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Musculoskeletal

CHAPTER 31

Pediatric Differences
Ossification nearly complete at birth Posterior fontanel closes 2-3 months of age Anterior fontanel closes approx. 18-24 months of age Most skull growth by 2 years of age Long bones of children porous and less dense than adults Muscles increase in length and circumference, not in number  Until puberty, ligaments & tendons are stronger than bone  Cartilage replaced by bone & skeletal maturation by approximately 20 years of age
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Who am I?

Immobilized Child  Once thought to be restorative for patients with illness and injury  We now know that immobilization has serious consequences  Especially on growth & development of the child Inactivity leads to decrease in functional capacity of the entire body  Can delay age appropriate milestones  Decreased muscle mass & strength  Decreased metabolism  Decreased bone mineralization  .

During immobilization INCREASED calcium leaves the bone causing osteopenia (demineralization)  Negative calcium balance .Immobilization  Muscular system  Decreased muscle strength and endurance  Disuse atrophy  Loss of joint mobility  Skeletal system  Bone demineralization Daily stresses on bone by motion & weight bearing maintain balance between bone formation (osteoblastic activity) and bone resorption (osteoclastic activity).

Immobilization psychologically  Movement is critical : immobility deprives child of natural outlet for feelings  Physical growth and development depend on movement  instrument of communication. expression and learning  Respond to anxiety with increased activity .

Not Happy! .

Traumatic Injury  Soft Tissue Injury  Muscles  Ligaments  Tendons Sports injuries Mishaps during play .

pain disability  Crush injuries .Contusions  Damage to soft tissue. subcutaneous tissue and muscle  Escape of blood into tissue-ecchymosis-black and blue  Swelling.

Contusions .

Dislocations  Occur when force of stress on ligament is sufficient to Pain increased with active or passive movement of extremity May be an obvious deformity & inability to move joint Most common type : Phalanges  elbow  displace normal position of opposing bone ends or bone ends to socket     Hip dislocation: (< 5 yrs old) potential loss of blood supply to head of femur  Shoulder dislocation: (adolescents) sports related   Reduce ASAP Unreduced dislocations: increased swelling. increased risk neurovascular problems . reduction is difficult.

Dislocations .

tendons.Sprains  Trauma to a joint from ligament partially or completely torn or stretched by force  May have associated damage to blood vessels. muscles. and nerves  Presence of joint laxity is indicator of severity  Rapid onset of diffuse swelling with disability .

Strains  Microscopic tear to musculotendinous unit  Similar to sprain  Swollen. painful to touch  Generally incurred over time .

Soft Tissue Injury  Therapeutic  Management RICES and ICES  Rest the injured part  Ice immediately (max 30 min at a time)  Compression with elastic bandages  Elevation of extremity  Immobilize and support  Crutches (proper size and height) .

Soft Tissue Injury treatment .

motorcycle sports Patterns of fractures. skateboards. especially under 10 years. problems of diagnosis& methods of treatment are different in pediatrics than in adult population . ATV’s.Fractures  Common injury in children (rare in infants. except with a     MVA) Clavicle the most frequently broken bone. (Neonates if they are too large for moms small pelvis) School aged: bicycle/vehicle or skate board injuries Adolescents: bicycles.

Epiphyseal(physeal) Injuries  Weakest point of long bones: cartilage growth plate (epiphyseal plate)  Frequent site of damage during trauma  May affect future bone growth  Treatment may include ORIF to prevent growth disturbances .

Epiphyseal plate .

Types of Fractures  Simple or closed (no break in the skin)  Compound or open: fractured bone protrudes through the skin  Complicated: bone fragments have damaged other organs or tissue (lung or bladder)  Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue (rare in children) .

Types of fractures in children
 Bend: Bone is bent but not

broken  Buckle or torus: Compression of porous bone, bulging projection at fracture site (more common in young children)  Greenstick: compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture  Complete: divides the bone fragments

severe muscular rigidity.Clinical Manifestations of Fractures  Generalized swelling  Pain or tenderness  Deformity  Diminished functional use  May have bruising. crepitus .

Bone healing and remodeling  Typically rapid healing in children (femoral shaft)     Neonatal period:2-3 weeks Early childhood:4 weeks Later childhood: 6-8 weeks Adolescence: 8-12 weeks .

