STRUCTURAL DEFORMITIES

SKELETAL LIMB ABNORMALITIES:

• Skeletal limb abnormalities are problems in the bone structure of your arms or legs.
They can affect a part of your limb or the entire limb. Usually, these problems are
present at birth and sometimes babies are born with abnormalities in more than one
limb.
• Certain diseases or injuries can disturb the normal growth of your bone structure and
lead to skeletal abnormalities as well.

Types of skeletal limb abnormalities:

• Congenital abnormalities- A congenital skeletal abnormality is present when you’re
born. The abnormality may mean that one of your limbs is smaller or larger than
normal or that you have more fingers or toes than normal.
• Acquired abnormalities- An acquired abnormality is one that happens after birth.
Such a condition occurs if you were born with normal limbs but experienced a bone
fracture during childhood. The broken bone might grow more slowly than usual,
leading to the affected arm or leg developing abnormally.

Causes:
• Currently, the causes of congenital skeletal limb abnormalities are not fully
understood.
Possible risk factors include:
• Being exposed to viruses, medications, or chemicals before birth
• Tobacco use by the mother while pregnant
• Having other kinds of abnormalities, including omphalocele, a heart defect, or
gastroschisis
• congenital constriction band syndrome, in which bands of amniotic tissue get
tangled in your arms or legs before your birth

• Acquired limb abnormalities can be caused by childhood injury. Some of these

injuries result in slower bone growth. They can also be caused by a number of
diseases that affect your bone structure, including:
✓Rickets, or vitamin D deficiency
✓Marfan syndrome, a connective tissue disorder
✓Down syndrome, a genetic disorder involving extra chromosomes

Diagnosis:
• If the abnormality is present when you’re born, it usually can be diagnosed
immediately with a physical examination.
• An acquired skeletal abnormality requires a fairly extensive examination. This
procedure includes viewing your medical history, taking a physical exam, and
measuring your limbs. X-rays, CT scans, and other types of medical imaging also can
be used to view underlying bone structure and diagnose abnormalities.

Nursing Management:
• Relieve pain.
• Maintain an appropriate degree of therapeutic restriction and mobility. • Constantly
monitor and reduce the risk of neurovascular complications such as compartment
syndrome and VTE.
• Maintain a safe environment.
• Explore the patient’s and family’s understanding of the condition and provide
support and education based on individual needs.
• Coordinate multidisciplinary intervention for psychosocial problems. • Facilitate
rehabilitation

HIP DEFORMITIES

• Developmental dysplasia of the Hip (DDH) also known as a congenital hip

dislocation is a general term used to describe certain abnormalities of the femur, or
the acetabulum, or both, nearly always diagnosed within the first two years of life,
that results in inadequate containment of the femoral head within the acetabulum,
resulting in an increased risk for joint dislocation, dislocatability, or inadequate joint
development. In the joint, the articulating bones are displaced which leads to
separation of the joint surfaces.

There are two types of dislocation:

• Typical and Teratological. It occurs in approximately 1 in 1000 live births. The
dislocation is more common in girls and the left hip is more affected than the right.
There is also a chance that the dislocation is bilateral.

Characteristics/ Clinical presentation:

• A hip is unstable when the femoral head is able to move within (subluxated) or
outside (dislocated) the confines of the acetabulum.
• Hip dysplasia will occur during the development of the hip. This means prenatal,
during infancy and childhood. In this case the femoral head will be dislocated
upwards and laterally from the acetabulum. This is because femoral head is not
reduced into the depth of the socket. The femoral neck will be anteverted and the
ossific centre for the roof of the acetabulum will develop late. Because of this process
the surrounding muscles become contracted and there will be a limited abduction of
the hip.

Treatments for Hip Dysplasia:

• People with hip dysplasia don’t always need surgery. If the condition is diagnosed
early (in the prenatal period or during infancy) it can often be treated effectively with
bracing. A mild hip dysplasia may not require any treatment, but may need to be
monitored as the child grows. In such cases, complications may never arise or they
may arise only once the child becomes an adolescent or young adult.
• For more serious cases, hip dysplasia in a skeletally immature child can be treated
with a variety different surgical procedures of the pelvis and acetabulum. In a
skeletally mature teenager or young adult, a procedure called periacetabular
osteotomy (PAO) is done. In a PAO, portions of the pelvis are cut in order to
reposition the acetabulum so that it gives better coverage to the femoral head. This
surgery has great potential to prevent or delay hip arthritis, especially if it is
performed prior to irreversible cartilage injury, such as a torn labrum.

