Musculoskeletal Disease in Children

Skeletal Function
F- Framework

L- Lever
I - It produces RBC
P- Protection
S- Stores Calcium &
Phosphorus
 STRAIN & SPRAIN
• STRAIN
– Injury to tendon and
muscle
– overstretching
• SPRAIN
– Injury to the
ligaments
– Twisting
 STRAIN & SPRAIN

• ASSESSMENT
– PAIN = principal complaint
– (+) swelling
 STRAIN & SPRAIN

• THERAPEUTIC MANAGEMENT
R - Rest
I - Ice (24-48
hours) C - Compression
E - Elevate
 TRACTION

• Act of pulling and drawing which is associated with

counter traction
• Purpose:
P - Prevent & correct deformity R
- Reduce pain & muscle spasm
I - Immobility
S - Support affected extremities
M - Maintain body alignment
 TRACTION

• Types:
–S - Skeletal
–M - Manual
Skin
–S -
• Principles
– A - Avoid friction
– B - Both have counter
– C - Continuous traction
– D - During pulling; must be align with
the deformity
 TRACTION
• Maintain efficiency of traction
A - Always be sure that rope is
running along the pulley
B - Bags should be hanging
freely
C - Check for the wear &
tear
D - D’ knots must be away
from the pulley
• Nursing care
– Watch out for:
TRACTION
• Pneumonia
• Bedsore/ decubitus ulcer

• Joints contractures/ muscle atrophy

• Constipation
• Infection
– Hygiene
– Comfort
– Exercise
– Divert activities
– Diet
 CAST

• Immobilize a bone that has been injured

• Types of Cast
– Plaster of Paris

– Fiber Glass Cast

 CAST
• Nursing Management
– Distraction and comfort
– Cleanliness inside the cast
– Don’t write or put small objects
– Check for compartment syndrome
– Support with pillow- elevate
– Move gently
– Check for foul odor/ itch
– Air dry
– “wet spot” = window
– Palm; no finger in mold
– Electric cast saw
– Encircle the drainage
 FRACTURE

• Break in the continuity of the

bone
• Trauma, twisting, muscle spasm
• Not common in pedia (child
abuse)
 FRACTURE

• Assessment
– Pain
– Loss of function
– Deformity
– Erythema
– Edema
– Muscle spasm
– Impaired sensation
 FRACTURE
• 4 Rs of treatment
– Recognition
– Reduction- restore proper alignment
– Retention
– Rehabilitation
 FRACTURE
• Common site
– Clavicle
– Humerus
– Radius & Ulna
– Femur
• Causes
– Results of trauma
– Motor vehicle accidents
– Falls
– Child abuse
 FRACTURE
• FRACTURE common in
children
– Bend fracture
• Bending bone
• Don’t straighten
without
intervention
– Buckle fracture
• Result from compression failure
of the bone
– Greenstick fracture
• Incomplete fracture
 FRACTURE
• Diagnostic Evaluation
– X-ray is most useful diagnostic tool
• Assessment of Fractures (5 Ps)
– PAIN and point of tenderness
– PULSE – distal to the fracture site
– PALLOR
– PARESTHESIA – sensation distal to the fracture site
– PARALYSIS – movement distal to the fracture site
 FRACTURE
Stages of Bone healing
I. Hematoma II. Cellular III. Callus IV. Ossification V.
formation proliferation formation Consolidation
&
remodeling
Impact – 1st 24 After 24 hours 6 – 21 days 3 – 10 weeks After 9 months
hours to 3 days
•Fracture •Blood supply •Bridging •Callus form •Bone marrow
•Bleeding increases fracture ends into bones restore
•Hematoma •Cell •Union stage •Fracture line
form & clots proliferat is visible to x-
•Osteoblastic e ray
activity
 FRACTURE
• Bone healing
– Neonate (2 to 3 weeks)
– Early childhood (4 weeks)
– Late childhood (6-8 weeks)
– Adolescence (8-12 weeks)

– Thicken periosteum & generous blood supply

• Apply cold to injured area
• Limitation of complication
• Control of pain, hemorrhage & edema
 FRACTURE
• Nursing Management
– Immobilize
– Cover with sterile gauze (open)
– Elevate part
– Prevent complications
• Compartment syndrome
• Infection
• Renal calculi
• Fat metabolism (72 hours after fracture)
• Congenital malformation of the lower
extremities
• Boys
• Unilateral/ bilateral
• Defect are rigid and cannot be
manipulated into a neutral
position
• Long term follow up is required until the
child reaches skeletal maturity
• Categorie
s
– Positional
• Stretchi
ng,
casting,
exercise

– Teratolog
ic/
syndromi
c
• Common foot

malformation:
– TALIPES
VARUS
• Inversion or
bending
inward
– TALIPES
EQUINO-
VALGUS
• Eversion or
bending
• Goal: functional foot

• Therapeutic Management
– Correction of deformity
– Maintenance of correction
– Observation
• Treatment
– Begins soon after birth
– Series of manipulation & casting are
performed weekly (2 weeks)
– If not corrected in 3 months; surgery is
indicated (postero-medial soft tissue
release)
– Splintage can be continued after surgery
with Dennis Browne splints
• Treatment
– Dennis Browne Shoes
• Dilwyn Evans’ bone operation-recurrent clubfoot
• Monitor for pain
• Monitor neurovascular status of the toes
• Instruct parents in cast care & signs of
neurovascular impairment
 LIMB DEFORMITIES