Remember….. .

Fractures  Diagnostic evaluation: x-ray is most useful tool  Therapeutic management goals  Nursing considerations   Nurses make initial evaluation (calm quiet voice) Calm the child and the parent to better assess  Good history of what occurred to see if abuse is possible  Spiral fx in young child may indicate abuse  Multidisciplinary team to further assess .

Assess Extent of Fractures The 5 P’s  Pain and point of     tenderness Pulse distal to fracture site Pallor: capillary refill Paresthesia: sensation distal to fracture site Paralysis: movement distal to the fracture site .

Neurovascular Assessment  PULSES  COLOR  MOVEMENT AND SENSATION  TEMPERATURE  SWELLING  PAIN .

Outline area to monitor  Educate parent on time to dry of plaster cast  S/S that cast too tight  If cast too loose  Home environment  Car seats  Protecting the cast transparent dressing or diaper  .The Child in a Cast  Cast application techniques Plaster of paris: drying  fiberglass  Nursing Care management  First few hours after application: Elevate extremity  assess sizing and monitor for degree of swelling  Assess for “hot spots”  Casts of open fracture has “window” over wound for assessment  First few hours after surgical reduction (casted as closed fracture) bleeding may soak through the cast.

Nursing Considerations  Swelling may continue thus cast becomes a tourniquet. circulation diminished. neurovascular complications  Elevate extremity  If swelling is severe: casts are bivalved  Permanent tissue damage can occur within 6 to 8 hrs COMPARTMENT SYNDROME .

Compartment Syndrome
 Pain

 Swelling
 Discoloration  Decreased pulses

 Decreased temperature
 Inability to move distal exposed part  CALL PHYSICIAN IMMEDIETLY

Compartment Syndrome

Casting

Child in Traction  Traction: Extended pulling force  Purposes:  Fatigue muscle involved and reduce muscle spasm so bones can be realigned  Position distal and proximal bone ends in desired alignment  Immobilize until healing has taken place to permit casting or splinting  Help prevent or improve contracture deformity  Promote immobilization  Reduce muscle spasms .

Traction: Essential Components  Traction: Forward force  Attaching weight to distal bone fragment  Counter traction: backward force  Body weight provides this ( for free)  Frictional force: provided by patients contact with the bed .

Types of Traction  Manual Traction: applied by the hand distal to fracture site  Skin Traction: Directly to skin surface and indirectly to skeletal structures  Skeletal traction: directly to skeletal structure with a pin (ouch) .

Skeletal Traction Pins .

 Dunlop traction: Lower arm is flexed and suspended vertically with traction. while upper arm maintains longitudinal direction and pull .Types of Traction  Upper Extremity Traction: Humerus  Overhead suspension: arm bent at elbow and suspended vertically & traction applied to distal end of the humerus.

Lower Extremity Traction  Bryant: running traction. pull in 1 direction  Buck’s Extension: legs in an extended position  Russell Traction: skin traction with a padded sling  90-90 traction: most common skeletal traction  Steinmann pin or Kirschner wire distal in femur at 90 angle both at hip and knee  Balance suspension traction with Thomas splint .

Types of Traction .

Cervical Traction  Halo Brace (vest) attached to head with 4 screws in outer skull: bars connected to vest> greater mobility of rest of the body .

Gardner-Wells) burr holes in the skull & weights attached to the head .Cervical Traction  Crutchfield tongs (Barton.

Nursing Care Management          Know the reason WHY traction is applied Assess patient  Assess pulses bilaterally  Alteration in sensation or increased pain  Assess any change in color of skin or nail bed  Skin breakdown/ massage pressure areas to stimulate circulation  Position changes  Wash and dry skin daily  Any neurovascular changes: record and call MD Assess traction apparatus  Check line of pull/ weights  Bandages in place/ excessive tightness  Do not remove unless under supervision of physician Diet  Balanced diet with fruits and vegetables (fiber)  calcium Encouraging fluids Offering laxatives Encourage deep breathing and Incentive Spirometry Prevent foot drop Encourage socialization/ discourage isolation .

Nursing Care Management  Pain management: increased initially as traction pull is fatiguing the muscle   Analgesics Muscle relaxants  Pin care: according to hospital policy or physician order   Frequently assessed and cleaned to prevent infection After first 48 to 72 hours assessment needed less frequently .

