Nursing Care

of the Child
with
Musculoskeletal
Disorder
Mary Grace Morada Cu, MAN, RN
Clinical Instructor, CNAHS
St. Paul University Manila
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OBJECTIVES
After completing this chapter, the Learners will be able to:
• Describe common musculoskeletal disorders in children.
• Assess a child with a musculoskeletal disorder.
• Formulate nursing diagnoses related to a child with a musculoskeletal
disorder.
• Establish expected outcomes for a child with a musculoskeletal
disorder.
• Plan nursing care for a child with a musculoskeletal disorder.
• Implement nursing care, such as supplying age-appropriate diversional
activities, for a child with a musculoskeletal disorder.
• Evaluate expected outcomes for achievement and effectiveness of
care.
• Integrate knowledge of musculoskeletal disorders with nursing process
to achieve quality maternal and child health nursing care.

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 THE MUSCULOSKELETAL
SYSTEM
• Bones • Muscle

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MGGMORADACU2020
 THERAPEUTIC MANAGEMENT
OF MUSCULOSKELETAL
DISORDERS IN CHILDREN
• Casting- used for immobilization (Cast Application, Cast
Removal)
• Traction- used to reduce dislocations and immobilize
fractures, involves pulling on a body part in one direction
against a counterpull exerted in the opposite direction.
• Distraction- use of an external device to separate opposing
bones, which encourages new bone growth (Ilizarov external
fixator)
• Open Reduction- surgical technique that is used to align and
repair bone, insertion of a rod or screw may be necessary to
stabilize the bones..

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 Care for Patients with
Cast & Traction

MGGMCUNOV2016
 CAST
• is a device used for immobilization
• applied by a trained orthopedic specialist under
the supervision and direction of a physician
• materials include Plaster of Paris, fiberglass, and
plastic

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 CAST PURPOSES
• To immobilize fractures and hold bone
fragments in reduction (placement for healing).

• To prevent movement in soft tissue injuries.

• To maintain proper alignment and correct

deformities.

• To permit early mobilization.

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 CASTING
MATERIAL
• Plaster casts (Plaster of Paris) are heavy, dry
slowly, and lose strength and integrity if they
become wet.

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 CASTING MATERIAL

• Fiberglass/plastic casts are light in weight, dry

quickly, and can be immersed in water and
redried

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 TYPES OF CASTS
Type of Cast Location Uses

Short arm cast Applied below Forearm or wrist

the elbow to the fractures. Also used
hand. to hold the forearm
or wrist muscles and
tendons in place
after surgery.

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 TYPES OF CASTS
Type of Cast Location Uses

Long arm cast Applied from the Upper arm, elbow,

upper arm to the or forearm fractures.
hand. Also used to hold
the arm or elbow
muscles and
tendons in place
after surgery.

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TYPES OF CASTS
Type of Cast Location Uses

Arm cylinder Applied from the To hold the elbow

cast upper arm to the muscles and
wrist. tendons in place
after a dislocation or
surgery.

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TYPES OF CASTS

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 TYPES OF CASTS
Type of Cast Location Uses

Shoulder Spica Applied around Shoulder

cast the trunk of the dislocations or after
body to the surgery on the
shoulder, arm, shoulder area.
and hand.

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TYPES OF CASTS
Type of Cast Location Uses

Minerva cast Applied around After surgery on the

the neck and neck or upper back
trunk of the area.
body.

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TYPES OF CASTS
Type of Cast Location Uses

Short leg cast Applied to the Lower leg fractures,

area below the severe ankle
knee to the foot. sprains/strains, or
fractures. Also used
to hold the leg or
foot muscles and
tendons in place
after surgery to
allow healing.

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 TYPES OF CASTS
Type of Cast Location Uses

Long Leg Cast Applied from the fractures and dislocat

upper thigh to ions of the knee; for
the base of the maintaining post-
toes. operative immobilizat
ion of the knee, distal
leg, and ankle; and f
or correcting or maint
aining the correcti
on of the foot,
distal leg, & knee.
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TYPES OF CASTS
Type of Cast Location Uses

Leg cylinder Applied from the Knee, or lower leg

cast upper thigh to fractures, knee
the ankle. dislocations, or after
surgery on the leg or
knee area.

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TYPES OF CASTS

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TYPES OF CASTS
Type of Cast Location Uses

Unilateral hip Applied from the Thigh fractures. Also

spica cast chest to the foot used to hold the hip
on one leg. or thigh muscles and
tendons in place
after surgery to
allow healing.

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TYPES OF CASTS
Type of Cast Location Uses

One and one- Applied from the Thigh fracture. Also

half hip spica chest to the foot used to hold the hip
cast on one leg to the or thigh muscles and
knee of the other tendons in place
leg. A bar is after surgery to
placed between allow healing.
both legs to
keep the hips
and legs
immobilized.
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TYPES OF CASTS
Type of Cast Location Uses

Bilateral long Applied from the Pelvis, hip, or thigh

leg hip spica chest to the feet. fractures. Also used
cast A bar is placed to hold the hip or
between both thigh muscles and
legs to keep the tendons in place
hips and legs after surgery to
immobilized. allow healing.

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TYPES OF CASTS
Type of Cast Location Uses

Short leg hip Applied from the To hold the hip

spica cast chest to the muscles and
thighs or knees. tendons in place
after surgery to
allow healing.

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TYPES OF CASTS
Type of Cast Location Uses

Abduction Applied from the To hold the hip

boot cast upper thighs to muscles and
the feet. A bar is tendons in place
placed between after surgery to
both legs to allow healing.
keep the hips
and legs
immobilized.

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CAST APPLICATION

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CARE OF THE PATIENT WITH A
NEWLY APPLIED CAST
a. Expose a newly applied cast to air circulation. (It
should never be covered, because the cover will
restrict the escape of moisture and heat.)

b. Handle a wet cast carefully. It takes 24-48 hours for a

cast to become dry and hard. Use pillow/palms of the
hands when lifting and supporting, never use fingers.)

c. Provide plastic-covered pillows to support the cast

along its entire length. (Never permit the wet cast to
rest directly on a flat or firm surface.)

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CARE OF THE PATIENT WITH A
NEWLY APPLIED CAST
d. Review the patient's clinical record for the type of cast
and the reason the cast has been applied. Instruct the
patient on care of the cast that is wet and after it is dry.

e. After a cast has cooled and begins to harden, elevate

the casted extremity (with the distal joints higher than
the proximal joints) to reduce swelling which often
occurs after application of a cast.

f. Observe all edges of the cast for any areas that cut or
put pressure on the skin.

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CARE OF THE PATIENT WITH A
NEWLY APPLIED CAST
g. Observe the extremity encased in plaster for circulatory
impairment by comparing fingers or toes.
(1) Check the skin temperature of the injured extremity.
It should not be colder than the unaffected limb.
(2) Check and compare the pulses. They should be
equal.
(3) Check for complaints of numbness, tingling, burning,
swelling, pain, pressure, or inability to move the
fingers or toes.
(4) Report presence of the above signs and symptoms
IMMEDIATELY to avoid possible tissue necrosis;
these findings indicate possible ischemia.
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CARE OF THE PATIENT WITH A
NEWLY APPLIED CAST
h. Perform the blanching (capillary refill) test.
(1) With pressure applied, the nail bed should turn pale
(blanch). When pressure is released, the color
should return within the time it takes to say
"capillary refill," indicating return of capillary action.
(2) Failure to blanch, or a blue tinge, indicates impaired
venous circulation and congestion of tissues.
(3) Failure of color to return, or cold, pale fingers or
toes suggests impaired arterial circulation.
(4) In either case, report findings IMMEDIATELY. Do
not wait. Permanent damage can result from
impaired circulation caused by cast pressure.
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 FINISHING THE DRY
CAST
Cast edges may have been trimmed and finished
with a smooth edge at the time of application or edges may
be finished after the cast is dry.

a. When a cast is lined with stockinette, it may be pulled

out from within the cast and folded back over the edges
of the cast and taped in place.

b. Adhesive tape may be used to cover rough edges of the

cast by applying overlapping pieces in a "petal" fashion.

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 FINISHING THE DRY
CAST
c. Nursing implications. A cast without a smooth,
unwrinkled finish is a potential source of problems.

(1) Rough, unfinished cast edges will scrape or cut the

skin. Broken skin surfaces may become infected.

