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THE CHILD WITH

MUSCULOSKELETAL
ALTERATIONS
SOFT TISSUE INJURY
Includes injuries to muscles, ligaments, and tendons
Sports injuries
Mishaps during play
Contusion (bruise) is damage to soft tissue, subcutaneous
tissue, and muscle
Escape of blood into tissues (ecchymosis) causing black
and blue discoloration
Immediate treatment with cold application
Return to participation when strength and range of motion
(ROM) is equal on both side and demonstrated in
activity/sport specific tests
CONTUSION
(https://www.coreconcepts.com.sg/wp-content/uploads/2010/08/bruise-source-webshots.jpg)
DISLOCATIONS
Occur when force of stress on a ligament is sufficient to
displace the normal position of opposing bone ends or bone
ends to socket
Pain is the predominant symptom
Increases with active or passive movement of the affected
extremity
Common injury is nursemaids elbow(pulled elbow)
Subluxation or partial dislocation of the radial head
Hip dislocation: Potential loss of blood supply to the head of the
femur
SPRAINS/STRAINS
Sprains
Trauma to a joint from a ligament partially or completely torn or
stretched by force
May have associated damage to blood vessels, muscles, tendons,
and nerves
Presence of joint laxity as an indicator of severity
Rapid onset of swelling with disability
Strains
Microscopic tears to a musculotendinous unit
Similar to a sprain
Swollen and painful to the touch
Generally incurred over time
NURSING CARE of SOFT TISSUE INJURY
Rest, ice, compression, and elevation (RICE) and ICES
Rest the injured part
Ice immediately (maximum 30 minutes at a time)
Wet elastic bandage for compression
Elevation of the extremity
Immobilization and support (casts or splints as appropriate to
the injury)
Crutches (depending upon injury)
FRACTURES
Common injury in children
Methods of treatment are different in pediatric population than
in the older adult population
Rare in infants (motor vehicle crashes and falls from heights)
Most common fracture is of the distal forearm (radius, ulna, or
both)
Clavicle is also a common fracture in childhood (<10 years old)
In school-age children, playground, bicycle and sports injuries
Clinical manifestations: generalized swelling, pain or
tenderness, deformity, diminished use of limb or digit. Possibly:
bruising, muscular rigidity, crepitus
MOST COMMON FRACTURES IN CHILDREN
Plastic deformation: bone is bent but not broken; most common
in the ulna and fibula and often associated with fractures of the
radius and tibia
Buckle: produced by compression of porous bone; appears as a
raised or protruding projection at the fracture site; more
common in young children
Greenstick: occurs when bone is angulated beyond the limits of
bending; incomplete fracture on the opposite side of the bend
Complete: divides bones into fragments that often remain
attached by a periosteal hinge, which can hinder reduction
GROWTH PLATE INJURIES
FRACTURES
Diagnosed with x-ray
Treatment is usually casting, but can include surgery
Bone healing is typically rapid in children
In neonatal period, 2 to 3 weeks
In early childhood, 4 weeks
In later childhood, 6 to 8 weeks
In adolescence, 8 to 12 weeks
FRACTURED FEMUR
CALLUS FORMATION
EVALUATION OF COMPARTMENT
SYNDROME
Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Pressure
CASTING
Immobilizes to promote healing
Completeness of fracture, type of bone involved, and the
amount of weight bearing influence how much of the extremity
must be included in the cast
Two types of casting material:
Plaster
Synthetic
Cast removal
TYPES OF CASTS
NURSING CARE
Pain management
Evaluate for compartment syndrome
Educate
Nothing put into the cast
Circulation checks
Keeping cast dry
Medication administration
Follow up visits
TRACTION
Traction: Extended pulling force may be used
To provide rest for an extremity
To position for bone healing