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delivery type. family history.Developmental Dysplasia of Hip DDH  Spectrum of disorders describing abnormal development of hip that can occur    Infancy childhood Fetal life  Cause unknown  Gender. positioning. birth order. joint laxity & post natal positioning .

Developmental Dysplasia of Hip DDH  Diagnostic Evaluation   Not detected at initial exam after birth Most often found in pediatrician office for well baby check up  Exhibits as hip joint laxity and NOT out right dislocation     Shortening of the limb on affected side Asymmetric thigh and gluteal fold Broadening of the perineum Ortolani and Barlow tests most reliable from birth to 3 months   Barlow: thighs are adducted Ortolani: abducting the thighs to test for hip subluxation or dislocation .

DDH .

Ortolani Test limited hip abduction in flexion .

Barlow Test thighs adducted .

Signs of DDH asymmetry of gluteal and thigh folds .

Therapeutic Management  Treatment initiated as soon as recognized  GOAL: obtain and maintain a safe and congruent position of hip joint to promote normal development  Early intervention more favorable in restoration of normal bony architecture and function. .

Therapeutic Management  Newborn to 6 months     Pavlik Harnace Hip joint in dynamic splint Proximal femur centered in acetabulum Worn continuously until proven stable on exam and with x-ray .

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Therapeutic Management  Ages 6 to 18 months  Gradual reduction by traction for 3 weeks  Closed reduction of hip under general anesthesia If not successful then open reduction Then placed in hip spica cast for 2 to 4 months Once hip is stable a flexion abduction brace is applied .

Hip Spica cast .

Therapeutic Management  Older Child  Increasingly difficult after age 4  Impossible or inadvisable > 6 yrs Contractures of muscles  Deformity of femoral and acetabular structures    Correction is challenging as most likely is secondary to arthritis or CP Operative reduction with or without presurgical traction Contracted muscles  Osteotomy procedures  .

Nursing Management  Nurses can detect DDH on initial assessment  Ambulatory child who displays limp or unusual gate is referred  Primary Nursing Goal: Teaching Parent  WHY DEVICE BEING USED!!   Application of device Maintenance of device Keep in mind rapid growth of the infant/child (check straps)/check for rubbing/ red marks .

Nursing Management  Normalcy is the goal  Involve the child in all activities of any other child in same age group  Maintain active role in family and activities .

Congenital Clubfoot  Deformity of ankle and foot which includes adduction  Midfoot supination  Hindfoot varus  Ankle equinus  Most common talipes equinovarus  Foot is pointed downward and inward in varying degrees  forefoot .

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Congenital Clubfoot  Cause unknown  Some attribute to abnormal positioning and restricted movement in utero  Arrested or abnormal embryonic development  Increased risk of hip dysplasia .

Congenital Clubfoot  Classification  Positional: intrauterine crowding  Responds to simple stretching and casting  Syndromic (teratologic): associated with other congenital anomalies More severe form/ often resistant to tx  Surgical intervention may or may not be effective   Congenital/idiopathic: can occur in otherwise normal child  Always requires surgical intervention because there is a bony abnormality .

Diagnostic Evaluation  Detectable prenatally through U/S  Noted at birth .

plantigrade and stable foot  Serial casting before discharge  Successive casts encourage gradual stretching and accommodate rapid growth  Maximum correction achieved within 8 to 12 weeks  If no positive result after 3 months= surgical intervention  Three stages    Correction of deformity Maintenance of correction until normal muscle balance is regained Follow up observation to prevent possible recurrence .Therapeutic Management  Goal: achieve a painless.

Ponseti .

Nursing Care Management  Casted child:  observation of skin and circulation  Rapid growth  Educate the parent Signs of skin breakdown Signs new cast needed Help the child to live as normally as possible .

Metatarsus Adductus (Varus)  Most common congenital foot deformity  Result of abnormal intrauterine positioning  Type I: foot flexible and corrects easily  Type II: partial flexibility in forefoot  Type III: foot rigid and will not stretch .

Treatment Type I & II Often times corrected with gentle manipulation    Passive stretching of foot Parent teaching performed Continue for 6 weeks Type III Serial manipulation and casting .

Nursing Management  Teaching the parent hold heal firmly and to stretch ONLY the forefoot  Cast teaching Signs of skin breakdown Signs new cast needed Help the child to live as normally as possible  .

