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MUSCULOSKELETAL CONDITIONS
Dr Sally Lo
sallylows@cuhk.edu.hk
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Learning Outcome
1. Congenital clubfoot
2. Developmental dysplasia of the hip
3. Scoliosis
Club Foot
• Complex deformity of the ankle and foot.
• Involves several bones in hind foot:
❑Tarsals
❑Talus
❑Calcaneus
❑Metatarsals
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Club Foot
• Named according to the anatomy and orientation of the deformity
• For example:
❑Talipes = talus (Latin = ankle bone)
❑Pes (Latin = foot)
❑Cavus/ Adductus/ Varus/ Equinus/ etc.
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Club Foot
• Talipes equinovarus (TEV) is the most common
• Incidence: 1-2/1000 live births, commonly in boys (2:1)
• Etiology is multifactorial:
❑Abnormal positioning and restricted movement in-utero
❑Arrested or abnormal embryonic development
❑Neurological disorders and neural tube defects
❑Environmental factor
❑Genetic factor
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• Nursing assessment
❑Family history of foot deformities
❑Obstetric history for risk factors
❑Physical assessment for presence of other
❑abnormal and classic foot position and ROM
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• Involves 3 stages
1. Correction of deformity
2. Maintenance of the correction
3. Follow up
• Treatment options:
❑French management
❑Ponseti method
❑Surgical treatment
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3. Bracing
❑Ligaments and tendons are stretched with manipulations
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Liu, Y. B., Li, S. J., Zhao, L., Yu, B., & Zhao, D. H. (2018). Timing for Ponseti clubfoot management: does the age
matter? 90 children (131 feet) with a mean follow-up of 5 years. Acta orthopaedica, 89(6), 662-667.
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Anatomy of hip
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• 2 major groups:
❑Typical: occurs in neurotically intact patients or those without
defined syndromes or genetic conditions
❑Teratologic: involves a neuromuscular defect or have identifiable
causes
DDH - Classifications
• Acetabular dysplasia:
❑Mildest form.
❑With subluxation or dislocation.
❑Abnormal morphology and development of the acetabulum.
• Hip subluxation:
❑Largest percentage.
❑Incomplete dislocation of the hip.
• Dislocation:
❑No contact between the articulating surfaces of the hip
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DDH - Classifications
(Perry, 2014)
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• Mechanical factors:
❑Breech presentation
❑Multiple fetuses
❑Any condition that leads to tightened intrauterine space
• Genetic factors:
❑Positive family history for DDH
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DDH - Etiology
• Exact etiology is unknown
• Commonly due to increased laxity of the hip capsule due to a
combination of factors, including:
1. Genetic factors
• 2 heritable features: generalized joint laxity, and shallow
acetabular
2. Hormonal factors
• High levels of maternal estrogen, progesterone, and relaxin may
lead to ligamentous laxity
3. Intrauterine malposition
• Breech presentation with extended legs
• Vertex presentation Intrauterine crowding
4. Postnatal factors
• Swaddles babies
• Carries babies with legs together, hips and knees fully extended
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Neonates:
• Asymptomatic
• Physical findings:
❑Barlow test A. Barlow Test
❑Ortolani test
B. Ortolani Test
Kumari, P., & Rani, M. Developmental Dysplasia of the Hip. Orthopedics and Rheumatology Open Access
Journal (OROAJ), 10(4), 555794. DOI: 10.19080/OROAJ.2018.10.555794
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Walking child:
• Physical findings:
• Limp, waddling gait
• Leg-length discrepancy
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• USG
❑Provides information about the stability of the hip joint Uses to
monitor acetabular development
• X-ray
❑Recommended for infant
• CT scan
❑Assesses the position of the femoral head relative to acetabulum
• MRI
❑Shows soft tissue related to the hip
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> 18 months:
• Treats by open reduction
❑Pelvic osteotomy
❑Femoral shortening osteotomy Varus osteotomy
• Child is immobilized in a spica cast for 6-12 weeks after surgery
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• Cast Care
❑Teaches correct use of the appliance
• e.g., whether remove during bathing, not to adjust the harness
without medical supervision
❑Encourages parents to hold the infant with harness and continue
care and nurturing activities
Scoliosis
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Scoliosis
• Most common spinal deformity
• Involves lateral curvature, spinal rotation and thoracic hypokyphosis
• Complications:
❑> 80∘: restrictive pulmonary disease
❑>100-120∘: reduced life expectancy
• Types:
❑Idiopathic (most common)
❑Congenital
❑Neuromuscular
❑Genetic syndromes
❑Compensatory
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Others: early onset (0-5 years) and late onset (after age of 5 years)
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• Adams test:
• Asymmetry of the ribs and
flank (Smith, Sciubba, & Samdani, 2008)
• Neurologic assessment:
❑Pain
❑Sacral dimple or hairy patches
❑Cutaneous vascular change
❑Absent or abnormal reflexes
❑Bowel or bladder incontinence
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• MRI:
❑Uses when an underlying
cause is suspected or in
abnormal findings
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• Treatment options:
❑Observation
❑Bracing
❑Surgical intervention
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2. Bracing:
• For mild to moderate curvatures (30∘ -
45∘)
• Goal: to prevent progression of deformity
thus ↓ need for surgery
• Not curative and works together with
exercises
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• Goal:
o Correct the curvatures on sagittal and coronal planes
o With maximum mobility of the remaining spinal segments
A. Halo-gravity traction
B. Spinal Surgery
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B. Spinal Surgery
❑Goal: Halts progression and Improves cosmesis.