• Types of Limb Deformities

– Amelia
• Absence of entire extremity
– Meromelia
• Partial absence of extremity
– Phocomelia
• Deficiency of long bones
with relatively good
development of hands and
feet attached at or near
shoulder or hip (“seal
limbs”)
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Condition in which the head of the femur

is seated improperly in the acetabulum,
or hip socket of the pelvis
• Females
• Range from mild to
severely
dislocated
• Can be congenital
or can
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Causes:
– Unknown
– Family
history
– Intrauterine
position
– Delivery
type
– Joint laxity
– Post natal
positionin
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Degree
– DYSPLASIA
• Mildest form
• Delay acetabular
development
– SUBLUXATION
• Largest percentage
• Incomplete dislocation; femoral head remains
partially in contact with the acetabulum
– DISLOCATION
• Severe form
• Femoral head losses contact with the acetabulum
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Clinical
manifestations
– Asymmetry of
thigh
– Unequal knee
height
– Limitation of hip
abduction
– (+) trendelenburg
sign
– “Clunk” sound
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Treatment
– Initiated before 2 months
– By 6 months – Ortolani (-)

• Goal
– Maintain hip joint so that femoral head and
acetabulum can develop properly
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Interventio
n
– <6 months
• Splinting the hip with PAVLIK
HARNESS to maintain flexion
& abduction & external
rotation
• Not curative
– 6 months to 2 years old
• Close reduction – Spica cast
(12 weeks)
– 2 years old
• Open surgical reduction
 DEVELOPMENTAL DYSPLASIA OF THE HIP

• Following surgery
– Position & immobilization in spica cast until
healing is achieved, then abduction splint
– Don’t double or triple diaper
– Put undershirt
– Diaper under straps
– Feed football/ supine (when in cast)
– Look for location of marking in harness
when adjusting
– Place baby on back when asleep =
• Lateral curvature of the
spine
• Surgical & non-surgical
intervention are used
• Treatment depends on
age, degree of
curvature, & amount of
growth that is
anticipated
• Long term monitoring
• Causes
– Congenital infantile
– Paralytic
– Idiopathic/ adolescent
• Assessment
– Visible curve fail to strengthen
when child bends forward &
hang arms toward feet
– Asymmetry – hips, shoulder,
ribs
– Leg length discrepancy
• 4 Common types of curves:
– Thoracic
• 90% on R side
– Lumbar
• 70% on L side
– Thoracolumba
r
• 80% on R side
– Double major
• Curve that
occur left to
• Not all
curvature of
spine is
Scoliosis
– <10 degrees =
postural variation
– 25-50 degrees =
bracing
– >45 degrees
= surgical
• Intervention
– Monitor curvature
– Prepare use of braces/ surgery
BRACES
• Worn 16-23 hours/ day
• Inspect skin breakdown
• Keep skin clean & dry
• Inconvenient
• 15-16 years old cessation of bracing
• Not curative; compliance
SURGERY (Rods are left in spine throughout life)
• May return to school after 1 month
• 5-7 day = discharge
• After 2 days = ROM, log roll, elevate head
• Diet
• Intervention
– Physiotherapy
• Gives more emphasis on
posture
• Strengthening the muscles
• Correction of muscle in balance
• Condition in which bacteria invade the
joint space (hip)
• <10 years old (3-7 y/o)
• Bacteria access
– Direct puncture/ wound infection
– Seeding from distal infection site
– Compression of joint capsule from adjacent
osteomyelitis
• Causative agents:
– Staphylococcus Aureus
– Haemophyllus Influenza type
B
– Streptococci (most common)
• Goal:
– Prevent destruction of the joint cartilage and
maintain function, motion and strength
• Treatment
– Joint aspiration or orthrotomy followed by
IV antibiotics
– Oral antibiotics
• Assessment
– Fever to moderate severe pain
– Refusal to bear weight
– Limited range of motion
– Affected joint is warm and swelling
• Management
– Assess signs of infection
– Resolution of fever
– Analgesics
– Codeine or morphine
– Antibiotics
– Assistive devices
• Systemic, chronic disorder of
connective tissue, resulting from an
autoimmune reaction
• Characterized by inflammation of
the joint
• Results in eventual joint
destruction
• Affected by stress, climate, and
genetics
• More common in girls; peak ages
2-5 and 9-12 years
• Etiology: unknown
• Types
– Mono/ pauciarticular JRA (50%)
• Fewer than 4 joints involved (usually
in legs)
• Asymmetric in distribution; rarely
systemic
• Often large-weight bearing
joints
• Generally mild signs of arthritis
• Symptoms may decrease as child
enters adulthood
• Prognosis good
• Types
– Polyarticular JRA (35%)
• Multiple joints affected (5 or more)
• Both large & small joints
• Symmetrical symptoms of arthritis, disability
may be mild to severe
• Involvement of temporo-mandibular joint
may cause earaches
• S/S: chronic pain, swelling of
joints, long
term arthritis, wax and wane
• Characterized by periods of remissions and
exacerbations
• Prognosis poorer
• Treatment symptomatic for arthritis: PT,
ROM
exercises, aspirin
• Types
– Systemic disease with
polyarthritis (Still’s disease) –
20%
• Explosive course with remissions
and exacerbations lasting for
months
• Begins with fever, salmon-pink
macular rash, lymphadenopathy,
anorexia, and weight loss
• Systemic symptoms: arthritis,
hepatosplenomegaly,
leukocytosis and polyserositis
• Episodic remission of systemic
symptom in 1 year
• Diagnostic criteria
– Age of onset under 16 years
– Arthritis in one or more joint
– Duration >6 weeks
– Exclusion of other causes
• Goal
– To restore function, relieve pain, and
maintain joint motion
• Treatment
– NSAIDs
– ROM and muscle strength exercises
– Methotrexate
– Antipyrimidine medications