(2) Loose bits of plaster from an unfinished cast may

become lodged inside the cast, causing itching and
irritation.

(3) Wrinkled or "bunched-up" edging may result in

pressure areas and potential skin breakdown.
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 CAST CUTTING
Casts may be cut for different reasons-to allow for wound
dressings, to examine a painful area, or to relieve pressure.

a. Bivalving the Cast.

• method for emergency cutting to relieve pressure.
• cut along its entire length on two sides (medial and
lateral) and the base lining or padding cut completely
down to the skin.

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 CAST CUTTING
b. Windowing the Cast.
• done on specific order of the physician.
• is a potentially dangerous procedure because the
underlying tissue may bulge through the window
opening, causing "window edema.”

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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(1) Explaining the treatment regimen
• Information concerning the pathologic problem
• Purpose of the procedure
• Expectations of the prescribed regimen
-anticipated sights, sounds and sensation (heat)
 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(1) Explaining the treatment regimen
(2) Relieving pain
(3) Improving mobility
(4) Promoting healing of skin abrasions
(5) Monitoring and managing potential
complication
(6) Promoting home and community-based care
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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(2) Relieving Pain
• Evaluate pain ( location ,description & intensity) to
help determine its cause
• Elevation of involved part
• Cold compress as prescribed
• Administering analgesics as prescribed

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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(3) Improving mobility
• Every joint that is not immobilized should be
exercised and moved through its range of motion to
maintain function

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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(4) Promoting healing of skin abrasions
• Treat skin lacerations/abrasions
• Observe for systemic signs of infection- refer to MD
-odors from the cast
-purulent drainage staining the cast

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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(5)Monitoring and managing potential
complication
• Elevate no higher than heart to prevent
Compartment Syndrome
• Monitor patient’s increasing pain, tightness in the
area, stain in the cast & foul odor may indicate
Pressure Ulcers
• Encourage Isometric muscle contraction to prevent
Disuse Syndrome
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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(5) Monitoring and managing potential
complication (cont)
• Monitor circulation -5 P’s
 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(5)Monitoring and managing potential
complication (cont)
• Report immediately to physician if with:
 Increased pain
 Increased swelling above or below the cast
 Decreased ability to move extremity in the cast
 Complaints of numbness or tingling
 Drainage or foul odor from the cast
 Cool or cold fingers or toes
 If the cast becomes wet or soiled
 Blister, sores, or rash develop under the cast
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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(5)Monitoring and managing potential
complication (cont)
• If patient developed complication, physician will order
for Emergency Bivalving
• If pressure is not relieved and circulation is not
restored, Fasciotomy may be necesssary.

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 GENERAL NURSING
MANAGEMENT OF THE
PATIENT WITH A CAST
(6) Promoting home and community-
based care
• Teaching the patient self care to achieve
independence in ADLs such as:
-personal care
-use assistive device
-exercise

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CAST REMOVAL

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PATIENT CARE AFTER
CAST REMOVAL
a. Continue to provide support to joints and normal body
curves. Use firm pillows to support the patient while in
bed and use elastic bandages or an arm sling

b. Avoid vigorous attempts to remove skin exudate and

crusts of dead skin cells, which are present when a cast
has been in place for several weeks

c. The MD or PT may prescribe exercises to increase

strength. If the patient has been doing isometric muscle
contractions, he will not have to "relearn" to contract his
muscles and will progress more rapidly through
rehabilitation. MGGMORADACU2020
 TRACTION
• is the act of exerting a pulling force.
• applied in one direction requires countertraction
(exertion of pull in the opposite direction).
- countertraction is supplied by the patient's
body weight and friction against the bed.
- additional countertraction may be achieved
by elevating the head or foot of the bed or by
application of counter traction apparatus

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 TRACTION
PURPOSES
• Reduce and immobilize fractures.
• Prevent fracture deformities.
• Relieve muscle spasm.
• Reduce pain.
• Help regain the normal length and alignment of
an injured extremity.

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TWO BASIC FORMS OF
TRACTION
(1) Balanced Suspension Traction

(2) Running Traction

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TWO BASIC FORMS OF
TRACTION
(1) Balanced Suspension Traction
• direct pull on the part is applied with the extremity
supported in a splint and held in place with
balanced counterweights (examples: Thomas splint
with Pearson attachment).
• the extremity "floats" or is suspended in the traction
apparatus by the balanced weights.
• the line of traction on the extremity remains fairly
constant despite any changes in the position of the
patient. This principle may be utilized in both skin
and skeletal traction and may be either unilateral or
bilateral.
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TWO BASIC FORMS OF
TRACTION
(2) Running Traction
• direct pull is applied without support of the part
(example: Buck's traction).
• the pull is exerted in only one plane. This principle
may be utilized in both skin and skeletal traction, and
may be either unilateral or bilateral.

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BASIC METHODS OF
APPLYING TRACTION
(1) SKIN TRACTION

(2) SKELETAL TRACTION

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BASIC METHODS OF
APPLYING TRACTION
(1) SKIN TRACTION
• adhesive material is applied to a limb or a halter is
fitted to the patient's head or pelvis.
• the adhesive material or the halter is then attached to
a traction apparatus and force is exerted by means of
a pulley and weights.
1.1. Bucks Extension Traction (lower leg)
1.2. Russell Traction
1.3. Pelvic Traction Girdle (back pain)
1.4. Pelvic Traction Sling
1.5. Cervical Traction Halter (neck pain)

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 TYPES OF SKIN
TRACTION
1.1. Bucks Extension Traction (lower leg)

1.2. Russell Traction

1.3. Pelvic Traction Girdle (back pain)

1.4. Pelvic Traction Sling

1.5. Cervical Traction Halter (neck pain)

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 TYPES OF SKIN
TRACTION
1.1. Bucks Extension Traction (lower leg)
• provides for straight pull through a single
pulley attached to a crossbar at the foot of the
bed.
• the limb in traction lies parallel to the bed
• the foot of the bed is routinely elevated to
provide counter traction and to keep the
patient from being pulled down to the foot of
the bed.
• the patient is usually not allowed to turn and
must remain flat on his back. MGGMORADACU2020
 TYPES OF SKIN
TRACTION
1.1. Bucks Extension Traction (lower leg)

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 TYPES OF SKIN
TRACTION
Care of Patient in Bucks Extension Traction
• Check alignment of the leg to maintain a straight line
of pull from the rope attached to the spreader bar to
the pulley mounted on the foot of the bed.
• Check the bandage wrappings and tape or strips to
be sure that they are adhering properly and have not
slipped downward.
• Report immediately if any part of the wrappings or
traction apparatus appears to be out of place.

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 TYPES OF SKIN
TRACTION
1.2. Russell Traction
• a system of suspension and traction pull is used.
• adhesive strips are applied and the knee is
suspended in a sling.
• a rope is attached to the sling's spreader bar. This
rope passes over a pulley which is attached to an
overhead bar and is then directed to a system of three
pulleys at the foot of the bed:
- 1st to a pulley on the bed's foot bar,
- 2nd to a pulley attached to the foot spreader bar, &
- 3rd back to a second pulley on the bed's foot bar.
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 TYPES OF SKIN
TRACTION
1.2. Russell Traction (cont)
• an upward pull from the sling pulley and a forward
pull from the pulleys at the foot of the bed.
• the angle between the thigh and the bed is
approximately 20° and there is always slight flexion of
both the hip and the knee.
• advantage of RT is that some movement in bed is
permissible.
• the patient can turn slightly toward the side in traction
for back care, bedpan placement, or linen change.

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 TYPES OF SKIN
TRACTION
1.2. Russell Traction

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 TYPES OF SKIN
TRACTION
Care of Patient in Russell Traction
• Check the popliteal space for signs of pressure from
the sling such as redness, indentations, abrasions, or
pain.
• Check all the tape and wrappings as in Buck's
traction.
• Keep the patient from sliding down the bed. The foot
of the bed may be elevated to help prevent this.

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 TYPES OF SKIN
TRACTION
1.3. Pelvic Traction Girdle (back pain)
• is ordinarily used for treatment of low back pain and
muscle spasm.
• is fitted snugly and evenly over the iliac crests.
• the traction straps, extending on the lateral side of
each thigh, are hooked to a separate rope at mid-
thigh level and each rope leads to a separate but
equal weight at the foot of the bed.
• the foot of the bed is usually elevated to provide
counter traction.