SPINAL DEFORMITIES
• Spinal deformity refers to a group of conditions in which the spinal column bends
abnormally either to the right or to the left. It is commonly associated with a
forwardbending posture and increased hunching of the upper back. It is a deviation in
the alignment of the spinal column of more than 10 degrees when viewed from the
front, or a loss in normal curvature when viewed from the side. It can have a major
impact on quality of life.

Types of Spinal Deformities:

1) Scoliosis- It is a sideways curvature of the spine that occurs most often during the
growth spurt just before puberty. While scoliosis can be caused by conditions such as
cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown. About
3% of adolescents have scoliosis.
Symptoms of Scoliosis:
• Uneven shoulders
• One shoulder blade that appears more prominent than the other
• Uneven waist
• One hip higher than the other Causes of Scoliosis
• Neuromuscular conditions, such as cerebral palsy or muscular dystrophy
• Birth defects affecting the development of the bones of the spine • Injuries to or
infections of the spine

2) Kyphosis - Kyphosis is an exaggerated, forward rounding of the back. It can occur

at any age but is most common in older women.

• Symptoms:
Mild kyphosis may produce no noticeable signs or symptoms. But some people
experience back pain and stiffness in addition to an abnormally curved spine.

3) Lordosis- is the natural curve of the lower back (lumbar) area of the spine. With an
extreme curve, the lower spine will have a deep curve, causing the abdomen (stomach
area) to stick out and causing the pelvis (hip areas) to curve back and up. These
extreme curves can be brought on from bad posture, family genetics (passed from
father or mother), injury, illnesses of the spine, or surgery to the spine.

Nursing Management:
• Observe and monitor the spinal curvatures of the patient specially young children.
• Instruct to take oral medications or vitamin supplements with the Doctors order.
• Assist patient using good body mechanics

I N F E C T I O U S M U S C U LO S K E L ETA L D I S O R DE R S

OSTEOMYELITIS
- Is an infection and inflammation of the bone or the bone marrow. Bones can become
infected when an infection in one part of the body may spread through the
bloodstream into the bone or an open fracture or surgery may expose the bone to the
infection.

Causes:
• It is most often caused by a staph bacteria called Staphylococcus aureus in older
children and Streptococcus pyogenes in younger children.
• Around 80% of cases developed because of an open wound.
• Certain chronic conditions like diabetes may also increase your risk for
osteomyelitis.

Pathophysiology:
• Osteomyelitis tends to occlude to local blood vessels which causes bone necrosis
and local spread of infection. Infection may expand through the bone cortex and
spread under the periosteum with formation if subcutaneous abscesses that may drain
spontaneously through the skin.
• In vertebral osteomyelitis, paravertebral or epidural abscess can develop.
• If treatment of acute osteomyelitis is only partially successful, low-grade chronic
osteomyelitis can be developed.

Signs and Symptoms:

• Pain which can be severe and swelling, redness and tenderness in the affected area
• Irritability, lethargy or fatigue
• Fever, chills and sweating
• Drainage from an open wound near the infection site or through the skin • Other
symptoms may include swelling of the ankles, feet, legs and changes in walking
pattern

TREATMENT:
• A course of antibiotics or antifungal medicine is normally effective. For adults, this
is usually a 4-6 week course of intravenous or sometimes oral, antibiotics or
antifungal.
• Some patients need treatment in hospital, while others may receive injections as an
outpatient or at home if they can manage to inject themselves.
• Possible side effects from antibiotics include diarrhea, vomiting and nausea.
Sometimes there may be an allergic reaction to some patients.

• Some of the surgeries that can treat chronic osteomyelitis includes: 1. Draining- The
area around the infected bone may need opening up for the surgeon to drain any pus
or fluid that has built up in response to the infection.

2. Debridement- The surgeon removes as much diseased bone as possible and takes a
small margin of healthy bone to ensure that all the infected areas are removed. Any
surroundings tissue with signs of infection may also need removing.

3. Restoring blood flow to the bone- Any empty space left by debridement may have
to be filled with a piece of bone tissue or skin or muscle from another part of the
body. Temporary fillers can be used until the patient is healthy enough for a bone or
tissue graft. The graft helps the body repair damaged blood vessels and it will form
new bone.

4. Removal of foreign objects- If necessary, foreign objects placed during previous

surgery may be removed such as surgical plates or screws.