To immobilize a fracture until healing is sufficient to permit casting or splinting
To help prevent or improve contracture deformity
To provide immobilization
To reduce muscle spasms (rare in children)
Traction: Forward force produced by attaching weight to a distal
bone fragment
Adjust by adding or subtracting weights
Countertraction: Backward force provided by body weight
Increase by elevating the foot of the bed
Frictional force: Provided by patients contact with the bed
TRACTION
TYPES OF TRACTION
Manual traction is applied to a body part by the hand placed
distally to the fracture site
Skin traction involves pulling mechanisms that are attached to
the skin with adhesive material or an elastic bandage
Skeletal traction is applied directly to the skeletal structure by a
pin, wire, or tongs inserted into or through the diameter of the
bone distal to the fracture
BUCK EXTENSION TRACTION
HALO VEST
ILIZAROV EXTERNAL FIXATOR
NURSING CARE
Assessing the patient in traction
Skin care issues
Pain management and comfort
DEVELOPMENTAL DYSPLASIA OF THE
HIP (DDH)
Formerly called congenital hip dysplasia or congenital
dislocation of the hip
Girls > boys
Family history increases risk
DDH is categorized in two major groups
Idiopathic
Infant neurologically intact
Teratologic (occur in utero and less common)
Neuromuscular defect
DEVELOPMENTAL DYSPLASIA OF THE
HIP (DDH)
3 Types of DDH
Acetabular dysplasia (preluxation)
Mildest form; osseous hypoplasia of the acetabular roof
Femoral head remains in the acetabulum
Subluxation (incomplete dislocation of the hip)
Dislocation (femoral head loses contact with the acetabulum and is
displaced posteriorly and superiorly; ligaments are elongated and
taut)
DEVELOPMENTAL DYSPLASIA OF THE
HIP (DDH)
THERAPEUTIC MANAGEMENT

Importance of early intervention


Newborn to age 6 months: Pavlik harness for abduction of the
hip
Age 6 to 24 months: Dislocation is unrecognized until the child
begins to stand and walk; use traction and cast immobilization
(spica)
Older child: Operative reduction, tenotomy, osteotomy; difficult
after 4 years
CLINICAL MANIFESTATIONS
Infant
Shortened limb on the affected side
Restricted abduction of hip on the affected side
Unequal gluteal folds when the infant is prone
Positive Ortolani test
Positive Barlow test
Older children
Affected leg is shorter than the unaffected leg
Telescoping or piston mobility of the joint
Trendelenburg sign
Greater trochanter is prominent and appears above the line from the
anterosuperior iliac spine to the tuberosity of the ischium
Marked lordosis if bilateral dislocations
Waddling gait if bilateral dislocations
SIGNS OF DDH
SIGNS OF DDH
(https://www.hss.edu/images/articles/dev-hip-dysplasia-6.jpg)
PAVLIK HARNESS
HIP SPICA CAST

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NURSING CARE
Pavlik harness
Maintaining reduction
Teaching the parents
Providing skin care
Cast care with older children
CLUB FOOT
Talipes equinus is plantarflexion with the toes lower
than the heel
Boys twice as much as girls
50% of cases are bilateral
Precise cause is unknown
Complex deformity of ankle and foot that includes
forefoot adduction, midfoot supination, hindfoot varus,
and ankle equinus
The foot is pointed downward (plantar flexed) and inward
in varying degrees
BILATERAL CONGENITAL TALIPES
EQUINOVARUS
CLASSIFICATION OF CLUB FOOT
Transitional, mild, or postural
Due to intrauterine crowding
May correct spontaneously or require passive exercise or serial
casting
Syndromic or Teratologic
Associated with other congenital anomalies
Usually requires surgical correction and has a high incidence of
recurrence
Congenital, idiopathic or true clubfoot
Bony abnormality almost always requiring surgical intervention
PONSETI SANDAL
(http://www.ormedes.com/rivenditori/images/ponseti%20imm.%20copertina.png)
NURSING CARE
Cast care
Educate parents
Cast care