• Technique:
1. Instrumentation: Applying mechanical implants
2. Fusion: Joining 2 vertebrae by bone graft
• Options:
❑Instrumentation without spinal fusion or with limited fusion
❑Posterior instrumentation with both anterior and posterior fusion
❑Anterior fusion with instrumentation
❑Posterior fusion with instrumentation *most common
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• Preoperative teaching:
❑How to manage PCA, log-roll
• Postoperative care:
❑Wound assessment, circulation, vital signs, neurologic status of
extremities
❑Pain management
❑Skin integrity
❑Family involvement in patient care
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Summary
• Congenital clubfoot (TEV) is the commonest congenital anomaly with
an incidence of one to two per 1000 live births.
❑Ponseti method
References
• Bergerault, F., Fournier, J., & Bonnard, C. (2013). Idiopathic congenital clubfoot: Initial treatment.
Orthopaedics & Traumatology: Surgery & Research, 99(1), S150-S159.
• Horne, J. P., Flannery, R., & Usman, S. (2014). Adolescent idiopathic scoliosis: diagnosis and
management. American family physician, 89(3), 193-198.
• Hinkle, J., & Cheever, K. (2018). Brunner & Suddarth's Textbook of Medical-surgical Nursing.
• Frymoyer, J. W., Wiesel, S. W., An, H. S., Boden, S. D., Lauerman, W. C., Lenke, L. G., McLain, R. F.
(2004). The Adult & Pediatric Spine (3rd ed.). Philadelphia : Lippincott Williams & Wilkins
• Gould, B.E. & Dyer, R. M. (2011). Pathophysiology for the health professionals. (4th ed.). St. Louis:
Saunders.
• LeMone, P., & Burke, K. (2019). LeMone and Burke’s medical-surgical nursing: Critical thinking for person-
centered care (4th ed.). Pearson Education Austral.
• Lewis, S. L., Dirksen, S.R., Heitkemper, M.M., Bucher, L. & Camera, I.M. (2011). Medical -surgical nursing:
assessment and management of clinical problems (8th ed.). St. Louis: Mosby Elsevier.
• Lewis, S. L., Dirken, S.P., Heitkemper, M.M., Bucher, L & Camera, I.M (2011).Study Guide for Medical-
Surgical nursing: Assessment and Management of Clinical Problems (8th ed.). .St. Louis, : Mosby Elsevier.
• Nettina, S. (2019). Lippincott Manual of Nursing Practice (11th ed.). . Philadelphia : Wolters Kluwer
• Perry, Hockenberry, Lowdermilk, Wilson, Wong, Hockenberry, Marilyn J., . . . Wong, Donna L. (2014).
Maternal child nursing care (Fifth ed.). St. Louis, Missouri: Elsevier.
• Robinson, M. J., & Roberton, D. M. (2003). Practical paediatrics. (5th ed.). New York: Churchill Livingstone.
• Sabella, C., & Cunningham III, R. J. (2010). The Cleveland Clinic intensive review of pediatrics (3rd ed.).
Philadelphia, PA : Wolters Kluwer Health/Lippincott William & Wilkins.
• Smith, J. R., Sciubba, D. M., & Samdani, A. F. (2008). Scoliosis: A straightforward approach to diagnosis
and management. Journal of the American Academy of Physician Assistants, 21(11), 40-45
• Staheli, L. (2016). Fundamentals of pediatric orthopedics (Fifth edtion ed.). Philadelphia: Wolters Kluwer.
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