberty
• Supportive:
– Braces & splints
– PT
– Surgery:
• telescoping rods
• Nontelescoping
Therapeutic Management of OI
• Primarily supportive care
• Drugs of limited benefit
• May rule out OI if multiple fractures
occur
• Nursing care management:
– Caution with handling to prevent
fractures
– Family education
– Occupational planning and genetic
counseling
– OI Foundation
Legg-Calvé-Perthes Disease
• Self-limiting, idiopathic, occurs in
juveniles ages 3-12, more common
in males age
4-8 years
• Avascular necrosis of femoral head
• Kyphosis and Lordorsis
• Scoliosis
• 10%-15% of cases have bilateral hip
involvement
• Most have delayed bone age
• Pathophysiology: cause is unknown
but involves disturbed circulation to
the femoral head with ischemic
aseptic necrosis
• After resolving may have normal
femoral head or may have severe
alteration
Clinical Manifestations of Legg-Calvé-
Perthes Disease
• Insidious onset; may have history of
limp, soreness or stiffness, limited
range of motion, vague history of
trauma
• Pain and limp most evident on arising
and at end of activity
• Diagnosed by x-ray
Therapeutic Management of Legg-Calvé-
Perthes Disease
• Treatment goal: keep head of femur in
acetabulum
• Containment with various appliances
and devices
• Rest, no weight bearing initially
• Surgery in some cases
• Home traction in some cases
• Bracing: recommended,
?effectiveness
• Surgery: repositions head; select
cases
• Avoidance of Weight-bearing not
necessary
• Periodic x-rays
• Prognosis:
• Self-limiting disease
• Outcome has wide
variations due to
multiple factors
• Nursing care management:
• Identification of affected children
and referral
• Teaching care and management,
coping, hobbies
• Compliance issues with child and
family