Brace care
Importance for follow up visits
Post operative care if surgical correction
OSTEOGENSIS IMPERFECTA (OI)
A group of heterogeneous inherited disorders of connective tissue
A rare genetic disorder characterized by bones that fracture easily
Defective periosteal bone formation and reduced cortical thickness
of bone
Classifications based on clinical features and patterns of
inheritance:
Type I (most common and mildest)
Type II (most severe and lethal in infancy)
Type III
Type IV
Type V
Type VI
Type VII and VIII
TYPE I
Type A: Mild bone fragility, blue sclera, normal teeth, hearing
loss
Type B: Same as A except with abnormal dentition
Type C: Same as B but no bone fragility
Two thirds of all cases are type I
TYPE II
Lethal; infant is stillborn or dies in early infancy
Severe bone fragility with multiple fractures at birth
Autosomal recessive inheritance
TYPE III

Severe bone fragility leads to severe progressive deformities


Normal sclera, marked growth failure
Most cases have autosomal recessive inheritance, but some
have autosomal dominant inheritance
TYPE IV
Type A: Mild to moderate bone fragility, normal sclera, normal
teeth, short stature, variable deformity, autosomal dominant
Type B: Same as A except abnormal dentition (dentinogenesis
imperfecta)
Approximately 6% of OI cases are type IVB
BLUE SCLERA
THERAPEUTIC MANAGEMENT
Primarily supportive care
Rehabilitation is directed toward preventing
Contractures and deformities
Muscle weakness and osteoporosis
Malalignment of lower extremity joints
Bisphosponate therapy with IV Pamidronate to increase bone
density and prevent fracture
May rule out OI if multiple fractures occur
Nursing care management
Caution with handling to prevent fractures
Family education
Occupational planning and genetic counseling
ATTICUS SHAFFER
LEGG-CALVE-PERTHES DISEASE
Self-limiting, idiopathic, occurs in juveniles age 2 to 12 years,
more common in males age 4 to 8 years
Males 4 times more likely than females
Caucasian 10 times more likely than African American
Avascular necrosis of the femoral head
In 10% of cases have bilateral hip involvement
Most have delayed bone age
Pathophysiology: Cause is unknown but involves disturbed
circulation to the femoral head with ischemic aseptic necrosis
After resolving may have normal femoral head or may have
severe alteration
LEGG-CALVE-PERTHES DISEASE
Insidious onset; may have a history of a limp, soreness or
stiffness, or limited range of motion; vague history of trauma
Pain and limp are most evident on arising and at the end of a
long day of activity
Diagnosed by x-ray
Treatment goal is to keep the head of the femur in the
acetabulum
Containment with various appliances and devices
Rest; no weight bearing initially
Surgery in some cases
Home traction in some cases
LEGG-CALVE-PERTHES DISEASE
Prognosis
Self-limiting disease
Outcome depends on early and efficient treatment and age
of the child at the onset of the disorder
5 years have best prognosis
> 8 years have significant risk for degenerative arthritis
Nursing care management
Identification of affected children and referral
Teaching care and management
Compliance issues with the child and family
LEGG-CALVE-PERTHES DISEASE
LEGG-CALVE-PERTHES DISEASE
(http://www.radiologytutorials.com/getimage.cgi?i=bilder/2/302-1&r=1400)
SLIPPED CAPITAL FEMORAL EPIPHYSIS
Spontaneous displacement of the proximal femoral epiphysis in
a posterior and inferior direction
Most frequently develops shortly before or during accelerated
growth and onset of puberty (8-15 years)
Most frequently seen in boys and obese children
Clinical manifestations:
Limp on affected side
Inability to bear weight because of severe pain
Pain in hip, groin, knee, or thigh
Affected leg is externally rotated
Loss of hip flexion, abduction and internal rotation as severity
increases
Shortening of affected leg
SLIPPED CAPITAL FEMORAL EPIPHYSIS