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 TYPES OF SKIN
TRACTION
1.3. Pelvic Traction Girdle (back pain)

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 TYPES OF SKIN
TRACTION
Care of Patient in Pelvic Traction Girdle (back pain)
• Keep the girdle and the underlying skin clean and dry
• Avoid using padding unless the patient is very thin or
the iliac crests are very prominent.
• Protect and support the feet. Foot exercises are
usually encouraged, but there must be no contact with
the traction ropes.
• The physician's orders may specify when the girdle
may be removed for skin care or bathroom privileges.

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 TYPES OF SKIN
TRACTION
1.4. Pelvic Traction Sling
• is used in the treatment of pelvic fracture.
• the patient is placed in a canvas sling or hammock
that is suspended by a tension spring to an overhead
frame bar.
• the pelvis is suspended so that it is just off the
mattress.

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 TYPES OF SKIN
TRACTION
1.4. Pelvic Traction Sling

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 TYPES OF SKIN
TRACTION
Care of Patient in Pelvic Traction Sling
• Padding may be placed along the sling edges or as
needed to relieve pressure on the coccyx.
• Keep the sling, the padding, and the skin clean and
dry.

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 TYPES OF SKIN
TRACTION
1.5. Cervical Traction Halter
• is used for treatment of the cervical spine.
• the halter fits snugly under the chin and around the
back of the head against the occipital protuberance.
• a pulley rope is attached to the spreader bar that
hooks to the top of the harness.
• the prescribed weights at the end of the pulley rope
keep the patient's neck and cervical spine in a
position specified by the physician

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 TYPES OF SKIN
TRACTION
1.5. Cervical Traction Halter

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 TYPES OF SKIN
TRACTION
Care of Patient in Cervical Traction Halter
• the patient's bed may be positioned in reverse to
allow easier access to the patient's head.
• the head of the bed may be elevated to provide
counter traction and to help prevent the patient's head
or the spreader bar from resting against the bed
frame.
• when positioning the bed, allow for plenty of room
around the head of the bed in order to prevent
bumping the weights.

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 TYPES OF SKIN
TRACTION
Care of Patient in Cervical Traction Halter
• feed the patient slowly and carefully.
• if turning is not permitted, remind the patient to face
forward and not turn toward the spoon, fork, or straw
• allow plenty of time for him to chew and swallow.
• check to be certain that the chinstrap is not pressing
on his throat.
• more importantly, keep suction equipment on hand for
immediate use to prevent the patient from aspirating
when eating, drinking, or receiving mouth care.
Remember, if the patient chokes or vomits, he cannot
be turned to the side or raised upward.
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 BASIC METHODS OF
APPLYING TRACTION
(2) SKELETAL TRACTION
• force is exerted directly on the bone by tongs inserted
into the skull or a pin or wire inserted through the
bone at a point distal to the fracture of an extremity.
• the tong, pin, or wire is then attached to the traction
apparatus and force is exerted by means of pulleys
and weights.
• a greater pull can be exerted by skeletal traction than
by skin traction.

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 TYPES OF SKELETAL
TRACTION
2.1. Cervical Skeletal Traction

2.2. Balanced Suspension Traction (extremity)

Skeletal Traction For The Femur

2.3. Arm Traction

a. Side arm traction
b. Overhead traction

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 TYPES OF SKELETAL
TRACTION
2.1. Cervical Skeletal Traction
• Crutchfield or Vinke tongs are used for skeletal
traction in the treatment of fractures of the cervical
spine.
• the tong points are inserted in the parietal area of the
skull (just in the outer layers of the bone) and the
tong is then attached to the pulling device.
• the procedures may be done under local anesthesia
in the operating room or on the ward.

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 TYPES OF SKELETAL
TRACTION
2.1. Cervical Skeletal Traction

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 TYPES OF SKELETAL
TRACTION
Care of Patient in Cervical Skeletal Traction
• Prepare the bed as for cervical halter traction such as
- the patient's bed may be positioned in reverse to
allow easier access to the patient's head.
- the head of the bed may be elevated to provide
counter traction and to help prevent the patient's head
or the spreader bar from resting against the bed
frame.
- when positioning the bed, allow for plenty of room
around the head of the bed in order to prevent
bumping the weights.
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 TYPES OF SKELETAL
TRACTION
Care of Patient in Cervical Skeletal Traction
• Feed the patient as for cervical halter traction such as
- slowly and carefully.
- if turning is not permitted, remind the patient to face
forward and not turn toward the spoon, fork, or straw
- allow plenty of time for him to chew and swallow.
- check to be certain that the chinstrap is not pressing
on his throat.
- more importantly, keep suction equipment on hand
for immediate

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 TYPES OF SKELETAL
TRACTION
2.2. Balanced Suspension Traction (extremity) (Skeletal
Traction For The Femur)
• this method of treatment provides considerable
freedom of body movement while maintaining efficient
traction on the injured limb.
• the Thomas leg splint and Pearson attachment are
used to achieve balanced suspension traction.

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 TYPES OF SKELETAL
TRACTION
2.2. Balanced Suspension Traction (extremity) (Skeletal
Traction For The Femur)

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 TYPES OF SKELETAL
TRACTION
Care of Patient in Balanced Suspension Traction
• The Thomas splint (half ring) is applied in various
ways: with the ring fitted posteriorly against the
ischium or anteriorly in the groin.
• the thigh rests in a canvas or bandage-strip sling with
the popliteal space left free.
• the leather ring should not be wrapped or padded.
• if kept smooth, dry, and polished, the leather of the
ring is designed to rest against the skin and resist
moisture.

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 TYPES OF SKELETAL
TRACTION
Care of Patient in Balanced Suspension Traction
• the Pearson attachment is attached by clamps to the
Thomas splint at knee level.
• a canvas or bandage-strip sling supports the lower leg
and provides the desired degree of knee flexion.
• a footplate is attached to the distal end of the Pearson
attachment to support the foot in a neutral position.
• the heel should be left free.

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 TYPES OF SKELETAL
TRACTION
2.3. Arm Traction
• used for the upper extremities, depending on the
location of the fracture, any associated injuries, and
the preference of the physician.
• the position of the arm in traction may be:
Sidearm or Overhead

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 TYPES OF SKELETAL
TRACTION
Care of Patient in Arm Traction
• compare the radial pulse on the affected side with the
pulse on the unaffected side. Circulatory impairment
must be reported immediately.
• keep the elevated hand in a position of function at all
times, and observe for pressure points at the wrist.
• be sure that only the fingertips extend from the sling in
the overhead traction set-up.

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CARE OF PATIENT IN
TRACTION
Extremity
T • Temperature
Infection
R • Ropes Hang Freely
A • Alignment
C • Circulation check (5 Ps)
T • Type & Location of Fracture
I • Increase Fluid Intake
O • Overhead Trapeze
N • No weights on Bed/Floor
MGGMORADACU2020
Nursing Care
of the Child
with
Musculoskeletal
Disorder- Part 2
Mary Grace Morada Cu, MAN, RN
Clinical Instructor, CNAHS
St. Paul University Manila
MGGMORADACU2020
 MUSCULOSKELETAL DISORDERS
1. DISORDERS OF BONE
DEVELOPMENT
• Talipes Disorders***
• Developmental Hip
Dysplasia***
• Flat Feet (Pes Planus)
• Bowlegs (Genu Varum)
• Knock Knees (Genu Valgum)
• Blount’s Disease (Tibia Vara)
• Toeing-In
• Limps
• Growing Pains
• Osteogenesis Imperfecta
• Legg-Calvé-Perthes Disease
(Coxa Plana)
• Osgood-Schlatter Disease
• Slipped Capital Femoral
Epiphysis
2. INFECTIOUS AND
INFLAMMATORY
DISORDERS OF THE
BONES AND JOINTS
• Osteomyelitis***
• Synovitis
• Apophysitis
3. DISORDERS OF
SKELETAL STRUCTURE
• Functional (Postural)
Scoliosis***
• Structural Scoliosis***
• Osteoporosis
4. DISORDERS OF THE
JOINTS AND TENDONS:
COLLAGEN-VASCULAR
DISEASE
• Juvenile Arthritis (JA)***
5. DISORDERS OF THE
SKELETAL MUSCLES
• Myasthenia Gravis***
• Dermatomyositis
• Muscular Dystrophies***
6. INJURIES OF THE
EXTREMITIES
• Finger Injuries
• Bicycle-Spoke Injuries
• Fractures****
• Athletic Injuries
MGGMORADACU2020
MUSCULOSKELETAL DISORDERS
1. DISORDERS OF BONE DEVELOPMENT
• Talipes Disorders***
• Developmental Hip Dysplasia***
• Flat Feet (Pes Planus)
• Bowlegs (Genu Varum)
• Knock Knees (Genu Valgum)
• Blount’s Disease (Tibia Vara)
• Toeing-In
• Limps
• Growing Pains
• Osteogenesis Imperfecta
• Legg-Calvé-Perthes Disease (Coxa Plana)
• Osgood-Schlatter Disease
• Slipped Capital Femoral Epiphysis