Skeletal Limb Deficiency  Underdevelopment of skeletal elements of extremities  Can range from minor defects (missing digit) to serious abnormalities    Amelia: loss of entire extremity Meromelia: partial absence of an extremity Phocomelia: seal limbs  Most are primary defects of development of limb  Prenatal destruction can occur due to constriction of amniotic band .

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Meromelia partial absence of extremity .

Skeletal Limb Deficiency  Therapeutic Management  Prosthetic devices  Applied at earliest possible stage  Nursing Care Management  Teaching parent about prosthetic application  Occupational therapist  Encourage parent to assist the child in making age appropriate advancements  Do not OVERPROTECT child .

Calve-Perthes Disease  Self limiting disorder with     femoral head aseptic necrosis Affects ages 2 to 12 Most commonly in boys ages 4 to 8 Cause unknown Can take place over 18 months or as long as several years .Legg.

Cameron’s Personal Story .

Calve-Perthes Disease  Insidious onset  History may reveal intermittent limp or persistent ache or stiffness  Diagnosed with x-ray and confirmed with MRI  Revealing osteonecrosis .Legg.

Calve-Perthes Disease  Therapeutic Management  Goal: Keep head of femur in acetabulum  Treatment varies based on:  Age  Appearance of femoral head vasculature and position within acetabulum  Rest and non weight bearing  At times traction applied to stretch tight adductor muscles  Non weight bearing devices:  Abduction brace  Leg casts  Leather harness sling  Surgery in some cases .Legg.

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Legg.Calve-Perthes Disease  Self limiting  Younger children have better prognosis for complete recovery  Epiphysis are more cartilaginous  Children 10 and older have high risk for degenerative arthritis  The later the diagnosis. the more damage to femoral head .

Legg- Calve-Perthes Disease
 Nursing Care Management
 Identify

the affected child and refer  Educate the parent Why device being ordered Management and application of corrective device Signs of skin breakdown Signs that a new size needed Help the child to live as normally as possible

Skeletal deformity
 Kyphosis: increased convex angulation in curvature

of the thoracic spine

Secondary to
TB  Arthritis  Osteodystrophy  Compression fractures of thoracic spine

 Lordosis: accentuation of cervical or lumbar

curvature
Trauma  idiopathic

Idiopathic Scoliosis  Complex spinal deformity in three plains  Lateral curve  Spinal rotation causing rib asymmetry  Thoracic kyphosis  Most common spinal deformity  Classified according to age of onset  Infantile: birth to 3 yrs  Juvenile: develops during childhood  Adolescent: develops during the growth spurt of early adolescents.  Most noticeable during the pre adolescent growth spurt .

Idiopathic Scoliosis diagnostic evaluation  Observation: behind standing child  Symmetry of shoulder height  Scapular or flank shape  Hip height and alignment  As child bends forward at the waist (Adams test) with hanging arms   Assymetry of ribs and flanks may be noted Scoliometer used to measure truncal rotation  Definitive diagnosis made by radiograph of child in standing position .

TLSO (thoracolumbosacral orthosis). Charleston Nighttime Bending Brace  Orthotic intervention (bracing)   Surgical spinal fusion: realignment and straightening with internal fixation and instrumentation combined with bony fusion of the realigned spine.Idiopathic Scoliosis Therapeutic Management  Observation with clinical and radiographic evaluation   Curve < 10 degrees is postural variation Curve < 20 degrees is mild Boston.Milwaukee.   Curve >40 degrees Paralytic and Congenital curves generally -progress . Wilmington.

Idiopathic Scoliosis Nursing Care Management  Treatments extends over years  Childs identity (physical and psychological) is formed in adolescents  Nursing care must take into consideration the adolescents perspective       Positive reinforcement Encouragement Independence Selection of clothing Participation of activities Socialization with peers .

stuffed animal.Idiopathic Scoliosis Nursing Care Management  Preoperative Care  Educate on complexity of surgery Teach patient to manage own PCA  How to Log Roll  Prepare for foley catheter  Possibility of a chest tube  Possibility of NG tube    Have a favorite toy. iPad Meeting with a peer who has undergone similar surgery as well .