5. Stabilizing the affected bone. Metal plates, rods, or screws may be inserted into the
bone to stabilize the affected bone and the new graft.

Nursing Management:
1. Protect the affected extremity from further injury and pain by supporting the limb
above and below the affected area.
2. Prepare the client for possible surgical treatment such as debridement, bone
grafting or amputation if necessary.
3. Administer prescribed medications, which may include opioid and nonopioid
analgesics and antibiotics
4. Promote healing and tissue growth
5. Provide local treatments as prescribed (e.g warm saline soaks, wet to dry dressing)
6. Provide a diet high in protein and vitamins C and D.

SEPTIC ARTHRITIS
- Septic arthritis(also known infectious arthritis) is an infection in the joint (synovial)
fluid and joint tissues. It occurs more often in children than in adults. The infection
usually reaches the joints through the bloodstream. In some cases, joints may become
infected due to an injection, surgery, or injury and it can cause septic shock , which
can be fatal.
- when an infection, such as a skin infection or urinary tract infection, spreads through
your bloodstream to a joint. Less commonly, a puncture wound, drug injection, or
surgery in or near a joint can give the germs entry into the joint space

signs and symptoms:

▪ Fever
▪ Mono arthritis

The most common type of bacteria that causes septic arthritis is called Staphylococcus
aureus. It is also known as S. aureus. The bacteria can enter the body in a number of
ways, such as:
• A broken bone that goes through the skin (open fracture)
An infection that spreads from another place on the body, such as the skin or genitals
• An infected wound
• Foreign object that goes through the skin
• Injury that breaks the skin

2 ways to manage the Septic Arthritis

• Surgical
• Antibiotics
Septic arthritis treatments include using a combination of powerful antibiotics as well
as draining the infected synovial fluid from the joint. It's likely that antibiotics will be
administered immediately to avoid the spread of the infection. Intravenous (IV)
antibiotics are given, usually requiring admission to the hospital for initial treatment.
The treatment, however, may be continued on an outpatient basis at home with the
assistance of a home health nursing service.

Initially, empiric antibiotics are chosen to cover a wide range of infections. If the
bacteria can be identified, antibiotics specific to that organism are used. It may take
four to six weeks of treatment with antibiotics to ensure complete eradication of the
infectious agents.

Surgical Management:
• Joint drainage. Removing the infected joint fluid is crucial. Drainage methods
include:
• Needle Aspiration. In some cases, your doctor can withdraw the infected fluid with a
needle inserted into the joint space.
• Scope procedure or Arthroscopic drainage. A flexible tube with a video camera at its
tip is placed in your joint through a small incision. Suction and drainage tubes are
then inserted through small incisions around your joint.
• Open surgery. Some joints, such as the hip, are more difficult to drain with a needle
or arthroscopy, so an open surgical procedure might be necessary

Pathophysiology:
• The highly vascularized joint synovium lacks a limiting basement membrane so is
prone to infection via hematogenous seeding from systemic infection. Septic arthritis
may also result from direct injury, puncture wounds, and intra-articular injections.
Contiguous spread from adjacent osteomyelitis may occur. The hip and shoulder are
vulnerable to contiguous spread. Septic arthritis occurs when there is a bacterial
invasion of the synovium and joint space followed by an inflammatory process.
Inflammatory cytokines and proteases mediate joint destruction. Other factors which
play a role in joint damage are bacterial toxins (based on animal models) and
microbial surface components like staphylococcal adhesins which promote the
binding of the bacteria to intraarticular proteins.

Nursing management:
• Rest your painful joint as directed.You may need to keep the joint still when it is
painful to prevent more damage.
• Elevate the joint to reduce swelling and pain. Keep the joint above the level of your
heart as often as possible.
• Apply ice to the joint to reduce swelling and pain. Ice may also help prevent tissue
damage. Use a cold compress, or put crushed ice in a bag. Cover it with a towel and
apply it to your joint for 15 to 20 minutes every hour, or as directed.
• Exercise as directed. Exercise may help keep your joints flexible and reduce pain.
Ask your healthcare provider how much exercise to get each day and which exercises
are best for you.