MGGMORADACU2020
 Talipes Disorders (Clubfoot)
• Talipes is a word formed from the Latin words talus (“ankle”) and pes
(“foot”).
• deformities are ankle–foot disorders, popularly called clubfoot
• foot cannot be properly aligned without further intervention.
• orthopedic correction techniques for normal foot position.
• 1 over 1000 children is born with a talipes disorder, more often in boys
than in girls.
Causes:
• inherited as a polygenic pattern.
• occurs as a unilateral problem (Eilert, 2008).
• newborns with Pseudo-talipes Disorder (foot turned in but can be be in
straight position by manipulation) due to intrauterine position

MGGMORADACU2020
 Talipes Disorders (Clubfoot)
Classification of Talipes Disorders
1. Idiopathic Clubfoot (Talipes Equinovarus)
• most common type of clubfoot and is present at
birth.
• one out of 1,000 babies, half of cases involving
only one foot.
• no known cause of idiopathic clubfoot,
2. Neurogenic Clubfoot
• caused by an underlying neurologic condition.
(child born with spina bifida)
• may also develop later in childhood due
to cerebral palsy or a spinal cord compression.
3. Syndromic Clubfoot
• found with other clinical conditions, which
relate to an underlying syndrome
(arthrogryposis, constriction band syndrome,
tibial hemimelia and diastrophic dwarfism).
MGGMORADACU2020
 Talipes Disorders (Clubfoot)
Four Separate Types of Talipes Disorders
• Talipes Equinus/ plantarflexion (an equinus or
“horsefoot” position, with the forefoot lower
than the heel, the foot points downward,

• Talipes Calcaneus/ dorsiflexion (the heel is

held lower than the forefoot or the anterior foot
is flexed toward the anterior leg);

• Talipes Varus/ varus deviation (the foot turns

in); most common form, foot look somewhat
like the letter J (when looking at the left foot
head-on).

• Talipes Valgus/ valgus deviation (the foot

turns out). the foot rotates outward like the
letter L.
 Talipes Disorders (Clubfoot)
Most children have a COMBINATION of TD
• Cavus. A foot deformity in which the arch of the
foot is high and often the heel adducted.
• Equinovalgus. combination of t. equinus and t.
valgus, marked by a plantar-flexed, everted,
and abducted foot.
• Calcaneovalgus. combination of t. calcenous
and t. valgus a child walks on the heel with the
foot everted).
• Cavovarus. combination of t. cavus and t.varus
The relatively strong peroneus longus and
tibialis posterior muscles cause a hindfoot varus
and forefoot valgus (pronated) position
• Equinovarus. combination of t. equinus
and t.varus, plantar flexion, inward tilting of the
heel (from the midline of the leg), and adduction
of the forefoot (medial deviation away from the
leg’s vertical axis).
• Calcaneovavus. combination of t. calcenous
and t.vavus, is flat or convex and dorsiflexed
with the heel turned outward.
MGGMORADACU2020
 Talipes Disorders (Clubfoot)
Therapeutic Management
• Correction is best if started at newborn period.
• cast is applied while the foot is placed in an
overcorrected position. (cast extends above
the knee to ensure firm correction).
• Teach parents how to check the infant’s toes
for coldness or blueness and how to perform
blanch test
• Change of cast q 1 or 2 weeks. 6 weeks final.
• Include other family member
• .
 Talipes Disorders (Clubfoot)
Therapeutic Management (cont)
• Teach parents to perform passive foot
exercises for infant’s foot and ankle
through a full ROM several times a
day for several months
MGGMORADACU2020
• After removal of cast: Infant sleep in
Denis Browne splints (shoes attached
to a metal bar to maintain position; or
high-top shoes at night for a few more
months).
• Surgery to achieve a final correction.
 Developmental Hip Dysplasia
• often referred to as congenital hip dysplasia
• is improper formation and function of the hip socket .
• occurs in 1 in 1000 births.
• may be evident as subluxation or dislocation of the head of the femur
• the acetabulum of the pelvis is flattened or shallow (prevents the head of the femur
from remaining in the acetabulum and rotating adequately).
• In a subluxated hip, the femur “rides up” because of the flat acetabulum;
• in a dislocated hip, the femur rides so far up that it actually leaves the acetabulum.
 Developmental Hip Dysplasia
CAUSES:
• unknown, but may be from a polygenic
inheritance pattern.
• uterine position that causes less-than-usual
pressure of the femur head on the
acetabulum.
• most often in children of Mediterranean
ancestry.
• six times more in girls than in boys, possibly
because the hips more flaring in females and
possibly because the maternal hormone
relaxin causes the pelvic ligaments to be more
relaxed.
• Involvement usually is unilateral.
• Sociocultural methods of childrearing (the way
infants are carried)
 Developmental Hip Dysplasia
ASSESSMENT:
• Assessing Barlow’s and Ortolani’s Signs
• https://www.youtube.com/watch?v=Qy3u
SkDhMZs

MGGMORADACU2020
Assessing Barlow’s and Ortolani’s Signs

MGGMORADACU2020
 Developmental Hip Dysplasia
ASSESSMENT:
• affected leg may appear slightly shorter than
the other (most noticeable in lying supine and
thighs are flexed to a 90-degree angle toward
the abdomen)
• one knee will appear to be lower than the
other
• unequal number of skin folds may be present
on the posterior thighs
• Subluxated or dislocated hips are best
assessed by noting whether the hips abduct
• difficult to detect at birth in an infant that is
footling or frank breech presentation because
the knees are stiff and do not flex readily.

DIAGNOSIS: Radiography, ultrasound, or MRI

reveal the shallow acetabulum and a more lateral
placement of the femur head than normal MGGMORADACU2020
 Developmental Hip Dysplasia
Therapeutic Management:
• Correction of subluxated and dislocated hips
involves positioning the hip into a flexed,
abducted (externally rotated) position to
press the femur head against the
acetabulum and cause it to deepen its
contour by the pressure.
• Splints, halters, or casts may be used:
 Multiple Diapers or Splints
 Pavlik Harness
 Spica Cast
• Surgery and a pin inserted to stabilize the hip

MGGMORADACU2020
 Developmental Hip Dysplasia
Therapeutic Management:
Multiple Diapers or Splints.
• splint correction (to hold the legs in a frog-
leg, or abducted, externally rotated position)
• begun during the newborn’s initial hospital
stay by placing two or three diapers on the
infant.
• extra bulk of cloth between the child’s legs
effectively separates and spreads them.
• Do not use cut narrow diapers or cloth
diapers: less effective

MGGMORADACU2020
 Developmental Hip Dysplasia
Therapeutic Management:
Pavlik Harness.
• adjustable chest halter that abducts the legs.
• method of choice for long-term therapy
because it reduces the time interval for
therapy to 3 to 4 weeks and simplifies care
• soft plastic stirrups (booties) with quick-
fastening closures such as Velcro attach to
leg extension straps and hold the hips flexed,
abducted, and externally rotated.

MGGMORADACU2020
 Developmental Hip Dysplasia
Therapeutic Management:
Pavlik Harness Nursing Care (cont).
Instruct parents to:
 lay the infant supine, grasp the infant’s
thighs and abduct them to place the femoral
head into the acetabulum, and then apply
the harness.
 harness is worn continually except bathing
 to assess the skin under the straps daily for
irritation or redness.
 does not show under a shirt and long
trousers and promotes gentle reduction of
the hip.