Slipped femoral capital epiphysis (SFCE)
• Slipping of proximal femoral epiphysis
posteriorly & inferiorly
• During growth spurt; adolescence
• Emergency; early dx & tx for cure
• Factors: idiopathic, endocrine
disorder, growth hormone therapy,
renal osteodystrophy & rx
• Cause: obesity, physeal architecture,
puberty
• Dx: c/o’s hip pain
• Radiography
• SFCE
• Sx:
• Acute slip: painful hip & limp: needs
immediate rx
• **Chronic slip: limp & inability to
internally rotate hip
• Mgt: surgical
• Bedrest/traction &/or
• Osteotomy
• Postsurgery: nonweight bearing &
crutches
• Nsg: same as cast care & traction
Kyphosis
• Abnormally increased convex
angulation in the curvature of the
thoracic spine
• Most common form is postural
• Can result from tuberculosis, arthritis,
osteodystrophy, or compression
fracture
• Accompanied by compensatory
postural lordosis
• Tx: postural exercises & bracing
• Selected sports: weight lifting, track,
dance, swim
• ?surgical fusion
Lordosis
• Accentuation of the cervical or lumbar
curvature beyond physiologic limits
• May be idiopathic or secondary
complication of trauma
• May occur with flexion contractures of
hip, congenital dislocated hip
• In obese children, abdominal fat alters
center of gravity, causing lordosis
• If severe: accompanied by pain
• Tx: manage predisposing cause
• Postural exercises &/or support
garments
Scoliosis
• Most common spinal deformity
• Complex spinal deformity in three
planes:
– Lateral curvature
– Spinal rotation causing rib
asymmetry
– Thoracic hypokyphosis
• May be congenital or develop during
childhood
Scoliosis (cont’d)
• Multiple potential causes; most cases
idiopathic
• Generally becomes noticeable after
preadolescent growth spurt
• May have complaints of ill-fitting
clothes
• School screening controversial
Diagnostic Evaluation of Scoliosis
• Standing radiographs to determine
degree of curvature
• Asymmetry of shoulder height,
scapular or flank shape, or hip
height
• Often have primary curve and
compensatory curve to align head
with gluteal cleft
Therapeutic Management of Scoliosis
• Team approach to treatment
• Exercise in conjunction w/ bracing:
strengthens spinal & abdominal
muscles
• Bracing: not curative; slows
progression
• Boston brace
• TLSO (thoracolumbosacral orthotic)
• Milwaukee (kyphosis)
Surgical mgt of scoliosis
• For correction of severe curves (>40
degrees)
• Surgical intervention for severe
curvature (instrumentation and
fusion):
– Harrington rods
– L-rods
– Multihook
– Anterior
Nursing Care Management of Scoliosis
• Concerns of body image
• Concerns of prolonged treatment of
condition
• Preoperative care
• Postoperative care
• Family issues
Nursing of Scoliosis
• Preop: Radiographs, PFS, ABG, CBC,
UA/Cx, autologous blood donation,
preop teaching
• Postop: ICU & logroll
• Skin care
• Assess: wound, circ, VS, I&O, neuro
• Pain: opioids
• PT
• Diversional activities
• Teach: brace/cast care
• Organizations: NSF & SRS
INFECTIONS OF BONES AND JOINTS
• Osteomyelitis
• Septic (Suppurative, Pyogenic,
Purulent) Arthritis
• Tuberculosis
Osteomyelitis
• Inflammation and infection of bony
tissue
• May be caused by exogenous or
hematogenous sources
• Signs and symptoms begin abruptly,
resemble symptoms of arthritis and
leukemia
• Marked leukocytosis
• Bone cultures obtained from biopsy or
aspirate
• Early x-rays may appear normal
• Bone scans for diagnosis
Exogenous Osteomyelitis
• Infectious agent invades bone
following penetrating wound, open
fracture, contamination in surgery, or
secondary extension from abscess or
burn
Hematogenous Osteomyelitis
• Preexisting infection spreads to bone
• Source may be furuncles, skin
infections, upper respiratory tract
infection, abscessed teeth,
pyelonephritis
• Any organism can cause osteomyelitis
• Infective emboli travel to arteries in
bone metaphysis, causing abscess
formation and bone destruction
Therapeutic Management of
Osteomyelitis
• May have subacute presentation with
walled off abscess rather than
spreading infection
• Prompt, vigorous IV antibiotics for
extended period (3-4 weeks or up to
several months)
• Monitor hematologic, renal, hepatic
responses to treatment
Osteomyelitis
• Frequently b/t 5-14 years; >boys;
femur or tibia
• Sx: acute hematogenous osteomyelitis
(Box 31-8)
• Infants: lack of systemic sx
• Labs: leukocytosis, ^erythrocyte SR,
+BC (unless on abx), +bone cx,
Technetium-labeled bone scans
• Blood cx->IV abx X3-4 weeks->PO
• Monitor systems related to drug SE’s
(heme, renal, hepatic)
• Local tx
• Complete BR
• Immobilization: splint or bivalved
cast
 • Surgery: sequestrectomy & surgical
drainage
Nursing Care Management of
Osteomyelitis
• VS, I&O, Pain, positioning, support
limb
• Abx long term: PICC
• Open wound: contact isolation
• Casts: immobilization
• assess neurovascular
• Diet: high-calorie liquids
• Wt bearing when healed
• Diversional activities
• PT
Nursing Care Management of
Osteomyelitis
• Complete bed rest and immobility of
limb
• Pain management concerns
• Long-term IV access (for antibiotic
administration)
• Nutritional considerations
• Long-term hospitalization, therapy
• Psychosocial needs
Septic Arthritis
• AKA suppurative, pyogenic, and
purulent arthritis
• May result from extension of soft
tissue infection
• May involve any joint, but most
common in hip, knee, shoulder
• Usually involves only 1 joint
• Infection of joints d/t *hematogenous
dissemination or soft tissue infection
• Hip, knee shoulder, large joints
common
• Hx: traumatic injury to joint
• Dx: BC, joint fluid aspirate, radiograph
• Tx: open surgical drainage of joint
infection & repeated needle
aspirations
• IV abx, pain, immobilize, no wt bearing
Signs and Symptoms of Septic Arthritis
• Characteristic appearance
• Sx: warm & tender joint, painful on
gentle pressure (differs from
osteomyelitis)
• Joint is warm, tender, painful, swollen
• Frequently follows traumatic injury
• Fever, leukocytosis, increased
sedimentation rate
• Neisseria gonorrhoeae is frequent
cause of septic arthritis in sexually
active teens
• Other pathogens
Therapeutic Management of Septic
Arthritis
• Diagnosis made from blood culture,
joint fluid aspirate, x-rays
• Treatment goals:
– Prevent destruction of joint
cartilage
– Decompress the joint to maintain
circulation to epiphysis
– Eradicate the infection
– Prevent secondary bone infection
or hematogenous spread
Bone Tumors
• Osteosarcoma and Ewing sarcoma
account for 85% of all primary
malignant bone tumors in children
• Rhabdomyosarcoma
• Occur more commonly in boys, with
highest incidence during accelerated
growth rate of adolescence
Diagnosis of Bone Tumors
• Rule out trauma or infection first
• Definitive diagnosis based on
radiologic studies (CT scans, bone
scans) and bone biopsy, Pain and
Physical exam
• Radiologic: CT, radioisotope bone
scans, needle or surgical bone bx
• MRI to evaluate neurovascular and
soft tissue extension
• Laboratory studies: elevated alkaline
phosphatase with some bone
tumors
Osteosarcoma
• Most frequent malignant bone tumor
type in children
• Peak incidence age 10-25 years
• Most primary tumor sites are in
metaphysis of long bones, especially
legs
• >50% occur in distal femur
• Other sites: humerus, tibia, pelvis, jaw
Therapeutic Management of
Osteosarcoma
• Traditional approach: radical surgical
resection or amputation of affected
area
• Limb-salvage procedures: resection of
bone with prosthetic replacement of
affected area
• Chemotherapy accompanying surgical
treatment
Nursing Care Management of
Osteosarcoma
• Preoperative preparation is crucial
• Support during adjustment to concept
of amputation, surgical resection
• Body image concerns—issues of
adolescents
• Straightforward & honesty
• Lack of alternatives
• Answer only questions
• Allow grieving
• Chemotherapy & SE’s: hair loss
• Prosthetics
• Stump care
• PT, activities
• Assess environmental barriers:
crutches/wheelchair
• Phantom limb pa
Ewing Sarcoma
• Second most common malignant bone
tumor in children and adolescents;
rare in those >30 years of age
• Arises in marrow, especially in:
– Femur, tibia, ulna, humerus
– Vertebrae, pelvis, scapula, ribs,
skull
• Malignant bone tumor, arising in
marrow space
• <30yrs (4-25)
Treatment of Ewing Sarcoma
• Radiation most common first
approach
• Chemotherapy as adjunct to radiation
• Surgical resection in some cases—
usually able to preserve affected
limb
• Prognosis best if no metastasis at time
of diagnosis; distal lesions have best
potential for cure
• Mgt:
Nursing Care Management of Ewing
Sarcoma
• Assisting family in dealing with
diagnosis of malignancy
• Managing complications of radiation
and chemotherapy
• Nutritional concerns throughout
treatment regimen
Nursing Considerations
• Psychological
• Preparation of diagnostic tests: bone
marrow aspiration, bx
• SE’s of therapies: photosensitivity,
N/V, neuropathy
• PT
Juvenile Idiopathic Arthritis (JIA)
• AKA juvenile rheumatoid arthritis,
juvenile chronic arthritis, or
idiopathic arthritis of childhood
• Possible causes
– unknown, infection,
autoimmunity trauma
• Peak ages: 1-3 years and 8-10 years
• Often undiagnosed
• Actually a heterogenous group of
diseases:
– Pauciarticular onset (involves ≤4
joints)
– Polyarticular onset (involves ≥5
joints)
– Systemic onset (high fever, rash,
hepatosplenomegaly,
 pericarditis, pleuritis, • Parental support: feelings, finance,
lymphadenopathy) work conflicts, SW, counselors,
• 90% of children have negative foundations
rheumatic factor • Pain management
• Symptoms may “burn out” and
become inactive
• Chronic inflammation of synovium
with joint effusion, destruction of
cartilage, and ankylosis of joints as
disease progresses