JUVENILE RHEUMATOID ARTHRITIS

• A type of arthritis that causes joint inflammation and stiffness for more than six
weeks in a child aged 16 or younger.Any joint can be affected, and inflammation may
limit the mobility of affected joints.
• An autoimmune disorder, which means that the body mistakenly identifies some of
its own cells and tissues as foreign

Diagnosis of juvenile idiopathic arthritis can be difficult because joint pain can be
caused by many different types of problems. No single test can confirm a diagnosis,
but tests can help rule out some other conditions that produce similar signs and
symptoms.

▪ Blood tests:
Erythrocyte sedimentation rate (ESR).The sedimentation rate is the speed at which
your red blood cells settle to the bottom of a tube of blood.

C-reactive protein. This blood test also measures levels of general inflammation in the
body but on a different scale than the ESR.
Antinuclear antibody. Antinuclear antibodies are proteins commonly produced by the
immune systems of people with certain autoimmune diseases, including arthritis.

Rheumatoid factor. This antibody is occasionally found in the blood of children who
have juvenile idiopathic arthritis and may mean there's a higher risk of damage from
arthritis.

Cyclic citrullinated peptide (CCP). Like the rheumatoid factor, the CCP is another
antibody that may be found in the blood of children with juvenile idiopathic arthritis
and may indicate a higher risk of damage.

• Imaging scans X-rays or magnetic resonance imaging may be taken to exclude other
conditions, such as fractures, tumors, infection or congenital defects.

Medications:
The medications used to help children with juvenile idiopathic arthritis are chosen to
decrease pain, improve function and minimize potential joint damage.
• Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as
ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve), reduce pain and
swelling. Side effects include stomach upset and, much less often, kidney and liver
problems.
• Disease-modifying antirheumatic drugs (DMARDs). Doctors use these medications
when NSAIDs alone fail to relieve symptoms of joint pain and swelling or if there is a
high risk of damage in the future.
• Biologic agents. These medications can help reduce systemic inflammation and
prevent joint damage.

Corticosteroids. Medications such as prednisone may be used to control symptoms

until another medication takes effect. They are also used to treat inflammation when it
is not in the joints, such as inflammation of the sac around the heart.

Nursing Management:
• Exercise. Exercise preserves joint range of motion and muscular strength, and it
protects joint integrity by providing better shock absorption; types of exercises that
may be advised include a muscle-strengthening program, rangeof-motion activity,
stretching of deformities, and endurance and recreational exercises.

• Synovectomy. Synovectomy is rarely needed, and long-term outcome is poor;

however, it may be used in children in whom a single joint or just a few joints are
involved and who have very active, proliferative synovitis.

• Osteotomy and arthrodesis. Osteotomy and arthrodesis are salvage procedures for
patients whose JIA is associated with severe joint destruction or deformity.

• Total hip and knee replacements. Total hip and knee replacements provide excellent
relief of pain and restore function in a functionally disabled child with debilitating
disease.

Brace Application:
1. Putting the brace on properly is important so it will be comfortable and do its job.
In almost all cases, your child will need help putting it on.
2. As you and your child are standing, put the brace around your child and tighten the
neck ring.
3. Hold the front metal upright with both hands and lift the brace toward your child's
head.
4. As you do this, tighten the strap on the pelvic piece as snuggly as possible; be
careful not to twist the pelvic piece around your child's midsection.
5. Finally, fasten the pads as marked.

Cast
• Cast are used to treat a wide range of musculoskeletal disorders, from fractures in
the extremities to correction of congenital structural bone disorders
The purposes of a cast are:
• To immobilize a body part in a specific position
• To apply uniform pressure on encased soft tissue
• To immobilize a reduced fracture
• To apply uniform pressure to underlying soft tissue, or  to correct a deformity
• To support and stabilize weakened joints

Management of Undried Cast:

• While damp (wet), the cast can be dented. Therefore,
• It must be handled with the palms of the hand and
• Not allowed to rest on hard surfaces or sharp edges
• should not be covered with clothing or bed linens • and should be exposed to
circulating air to dry
• Cast dents may press on the skin causing irritation and skin breakdown. • A dry
plaster cast is white and shiny, resonant, odorless, and firm
• A wet plaster cast appears dull and gray, sounds dull on percussion, feels damp, and
smells musty.