MGGMORADACU2020
 Developmental Hip Dysplasia
Therapeutic Management:
Spica Cast.
• afrog-leg, A-line cast or a spica cast for
severe case to maintain an externally
rotated hip position
• heavy and are so wide
• Nursing Care: assess hourly for
circulation to the extremities for the first
24 hours the cast is in place and daily
thereafter.

MGGMORADACU2020
 Developmental Hip Dysplasia
Therapeutic Management:
Spica Cast Nursing Care
Teach parents
• how to do neurovascular assessment
(temperature and circulation in toes)
before discharge.
• will be changed periodically but
maintained for 6 to 9 months.
• If a reduction maneuver for
• Watch out for necrosis -severest form,
this can lead to femoral head death and
loss of future growth at the proximal
growth plate causing unequal leg
lengths

MGGMORADACU2020
 Developmental Hip Dysplasia
General Care Guidelines
• Surgery may still be necessary for a final
correction.
• Making parents aware of this from the
start (prevent becoming discouraged or
dissatisfied with health care).
• Some children will be 2 years old before
the final cast or harness is removed.
• The child and parents will be visiting
their orthopedist frequently during these
early years.
• Assess that parents also schedule
general health maintenance visits for
routine immunizations and overall growth
and development assessment.

MGGMORADACU2020
 Developmental Hip Dysplasia
General Care Guidelines (cont)
• Spend time during health maintenance
visits talking with them about infant
stimulation.
• Teach parents to hold their child for
feeding and to rock and cuddle the infant,
even though a large cast or a brace may
be bulky and awkward.
• A child’s wagon can supply convenient
and fun transportation.
• The child may also be able to lie prone
and move about on a large skateboard.
• When the cast is removed, the child will
quickly catch up with developmental step/
walking

MGGMORADACU2020
Nursing Care
of the Child
with
Musculoskeletal
Disorder- Part 3
Mary Grace Morada Cu, MAN, RN
Clinical Instructor, CNAHS
St. Paul University Manila
MGGMORADACU2020
 MUSCULOSKELETAL DISORDERS
2. INFECTIOUS AND INFLAMMATORY
DISORDERS OF THE BONES AND
JOINTS
• Osteomyelitis***
• Synovitis (inflammation of a synovial
membrane)
• Apophysitis (inflammation of the
epiphysis of a heel bone)

MGGMORADACU2020
 Osteomyelitis
• infection of the bone.

Causes:
• Staphylococcus aureus in older children and
by Streptococcus pyogenes in younger
children.
• Children with sickle cell anemia have a
special susceptibility to Salmonella invasion
in long bones.
• Organisms are carried to the bone site by
septicemia (blood infection).
• occur after extensive impetigo, burns, or
something as simple as a furuncle (skin
abscess).
• occur directly by outside invasion from a
penetrating wound, open fracture, or
contamination during surgery
MGGMORADACU2020
 Osteomyelitis
• begins typically as a metaphyseal infection,
because the blood supply is sluggish in that
portion of the bone.
• abscess forms and spreads along the shaft
of the bone under the periosteum, possibly
extending to and penetrating the bone
marrow.
• Sinuses may form between the marrow and
the periosteum, or between the infected
bone and the skin above.
• If the epiphyseal plate is infected, altered
bone growth may result.

MGGMORADACU2020
 Osteomyelitis
Assessment
• Acute symptoms:
• systemic malaise, fever, and irritability.
• sharp pain at the bone metaphysis.
• By 2nd day, area of skin over the infected
bone feels warm to the touch; edema
• Sequestrum- dense on radiographs are
Dead bone tissue (5-10days),

Diagnostic:
• increased WBC count, C-reactive protein
level, and sedimentation rate; blood
culturepositive.
• CT demonstrate early-stage bone changes.
• Simple radiographs for sequestrum

MGGMORADACU2020
 Osteomyelitis
Therapeutic Management
• limitation of weight bearing on the affected
part, bedrest, immobilization,
• administration of an IV antibiotic such as
oxacillin (Bactocill), for 2 weeks
• oral antibiotic for 3 to 4 more weeks.
• administration of bisphosphonates to help
reduce bone loss
• If pus forms under the periosteum, it may be
aspirated using a technique similar to bone
marrow aspiration.
 After the procedure, a tube may be
inserted into the area for instillation of an
antibiotic solution.
 A drainage tube may be inserted and
attached to suction to evacuate the
subperiosteum area.
MGGMORADACU2020
 MUSCULOSKELETAL DISORDERS

3. DISORDERS OF
SKELETAL
STRUCTURE
• Functional
(Postural)
Scoliosis***
• Structural
Scoliosis***
• Osteoporosis
(is a disease in
which the density
and quality of bone
are reduced) MGGMORADACU2020
 Scoliosis
• is a lateral (sideways) curvature of the spine.
• may involve all or only a portion of the spinal column.
• may be functional (a curve caused by a secondary problem) or structural (a
primary deformity).
• may be dextroscoliosis (spine curves to the right), or levoscoliosis (spine curves
to the left)

MGGMORADACU2020
 Functional (Postural) Scoliosis
• occurs as a compensatory mechanism in
children who have:
 unequal leg lengths,
 ocular refractive errors
 accompanying neuromuscular
disorders such as cerebral palsy
• The pelvic tilt caused by unequal leg
length or muscle strength results in a
spinal deviation because this is necessary
for the child to stand upright.
• The curve that occurs in functional
scoliosis tends to be a C-shaped curve,
whereas that in structural scoliosis tends
to be S-shaped (composed of two
separate curves).
• there is little change in the shape of the
vertebrae on radiography. MGGMORADACU2020
 Functional (Postural) Scoliosis
Therapeutic Management:
• Children with noncorrectable euromuscular
conditions may need spinal fusion
• Leg length is measured from the anterior
iliac spine to the bottom of the medial
malleolus; a lift inserted in one shoe
corrects unequal leg length.
• Correction of ocular refractive errors
improves problems caused by head tilt.
• Remind children to maintain good posture
during everyday activities.
• Walking with a book on the head for 10
minutes, three times a day, or hanging by
the hands from a door frame (chinning
themselves) stretches the back and is
often helpful.
• Sit-ups and push-ups.
• Swimming also is good exercise,
MGGMORADACU2020
 Functional (Postural) Scoliosis
Guidelines for Parents and Children:
• Parents and children need to be reassured
that disorder that can be corrected.
• Children need to be aware of this to
prevent problems with self-esteem and
bodyimage.
• Caution parents about nagging children of
this age to do exercises or maintain good
posture (puberty)
• Excessive reminders can lead to the child
ignoring the parents’ requests.
• Help them to find alternative, more positive
ways to exert their independence, such as
not making their bed.

MGGMORADACU2020
 Structural Scoliosis
• is idiopathic, permanent curvature of
the spine accompanied by damage to
the vertebrae.
• spine assumes a primary lateral
curvature.
• spine an S-shaped appearance
• the primary curve is often a right
thoracic convexity.
• Severe: rotation and angulation of
vertebrae occur.
• The thoracic rib cage rotates to
become very protuberant on the
convex curve.
• Vertebral growth may halt because of
extreme pressure changes.
MGGMORADACU2020
 Structural Scoliosis
• A family history upto 30% of children
although no specific inheritance
pattern
• It is 5x in girls than in boys
• eak incidence at 8 to 15 years of age.
• As long as the child is growing, the
spinal curves will become more
severe.
• most marked at prepuberty, a time of
rapid growth.

MGGMORADACU2020
 Structural Scoliosis
Assessment
• All children older than 10 yrs should
be assessed
• Develops insidiously and is prominent
before it is noticed because of the
preadolescent’s and adolescent’s
need for privacy and the lack of pain
that accompanies the condition.
• child bends forward, the curve
becomes even more noticeable.

MGGMORADACU2020
 Structural Scoliosis
Diagnostic
• Scoliometer device that can be used
to document the extent of a spinal
curve.(reading greater than 7 degrees
equals a 20-degree scoliotic curve
detected by radiography)
• Radiographs and photographs. (If the
child has a vertebral rotation causing
rib imbalance, pulmonary function
studies and a chest radiograph)
• If the child has 1 to 2 years of bone
growth remaining, some correction
most likely will be undertaken.