Diagnosed with x-ray in an anteroposterior (AP) and then in a
frog-leg position
Treatment:
Placing child non-weight bearing to prevent further slippage
and allow for physeal closure
Surgery within 24 hours of diagnosis
Nursing care is the same as child in cast, traction, or post
operative care
SLIPPED CAPITAL FEMORAL EPIPHYSIS
(http://www.raymondliumd.com/Conditions_Slipped_Capital_Femoral_Epiphysis.html)
SPINAL COLUMN DEFECTS
SCOLOSIS
Most common spinal deformity
Complex spinal deformity in three planes
Lateral curvature
Spinal rotation causing rib asymmetry
Thoracic hypokyphosis
May be congenital or develop during childhood
Multiple potential causes; most cases are idiopathic
Generally becomes noticeable after the preadolescent growth spurt
May have complaints of ill-fitting clothes
Scoliosis screening either in school, providers office, or nurses
clinic
Screen girls at age 10 to 12 years and boys at age 13 to 14 years
DIAGNOSIS OF SCOLOSIS
Standing radiographs to determine the degree of curvature
Adams forward bending test
Risser scale (evaluates skeletal maturity on x-ray)
Asymmetry of shoulder height, scapular or flank shape, or hip
height
Often have a primary curve and a compensatory curve to align
the head with the gluteal cleft
THERAPEUTIC MANANGEMENT
Team approach to treatment
Bracing
Exercise
Surgical intervention for severe curvature (instrumentation and
fusion)
Harrington rods
L-rods
SCOLOSIS BRACING
NURSING CARE
Concerns of body image
Concerns of social isolation
Concerns of prolonged treatment of condition
Preoperative care
Postoperative care
Family issues
OSTEOMYELITIS
Inflammation and infection of bony tissue
Most frequently seen in children 10 years with a
median age of 5-6 years
Most commonly affects the foot, femur, tibia, and
pelvis
Staphylococcus aureus is the most common
causative organism
Acute hematogenous osteomyelitis results when a
bloodbourne bacterium causes an infection in a
bone
OSTEOMYELITIS
Exogenous osteomyelitis is acquired from direct inoculation of
the bone from a puncture wound, open fracture, surgical
contamination, or adjacent tissue infection
Signs and symptoms begin abruptly and include pain, warmth,
tenderness, decrease ROM of limb, fever, irritability, lethargy
Marked leukocytosis, elevated erythrocyte sedimentation rate
(ESR) and elevated C-reactive protein (CRP)
Bone cultures are obtained from biopsy or aspirate
Early x-rays may appear normal
Bone scans for diagnosis
THERAPEUTIC MANAGEMENT
May have subacute presentation with a walled-off abscess
rather than spreading infection
Prompt, vigorous intravenous (IV) antibiotics for an extended
period (3 to 4 weeks or up to several months)
Nafcillin or clindamycin (Staphylococcus aureus)
Vancomycin with MRSA (methicillin-resistant S. aureus)
Monitor hematologic, renal, hepatic responses to treatment
NURSING CARE
Complete bed rest and immobility of the limb
Pain management concerns
Long-term IV access (for antibiotic administration)
Nutritional considerations
Long-term hospitalization and therapy
Psychosocial needs
SEPTIC ARTHRITIS
Bacterial infection in the joint
Usually results from extension of soft tissue infection (cellulitis)
or osteomyelitis
Most common causative agent is Staphylococcus aureus
May involve any joint but is most common in the hip, knee,
ankle, or elbow
Usually involves only one joint
Joint is warm, tender, painful, and swollen
Fever, malaise, headache, nausea, vomiting, leukocytosis, and
increased ESR or CRP
SEPTIC ARTHRITIS
Diagnosis is made from blood culture, joint fluid aspirate, and
MRI and CT scan
Treatment goals
Prevent destruction of the joint cartilage
Decompress the joint to maintain circulation to the epiphysis
Eradicate the infection
Prevent secondary bone infection or hematogenous spread
IV antibiotic therapy based on gram stain results and clinical
presentation