Management:
• To relieve the pressure, the cast must be bivalved (cut in half longitudinally) while
maintaining alignment, and the extremity must be elevated no higher than heart level.
• If pressure is not relieved and circulation is not restored, a fasciotomy may be
necessary to relieve the pressure within the muscle compartment. • The nurse records
neurovascular responses and promptly reports changes to the physician.
To inspect the pressure area, the physician may bivalve the cast or cut an opening
(window) in the cast.
• If the physician elects to create a window to inspect the pressure site, a portion of
the cast is cut out.
• The portion of the cast is replaced and held in place by an elastic compression
dressing or tape
• This prevents the underlying tissue from swelling through the window and creating
pressure areas around its margins.
• Disuse Syndrome While in a cast, the patient needs to learn to tense or contract
muscles (eg, isometric muscle contraction) without moving the part. This helps to
reduce muscle atrophy and maintain muscle strength.
• The nurse teaches the patient with a leg cast to ―push down‖ the knee and teaches
the patient in an arm cast to ―make a fist.
• Muscle-setting exercises (e.g., quadriceps-setting and gluteal setting exercises) are
important in maintaining muscles essential for walking. • Isometric exercises should
be performed hourly while the patient is awake.

• Traction - is used to reduce dislocations and immobilized fractures, involves pulling

on a body part in one direction against a counter pull exerted in the opposite direction.
Traction is the application of a pulling force to a part of the body.

PRINCIPLES OF EFFECTIVE TRACTION:

1. Whenever traction is applied, counter-traction (forces in opposite direction) must
be used to achieve effective traction.
2. Traction must be continuous to be effective in reducing and immobilizing fractures.
3. Skeletal traction is never interrupted.
4. Weights are not removed unless intermittent traction is prescribed. 5. Any factor
that might reduce the effective pull or alter its resultant line of pull must be
eliminated.

Nursing Interventions:
• Regularly assess sensation and motion.
• Monitor and prevent skin breakdown
• Immediately investigate any complaint of burning sensation under the traction
bandage or boot.
• Promptly report altered sensation or motor function.
Circulatory Assessment consists of the following:
▪ Peripheral pulses, color, capillary refill, and temperature of the fingers or toes
▪ Indicators of DVT, including calf tenderness, and swelling
▪ Maintaining effective traction
▪ Preventing skin break down
▪ Maintaining positioning
▪ Monitoring neurovascular status
▪ Promoting pin site care
▪ Promoting exercise (iso-metric excersice for immobilized parts)

Amputation or Surgery
• Amputation is the removal of a body part, usually an extremity.
• Amputation of a lower extremity is often made necessary by progressive peripheral
vascular disease (often a sequela of diabetes mellitus), fulminating gas gangrene,
trauma (crushing injuries, burns, frostbite, and electrical burns), congenital
deformities, chronic osteomyelitis, or malignant tumor. Of all these causes, peripheral
vascular disease accounts for most amputations of lower extremities. Amputation is
used to: Improve function, and relieve symptoms Save or improve the patient’s
quality of life

Complications of Amputation:
Complications that may occur with amputation include:
a. Hemorrhage
b. infection
c. skin breakdown
d. phantom limb pain, and
e. joint contracture
Medical Management:
• The objective of treatment is to achieve healing of the amputation wound, the result
being a non tender residual limb (stump) with healthy skin for prosthesis use.
• Healing is enhanced by gentle handling of the residual limb, control of residual limb
edema through rigid or soft compression dressings, and use of aseptic technique in
wound care to avoid infection
• A closed rigid cast dressing is frequently used to provide uniform, to support soft
tissues, to control pain, and to prevent joint contractures. Immediately after surgery, a
sterilized residual limb sock is applied to the residual limb.
• Felt pads are placed over pressure-sensitive areas.
• The residual limb is wrapped with elastic plaster-of- paris (POP) bandages while
firm, even pressure is maintained.
• Care is taken not to constrict circulation.
• A removable rigid dressing may be placed over a soft dressing to control edema, to
prevent joint flexion contracture, and to protect the residual limb from unintentional
trauma during transfer activities.
• This rigid dressing is removed several days after surgery for wound inspection and
is then replaced to control edema.
• The dressing facilitates residual limb shaping
• A soft dressing with or without compression may be used if there is significant
wound drainage and frequent inspection of the residual limb (stump) is desired.
• An immobilizing splint may be incorporated in the dressing.
• Stump (wound) hematomas are controlled with wound drainage devices to minimize
infect.
• Rehabilitation: Because the amputation is the result of an injury, the patient needs
psychological support in accepting the sudden change in body image and in dealing
with the stresses of hospitalization, long-term rehabilitation, and modification of
lifestyle. • Patients who undergo amputation need support as they grieve the loss, and
they need time to work through their feelings about their permanent loss and change
in body image.