MGGMORADACU2020
 Structural Scoliosis
Therapeutic Management
• If spinal curve is less than 20 degrees, no
therapy except for close observation 18
years of age.
• If the curve is greater than 20 degrees,
treatment consist of a conservative,
nonsurgical approach using a body brace
or traction, or it may include surgery or a
combination of both surgical and
nonsurgical measures.
• Curves greater than 40 degrees require
surgery with spinal fusion.
• The goal of both surgery and mechanical
bracing is to maintain spinal stability and
prevent further progression of the
deformity until bone growth is complete.

MGGMORADACU2020
 Structural Scoliosis: Bracing
Therapeutic Management
1. Bracing
• If the spinal curve is greater than 20
degrees but less than 40 degrees and the
child is still skeletally immature, is a prime
intervention
• The Milwaukee brace was the first type
braces extended to the neck and were
almost impossible to conceal under
clothing;
 today, they are underarm thoracolumbar
supports that are worn under clothing
worn for 23 hours per day (removed only
for showering or participation in a
structured athletic program.
• Charleston Bending Brace AT NIGHT
that confines the spine to an overcorrected
position. MGGMORADACU2020
 Structural Scoliosis
Types of Scoliosis Braces
1. Full-Time Braces
1.1. Milwaukee Brace
1.2. Boston Brace
1.3. Wilmington Brace

2. Nighttime Braces
2.1. Charleston Bending Brace
2.2. Providence Brace

MGGMORADACU2020
 Structural Scoliosis
Types of Scoliosis Braces
1. Full-Time Braces
1.1. Milwaukee Brace
• original cervico-thoracic-lumbar-sacral orthosis
(CTLSO), for high thoracic curve.
• has a distinctive design that is designed to
manipulate the wearer's full upper body.
• extends from the pelvis all the way up to neck and
is made with a contoured plastic pelvic girdle and
neck ring.
• connected with a metal bar in both the front and
back of the brace.
• metal bars help the torso to extend while the neck
ring keeps the wearer's head in a central position
over pelvis.
• pressure pads are placed to metal bars with straps,
aligning to the shape of the wearer's spinal curve.
• developed in 1945 by Dr Albert Schmidt and Dr
Walter Blount of the Medical College of Wisconsin
and Milwaukee Children's Hospital MGGMORADACU2020
 Structural Scoliosis
Types of Scoliosis Braces
1. Full-Time Braces
1.2. Boston Brace most common- today
• first developed in the early 1970s by Dr John Hall and Mr
William Miller of The Boston Children's Hospital
• type of thoracolumbosacral orthosis (TLSO), 'low-profile'
or 'underarm' braces.
• Other models such as a CTLSO, which is a TLSO with a
neck extension., used for high-degree curves located on
the thoracic spine
• is small in size, with plastic components that are custom-
made to fit the wearer's body exactly.
• At front, starts below the breast and extends to the
beginning of the pelvic area.
• At back, begins below shoulder blades and continues
down to the tail bone of the spine - covering most of the
torso.
• works by applying pressure to the spine's curve pattern to
prevent further curvature, forces lumbar areas to 'flex',
pushing in the abdomen and flattening the posterior
MGGMORADACU2020
lumbar curve.
 Structural Scoliosis
Types of Scoliosis Braces
1. Full-Time Braces
1.3. Wilmington Brace
• another common TLSO.
• is entirely custom-made for each wearer, based on
a cast taken while they patient is lying down and
facing upwards.
• once the cast is produced, corrective forces
specific to the wearer's spinal curve are added to
complete the brace.
• is applied to the body in a similar fashion to a tight
jacket and is known as a full-contact TLSO as a
result of its lack of open spots and gaps.

MGGMORADACU2020
 Structural Scoliosis
Types of Scoliosis Braces
2. Nighttime Braces
2.1. Charleston Bending Brace
• most commonly-prescribed night-time
• like the Wilmington brace, it is custom-
fitted based on a cast taken of the patient's
torso. Once the case has set, corrective
forces are added to the brace based on X-
rays of the patient's spine.
• designed to be worn laying down, not
while up and moving around. (allows brace
to apply greater forces and isn't restricted
by considerations for the head to remain
balanced over the pelvis)
• applying lateral forces to push the spinal
curve closer to the back's midline, also
applies pressure to bend and hold the
spine in an overcorrected position.
MGGMORADACU2020
 Structural Scoliosis
Types of Scoliosis Braces
2. Nighttime Braces
2.2. Providence Brace
• applies the same hypercorrective
force on the spine as the Charleston
bending brace, which is only possible
whilst laying down and sleeping at
night.
• the main difference is instead of the
spine's curve bending in the opposite
direction, one shoulder is slightly
elevated to apply lateral and rotational
forces on the curve.
• brace aims to push the curve toward
the midline or even beyond in some
cases.
MGGMORADACU2020
 Structural Scoliosis: Halo Traction
Therapeutic Management
2. Halo Traction.
• is the use of opposing forces to
straighten and reduce spinal curves
that are severe when first diagnosed
(over 80 degrees)
• is achieved using a ring of metal (a
halo) held in place with about four
stainless steel pins inserted into the
skull bones
• Countertraction is applied by pins
inserted into the distal femurs or iliac
crests
• apparatus is bulky and looks
frightening.

MGGMORADACU2020
 Structural Scoliosis: Halo Traction
Therapeutic Management
2. Halo Traction (cont)
• used for children with severe scoliosis
(experience respiratory involvement, cervical
instability, a high thoracic deformity, or
decreased vital capacity from severe spinal
curvature and rotation)
Nursing Care:
 let children see photographs of the
apparatus or talk to children who have the
apparatus in place before having it applied.
 give time to express their feelings about
being placed in such a cumbersome
device.
 provide orientation for the parents as it is
for the child.
 During the 1st week, parents are unsure
about how to care for their child, give
support to parent during this time.. MGGMORADACU2020
Structural Scoliosis: Halo Traction
Therapeutic Management
2. Halo Traction (cont)
Nursing Care (cont):
 Halo traction is prescribed for about 3
months’ time.
 Careful explanations about the child’s
care before it is given helps to reduce
anxiety.
 For the 1st 24 hours after application,
children experience a nagging level of
pain at pin insertion sites, give analgesia.
 Provide hair care to keep the pin sites
clean.
 Daily Pin care to avoid crusting around
sites (halfstrength hydrogen peroxide or
another appropriate solution)
 After optimal spinal correction, pins are
removed and skull heal within 1 week
without obvious scarring. MGGMORADACU2020
 Structural Scoliosis: Surgery
Therapeutic Management
3. Surgical Intervention:
Spinal Instrumentation.
• necessary if the spinal curvature is
greater than 40 degrees.
• Instruments, such as rods, screws, and
wires, are placed next to the spinal
column to provide firm reduction of the
curvature; the spine is then fused in the
corrected position.
• Bone from the iliac crests may be used
to strengthen the fusion procedure
• Newer procedures involve fusionless
interventions such as malleablerods,
intervertebral stapling, and a vertical
expandable prosthetic titanium rib

MGGMORADACU2020
 Structural Scoliosis: Surgery
Therapeutic Management
3. Surgical Intervention: Spinal Instrumentation.
Preoperative Nursing Care.
• extensive radiographs are taken to plan the exact location of the rods or staples.
• Introduce children to the postoperative deep-breathing exercises and incentive
spirometry they will need to perform.
• ensure that children have a good explanation of what they can expect after surgery.
• explain that pain is expected, feel tired and “not themselves” for several days (
Teaching will helps them adjust to the postoperative period, and they appreciate
being treated like adults.
• epidural anesthesia offers a great deal of pain relief (IV or epidural patient-
controlled analgesia system offers both pain relief and a feeling of control).
Harrington rods were the first such rods manufactured, so the surgery is frequently
referred to as Harrington rod placement, although newer types of rods are now more
commonly used.
Luque rods and Wisconsin for segmental approach and Cotrel-Dubousset rods also are
commonly used.
 Structural Scoliosis: Surgery
Therapeutic Management
3. Surgical Intervention: Spinal Instrumentation.
Postoperative Care.
• Head must not be raised, back must not be bent.
• Tape the latch of the bed in place or unplug electric controls so head of the bed
cannot be raised by accident by a parent or by uninformed auxiliary personnel.
• A NGT usually is inserted before surgery to prevent abdominal distention,
• child returns from surgery, the child may need to lie flat and be log-rolled (always by
two people) to a side-lying position every 2 hours to enhance respiratory status
• Check Neurologic dysfunction, Perform neurovascular assessment of lower-extremity
function every hour for the first 24 hours by assessing lower extremities for warmth,
whether the child can feel you touch a foot, and wiggle the toes.
• Assess and record vital signs carefully. (WOF shock and hypotension)
• A drainage system (Hemovac), may be inserted next to the incision to evacuate any
accumulating drainage.
• NPO until bowel sounds return (usually 12 to 24 hours)
• Indwelling urinary catheter is usually left in place for 24 hours,
• After 48 hours, Teach passive and active ROM exercises
• Encourage independence in ADL’s MGGMORADACU2020
 MUSCULOSKELETAL DISORDERS
4. DISORDERS OF THE
JOINTS AND
TENDONS:
COLLAGEN-
VASCULAR DISEASE
• Juvenile Arthritis
(JA)***

MGGMORADACU2020
 Juvenile Arthritis (JA)
• involves the joints of the body, although it
also affects blood vessels and other
connective tissues
• symptoms begin before 16 years of age and
last longer than 3 months.
• The peak incidence occurs at two times in
childhood: 1 to 3 years and 8 to 12 years.