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Idiopathic Scoliosis Nursing Care Management  Postoperative care  Monitored in an acute care setting Neurological assessments of extremities critical  Delayed paralysis may develop  Most common post op issues  • • • •  Neurological injury Spinal cord injury Hypotension from blood loss Wound infection  Log rolled Skin care  Risk for pressure ulcers  Pain management .

O.D.  Discharged after 1 week     Adequate urine output Fluid and electrolyte balance ileus Skin integrity  Start PT as soon as patient able  Self care always encouraged  Teaching of family  Body image American Association Orthopedic Surgeons Scoliosis Research Society  Refer family to resources   .Scoliosis  Ambulation begins 2 or 3 P.

Osteomyelitis  Inflammation and infection of bony tissue  May be caused by exogenous reasons ( trauma/ puncture wound/ or surgery)  Or hematogenous sources (pre existing infection/ tonsillitis/ impetigo where the organism travels) .

Osteomyelitis  Exogenous:  infectious agent invades the bone following penetrating wound. abscessed teeth. contamination in surgery or secondary extension from abscess or burn. open fracture. skin infection. causing abscess formation and bone destruction .  Hematogenous:  Existing infection spreads to bone  Sources may be furuncles. URI. pyelonephritis  Any organism can cause osteomyelitis  Infective emboli travel to arteries in bone metaphysis.

Anna .

MRI Bone culture obtained from biopsy or aspirate . Bone scan .Osteomyelitis  Staphylococcus aureus is most common causative      organism Signs and symptoms begin abruptly. resemble symptoms of arthritis and leukemia Marked leukocytosis and elevated Sed rate Early x-ray may appear normal CT.

Osteomyelitis therapeutic management  May have sub-acute presentation with walled off abscess rather than spreading infection  Prompt. hepatic responses to treatment . vigorous IV ABT for extended period (3-4 weeks or up to several months)  Monitor hematologic. renal.

Osteomyelitis Nursing Considerations  Complete bed rest and immobility of limb  Casting at time necessary     Pain management: position and medicate Surgery may be necessary Long term IV access (for ABT administration) Nutritional considerations   Child may have vomiting and poor appetite As infection controlled appetite returns  Long term hospitalization/ Physical Therapy to ensure restoration of optimum functioning  Psychosocial needs  Diversional and constructive activities .

000 children per year in caucasian children 113 per 100.9 per 100.Juvenile Idiopathic Arthritis (juvenile rheumatoid arthritis)  Chronic Autoimmune inflammatory disease causing inflammation of joints and other tissue      Starts before age 16 with peak onset between ages 1 and 3 years Twice as many girls are affected 13.000 children overall Unknown cause Immunogenic susceptibility  Environmental or external trigger such as a virus  .

Pathophysiology of JIA Chronic inflammation of synovium with joint effusion eventual erosion destruction fibrosis of the articular cartilage If inflammatory process continues adhesions between joint surfaces ankylosis of joints .

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JIA .

Clinical Manifestations  Variable and unpredictable   Not life threatening but can cause significant disability 70% of cases eventually becomes inactive  However child may have severe or minimal joint damage by time disease process abates Significant joint deformity and functional disability  Medical evaluations  PT  Possible joint replacements  Chronic or acute uveitis may occur  30% have progressive disease into adulthood  .

Diagnosis  Diagnosis of exclusion  Clinical criteria at age of onset before 16 years  Swelling and pain  Lab tests may or may not provide evidence Sedimentation rate may or may not be elevated  Leukocytosis usually present with acute exacerbation  Antinuclear antibodies common but not specific   Radiology studies  Show soft tissue swelling and joint space widening with increased synovial fluid  Uveitis Inflammation of anterior chamber of the eye  Can be sight threatening  .

Therapeutic Management  Control pain  NSAIDS  Preserve Joint ROM and function  PT: active range of motion  Minimize effects of inflammation/ Joint deformity  NSAIDs/PT/OT  Promote normal growth and development  Pool therapy  Nighttime splinting reduce flexion deformity .

ibuprofen and tolmetin  Take with food  Hydrate  bruising Methotrexate  Second line tx for children who have failed NSAID’s alone  Used in combination with NSAID  CBC and LFT’s Corticosteroids  Potent immunosuppressives  Incapacitating arthritis/ uveitis/life threatening complications Etanercept (TNFI) (Enbrel)  Tumor necrosis factor receptor blocker SAARDS  Slow acting anti rheumatic drugs  Work in combination with NSAIDS  Sulfasalazine  Hydroxychloraquine.Medications      NSAIDS  Naproxen. gold. . D-penicillamine.