Symptoms of JIA
• Morning Stiffness
• Swelling
• Loss of mobility in affected joints
• Warm to touch, usually without
erythema
• Tender to touch in some cases
• Symptoms increase with stressors
• Growth retardation

Diagnostic Evaluation of JIA

• No definitive diagnostic tests
• Elevated sedimentation rate in some
cases
• Antinuclear antibodies common, but
not specific for JIA
• Leukocytosis during exacerbations
• Diagnosis based on criteria of
American College of Rheumatology

American College of Rheumatology

Diagnostic Criteria for JIA
• Age of onset <16 years
• 1 or more affected joints
• Duration of arthritis >6 weeks
• Exclusion of other forms of arthritis

Therapeutic Management of JIA

• No specific cure
• Goals of therapy: preserve function,
prevent deformities, and relieve
symptoms
• Iridocyclitis, uveitis:
– Inflammation of iris and ciliary
body
– Unique to JIA
– Requires treatment by
ophthalmologist

Pharmacology for JIA

• NSAIDs
• SAARDs
• Corticosteroids
• Cytotoxic agents
• Immunologic modulators

Management of JIA
• Therapy individualized to child
• Physical and occupational therapy
• Nutrition, exercise
– Therapies: swim, walk, bike, play
– Pain: hot pack, warm bath
– Nighttime splinting
– Position: prevent flexion