CAUSE:
• unknown,
• probably an autoimmune process
(immunoglobulins) against body cells.
• revealed by the presence of antinuclear
antibodies (ANA). A genetic predisposition
may increase the risk in some children.

MGGMORADACU2020
Juvenile Arthritis (JA)

MGGMORADACU2020
 Juvenile Arthritis (JA)
Therapeutic Management
• therapy includes a :
 Balanced program of exercise, rest,
 Heat Application.
 Splinting.
 Nutrition.
 Medication administration to relieve pain,
restore function, and maintain joint
mobility.

MGGMORADACU2020
Nursing Care
of the Child
with
Musculoskeletal
Disorder- Part 4
Mary Grace Morada Cu, MAN, RN
Clinical Instructor, CNAHS
St. Paul University Manila
MGGMORADACU2020
 MUSCULOSKELETAL DISORDERS
5. DISORDERS OF THE
SKELETAL MUSCLES
• Myasthenia Gravis***
• Dermatomyositis
(autoimmune condition
that causes skin
changes and muscle
weakness)
• Muscular
Dystrophies***

MGGMORADACU2020
 Myasthenia Gravis
• is a neuromuscular disorder that causes
weakness in the skeletal muscles, which are
the muscles your body uses for movement.
• occurs when communication between nerve
cells and muscles becomes impaired
(acetylcholine (ACh))

CAUSES:
• impaired synthesis or storage of ACh,
• insufficient ACh release,
• Inadequate ACh receptors present at motor
end plates,
• opposition of ACh by an ACh factor,
• excessive cholinesterase.
• an autoimmune process (autoantibodies may
block receptor sites for ACh).

MGGMORADACU2020
 Myasthenia Gravis
Assessment:
Three forms in childhood:
1. Neonatal transient myasthenia,
2. Congenital myasthenia,
3. Juvenile myasthenia.

MGGMORADACU2020
 Myasthenia Gravis
Assessment:
Three forms in childhood:
1. Neonatal transient myasthenia,
• the mother has MG and the infant
demonstrates transient disease symptoms at
birth (transfer of antibodies from the mother).
• NB appears “floppy,” sucks poorly, and has
weak respiratory effort.
• Ptosis (drooping eyelids).
• symptoms disappear within 2 to 4 weeks, but
fatal because of respiratory muscle
dysfunction if they are not recognized when
present

MGGMORADACU2020
 Myasthenia Gravis
Assessment:
Three forms in childhood:
2. Congenital myasthenia,
• inherited disorder that results in faulty ACh
transmission or reception.
• Double vision (diplopia).
• Ptosis.
• grow more intense as facial, neck, jaw,
swallowing, and intercostal muscles become
affected.
• Fatigue is extreme
• increase with emotional stress, fatigue,
menstruation, respiratory infections, and
alcohol intake.
• Severe form, all muscles become unable to
contract.

MGGMORADACU2020
 Myasthenia Gravis
Assessment:
Three forms in childhood:
3. Juvenile myasthenia.
• an autoimmune process;
• it occurs most typically at 10 to 13 years of age
• girls more frequently than boys.
• Symptoms same with Congenical Myasthenia
• Thymus hypertrophy (enlargement); this sign
is autoimmune process.

MGGMORADACU2020
 Myasthenia Gravis
Diagnosis:
• accurate history,
• Check for ptosis.
• myography (poor muscle function).
• Chest radiography and computed
tomography (CT) (demonstrate the enlarged
thymus gland).
• Administration of edrophonium (Tensilon),
(prolongs the action of Ach, increases
muscle strength, renews exhausted muscles
in a few minutes. If this occurs, the diagnosis
is positive for myasthenia gravis.)

MGGMORADACU2020
 Myasthenia Gravis
Therapeutic Management:
• administration of neostigmine (Prostigmin) or
pyridostigmine bromide (Mestinon),
acetylcholinesterase inhibitors (prolong the
action ofACh)
• prednisone medication regimen (decrease
the amount of anticholinesterase)
• plasmapheresis to remove immune
complexes from the bloodstream or
administration of IV immunoglobulin (provide
immune suppression for reducing symptoms)
• excision of the thymus gland

MGGMORADACU2020
 Myasthenia Gravis
Health Teaching:
• Teach parents and children that symptoms
become worse under stress, so parents need
to prepare children well for new experiences.
• Help children plan their day to include rest
periods,
• If chewing and swallowing are difficult,
ensure a rest period before meals.
• Children may need to eat a soft diet and
learn to eat slowly and cautiously
• Scheduling medication administration for
about 1 hour before mealtime
• If symptoms of muscle weakness suddenly
become very severe, child should be seen at
a health care facility (loss of function of lead
to respiratory arrest).
• Atropine, an anticholinergic agent and the
antidote for an overdose of
anticholinesterase drugs, should be available
to administer as necessary.
MGGMORADACU2020
 Muscular Dystrophies
• a group of inherited disorders that lead to
progressive degeneration of skeletal
muscles,

CAUSE/S:
• lack of a protein (merosin) that is necessary
for muscle contraction

TYPES:
1. congenital myotonic dystrophy,
2. facioscapulohumeral muscular dystrophy,
3. pseudohypertrophic muscular dystrophy

MGGMORADACU2020
 Muscular Dystrophies
TYPES:
1. Congenital Myotonic Dystrophy,
• is inherited as an autosomal dominant trait.
• infant may already have severe myotonia
(muscle weakness) at birth.
• Muscle degeneration continues until
adequate respiratory muscle movement
becomes difficult.
• Mostly die before 1 year old (cannot sustain
respiratory function).

Diagnosis: serum enzyme analysis and muscle

biopsy.

MGGMORADACU2020
 Muscular Dystrophies
TYPES:
2. Facioscapulohumeral Muscular
Dystrophy,
• is inherited as a dominant trait, carried on
chromosome 4.
• symptoms begin at 10 years old.
• facial weakness is predominant symptom
• unable to wrinkle the forehead and cannot
whistle.
• symptoms usually progress so slowlythat a
normal life span is possible.

Diagnosis: Serum enzyme analysis and muscle

biopsy

MGGMORADACU2020
 Muscular Dystrophies
TYPES:
3. Pseudohypertrophic Muscular Dystrophy
(Duchenne’sDisease).
• Duchenne’s disease, the most common form
of muscular dystrophy, is inherited as a sex-
linked recessive trait.
• occurs only in boys.
• Symptoms at 3 years of age

MGGMORADACU2020
 Muscular Dystrophies
Therapeutic Management:
• Encourage boys to remain ambulatory for as
long as possible.
• plan a program of active and passive daily
range-of-motion exercises.
• Splinting and bracing lower-extremity stability
and avoid contractures.
• Nutrition: a low-calorie, highprotein diet to
avoid excessive weight gain.
• Prevent constipation, high intake of fiber and
fluids.
• assist the child and family with achieving the
optimal level of activity within the child’s
limitations.
• provide support for parents, to assist them
with coping,
• Help children and parents locate a parent
support group such as the Muscular
Dystrophy Association
MGGMORADACU2020
MUSCULOSKELETAL DISORDERS
6. INJURIES OF THE
EXTREMITIES
• Finger Injuries
• Bicycle-Spoke
Injuries
• Fractures****
• Athletic Injuries

MGGMORADACU2020
 Fractures
• is a break in the continuity or structure of
bone.
• any impairment in the bone integrity