Nursing Care Management  Assessment of all aspects of the child  General health  Status of involved joints  Emotional response  Support of the parents  Parental concerns of prognosis  Financial concerns  Spouse and sibling relationships  Job and schedule conflicts  Referral to social worker. counselors and support groups .

Nursing Care Management  Relieve Pain  Provide as much relief as possible   Medications  Opioids avoided Non pharmacologic  Behavior therapy  Relaxation techniques  Promote general health  Well balanced diet with sufficient caloric intake  Sufficient rest  Communication between family/PCP/rheumatology team is critical  Normalcy  Encourage independence!!!  Attending school important  Communicate with school and school nurse .

Nursing Care Management  Educate the patient and family on  Medications     Therapeutic levels r/t schedules Signs and symptoms of toxicity Proper placement and reason for device splints and appliances  available resources  Benefits of heat application  Moist heat  Bathtub  Electric blankets  Exercise • Pools : range of motion  Prevent isolation and foster independence  Encourage child to perform ADL’s independently  Encourage family to pursue normal activities .

tibia pelvis. jaw and phalanges .Osteosarcoma  Most common bone cancer in children  Peak incidence between 10 and 25 years of age  Primary tumor sites in metaphysis of long bones (most likely in lower extremities)   >50% femur Humerus.

Therapeutic Management  Surgery and chemotherapy  Biopsy followed by limb salvage or amputation .

Nursing Care Management  Education for family and child     Salvage vs amputation Prosthesis fitting promotes early functioning Chemotherapy and side effects Anger and depression are normal and expected  Honesty and straightforward answers   Be in the room when physician explains Everyone grieves and learns differently  Phantom limb pain   Sensations such as tingling itching and pain in amputated limb Elavil .

Nursing Care Management  Promote normalcy and resumption of pre amputation activities   Pick clothing that does not draw attention to amputation Body image critical to adolescents .

Ewing Sarcoma  Primitive neuroectodermal tumor  Second most common malignant bone tumor in childhood  Under age 30 majority being between ages 4 and 25  Originates in the shaft of long and trunk bones  Femur tibia fibula humerus ulna vertebrae scapula ribs pelvic bone and skull .

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Therapeutic Management  Intensive irradiation of the bone combined with chemotherapy  Amputation last resort .

Nursing Care Management  Less traumatic for family related to likelihood that no amputation will be necessary  Need education r/t   Diagnostic testing (BMT. peripheral neuropathy and possible cardiotoxicity  Encourage resumption of normal lifestyle and activities . biopsy) Radiation and chemotherapy Intense radiotherapy causes skin reaction  Dry or moist desquamation then hyperpigmentation  Increased sensitivity of area  Child should wear loose fitted clothing over the area to minimize additional skin irritation   Chemotherapy  Hair loss. n/v.

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Systemic Lupus Erythematosus (SLE)  Autoimmune disease of connective tissues and blood vessels  Chronic  Multisystem  Result of genetics as well as a “trigger” Exposure to ultraviolet light  Estrogen/pregnancy  Infections  drugs  .

Multisystem .

SLE  Clinical Manifestations          Malar rash Discoid rash Photosensitivity Oro nasal ulcers Arthritis Serositis Renal disorder Neurological disorders Hematologic disorders .

Therapeutic Management  Balance medications needed to avoid exacerbation and complications  While preventing or minimizing treatment associated morbidity     Corticosteroids Antimalarial: rash and arthritis NSAIDS Immunosuppressive: cyclophosphamide  Nutrition  Sleep  Exercise  Limited exposure to sun & UV light .

Nursing Care Management  Goal: assist family to positively adjust to disease & therapy  Recognize exacerbation  Recognize complications of medications  Discuss with health care provider  Body Image Problems  Rash/hair loss/ steroid therapy  Support Groups  Lupus Foundation of America  Arthritis Foundation  Teaching  Regular medical supervision  Seek attention QUICKLY during illness or prior to elective surgical procedures  Avoid sun and AVB exposure   Wear sunscreen and sun resistant clothing Limiting outdoor activities .