CAUSES:
• car accidents,
• falls
• sports injuries.
• Other causes are:
o low bone density
o osteoporosis,

MGGMORADACU2020
General Classification
of Fractures
1. ACCORDING TO EXTENT OF BREAK
1.1. Complete: The entire circumference of the
bone s impaired
1.2. Incomplete: Only partial circumference of the
bone is impaired
General Classification of
Fractures
2. ACCORDING TO EXTENT OF
ASSOCIATED SOFT TISSUE DAMAGE
2.1. Closed/Simple: No break in skin
2.2. Open/Compound: Break in skin with or
without protrusion of bone
2.3. Pathologic (spontaneous): Occurs after
minimal trauma to a bone that has been
weakened by a disease
2.4. Greenstick: One side of the bone is
impaired, the other side is bent; it affects
cartilaginous bones; common in children
 General Classification of
Fractures
3. ACCORDING TO PATTERN
3.1. Transverse: The line of break is across the bone
3.2. Oblique: The line of break goes diagonal along the
bone
3.3. Spiral: The line of break goes around the bone
General Classification of
Fractures
4. ACCORDING TO APPEARANCE
4.1. Comminuted: Bone ends are splintered into 2 or
more small pieces
4.2. Displaced: Fragments are separated from
fracture line
4.3. Impacted: One bone end enters the
intramedullary space of another bone end
4.4. Compression: Fractured bone compressed by
another bone (vertebra)/produced by a force
applied to the long axis of cancellous bone
4.5. Depressed: Bone fragments are pushed below
the normal surface (skull)
4.6. Longitudinal/Linear: Fracture parallel with long
axis
4.7. Fracture dislocation: Fracture is accompanied
by a bone out of joint
4.8. Stress fracture: Results from excessive stress
on the bone
4.9. Buckle (torus) Fracture on the tension side of
the bone near softened metaphyseal bone,
causing a buckling and raised area on the
harder diaphyseal bone (opposite side)
General Classification of
Fractures
5. According to relation to the joint
5.1. Intracapsular: Within the joint
5.2. Extracapsular: Outside the
capsule

6. According to location
6.1. Proximal- break of the upper
part of the bone
6.2. Mid-shaft- break of the middle
part of the bone
6.3. Distal- break of the lower part
of the bone
 STAGES OF BONE HEALING
1. Hematoma formation (24 hours): Blood accumulates into the area between
and around the fragments
2. Cellular proliferation (5 days): Hematoma undergoes organization; fibrin
strand form with the clot creating a network for revascularization and invasion of
fibroblast and osteoblast (beginning of external cartilaginous callus
formation/osteoid tissue)
3. Callus formation (2-3 weeks): Minerals are being deposited in the osteoid
tissue forming a large mass of differentiated tissue bridging the fractured bone
4. Ossification (3-4 months): Mineral deposition continues and produces a firmly
reunited bone
5. Consolidation and remodeling: final stage of fracture repair consists of
removal of any remaining devitalized tissue and reorganization of new bone
 COMPLICATIONS OF
HEALING
Interruption in the sequence of healing
are caused by:
1. Original injury
2. Debridement
3. Loss of bone substance
4. Infection
5. Loss of circulation
6. Improper immobilization
7. Inadequate fixation
8. Necrosis
9. Metabolic disturbance
COMPLICATIONS OF
FRACTURES
1. Hypovolemic shock: This is due to
massive bleeding

2. Pulmonary embolism: Caused by

immobility and precipitated by
fracture
2.1. Restlessness, apprehension;
substernal pain; dyspnea;
diaphoresis; ABG changes
2.2. O2 therapy; anticoagulant therapy
COMPLICATIONS OF
FRACTURES
3. Fat embolism (24-72 hours): This usually
follows fracture of the long bones (lower
extremities/multiple fractures); originating
from bone marrow (fat globules) occluding
the small blood vessels of lungs (respiratory
failure is the most common cause of death in
young adults (20-30 years old) and elderly),
brain, kidneys
3.1. Mental confusion; restlessness due to
hypoxia; tachycardia; tachypnea;
dyspnea; Cough, chest pain; thick white
sputum; petechial rash over the upper
chest and neck; decrease PaO2
3.2. O2 therapy; morphine/corticosteroids;
surgical fixation
 COMPLICATIONS OF
FRACTURES
4. Compartment syndrome: This results
from fractures of arms or legs; pressure
increases within one or more
compartments causing massive
compromise of circulation
4.1. Pain (throbbing); pallor;
pulselessness; paresthesia;
paralysis; cyanosis of nail beds;
cold finger or toes
4.2. Elevate leg above level of heart;
remove restrictive devices
4.3. Fasciotomy; passive ROM every 4-
6 hours; wound closure in 3-5 days
 PATHOPHYSIOLOGY

Fractures, tight dressings, tight cast

Edema of contents of the compartment

Increase pressure within closed compartment

Pain, pallor, pulselessness, paresthesia,

paralysis

Contractures (Volkmann’s)/Functional
disability
COMPLICATIONS OF
FRACTURES
5. Peroneal nerve palsy: It follows
fracture of the leg; results to
footdrop

6. Avascular necrosis: Decreased

bone tissue perfusion leads to
bone tissue death; neck of
femur commonly affected
 COMPLICATIONS OF
FRACTURES
7. Delayed union/nonunion/malunion:
May result from infection
(osteomyelitis), poor circulation,
ineffective immobilization, or poor
health condition; fibrous tissue exists
between bone fragments, no bone salts
have been deposited
7.1. Bone grafting, immobilization and
non-weight bearing
 COMPLICATIONS OF
FRACTURES

8. Osteomyelitis: Infection invades bone

tissue
8.1. Fever (>38°C); pain; erythema in the
area surrounding the fracture;
tachycardia; increased WBC Count
8.2. Aggressive IV antibiotic therapy
 Fractures
• is a break in the continuity or structure of
bone.
• common childhood injuries.

Types of Fractures in Children

• Plastic deformation (bend),
• Buckle (torus),
• Greenstick,
• Complete

MGGMORADACU2020
 Fractures

MGGMORADACU2020
 Fractures
• Fractures in children tend to be different
than in adults because:
Bone in childhood is fairly porous
allowing bones to bend rather than
break.
The periosteum is thick so the bone
may not break all the way through.
 Epiphyseal lines may cushion a blow
so that the bone does not break.
Healing is rapid as a result of overall
increased bone growth.

MGGMORADACU2020
 Nursing Assessment
1. Pain (increasing until
immobilized)

2. Loss of function
3. Localized swelling or
discoloration
4. Deformity
5. Crepitus (grating sound)
6. 5 P’s
 Heat or Cold
Application in Trauma
Cold Application Heat Application
• First 24 hours • After 24 hours
• To decrease • To relieve pain from
hemorrhage muscle spasms
• To relieve pain • To reduce swelling
• To reduce by increasing
inflammation circulation
• To promote healing
by increasing
oxygenation
 Therapeutic Principles and
Modalities
1. Reduction: Realigning bone fragments into anatomical position
1.1. Open: use of surgical methods with internal fixation devices
(screws, plates, pins, nails) to hold the bone fragments in
alignment which provides immediate bone strength; may involve
the removal of damaged bone and replacement with a prosthesis
1.2. Closed: use of non-surgical methods/manipulation

2. Immobilization: Maintenance of reduction until healing is sufficient to

prevent displacement
2.1. Cast
2.2. Traction
2.3. Braces
2.4. External fixation: an external frame is utilized with multiple pins
applied through the bone; provides more freedom of movement
than with traction

3. Rehabilitation: Preservation and restoration of musculoskeletal

function
 Treatment

Reduction

• Repositioning of the
bone fragments into • Application of a
normal alignment device or mechanism
that maintains
alignment until
healing occurs

Retention
 Legal & Ethical implications
when caring for a child with a
fracture?
• All fractures entering the hospital via ER require social
service consult for documentation of suspected abuse or
neglect.

• The nurse must report all suspected abuse to the

appropriate authority.

• Do not discuss the possibility of abuse with the parents

or guardians!! Do not attempt to prove or disprove
abuse.
Nursing Care
of the Child
with
Musculoskeletal
Disorder
Mary Grace Morada Cu, MAN, RN
Clinical Instructor, CNAHS
St. Paul University Manila
MGGMORADACU2020