MUSCULOSKELETAL DISORDERS

Presented by Marlene Meador RN, MSN,

CNE

Newborn Musculoskeletal System

Flexibility – prevents injuryLong bones – porousEpiphyseal plates – cartilaginousMuscular system – complete at birth

Clubfoot: Talipes EquinovarusAdduction and supination of forefoot with an

inversion (varus) of the heel and fixed plantar flexion and the midfoot directs downward (equinus).

Clinical Manifestations

Focus on early detectionAssessment

Diagnostic tests

TreatmentPonseti method - Serial manipulation with

corrective casting

Dennis Browne splints - horizontal bar attached to foot plates

Surgical correction

Nursing Care & EvaluationProvide Emotional Support

Promote bondingCast CareReferrals

Regular check-upsPrognosisROM after removal of casts

Clinical Judgment:An infant has a cast applied for treatment of club foot.

Which of the following symptoms requires immediate attention and should be reported to the health care provider?

A. Capillary refill of 4 seconds in the affected toes. B. Edema in the affected toes that improves with elevation. C. Numbness of the toes on the affected foot. D. Skin distal to the cast is warm

Developmental Dysplasiaof the Hip

Malrotation of the hip at birthImproper formation or function of

acetabulum

Clinical Manifestations

InfantGluteal folds+ Ortolani’ s - Barlow’s Maneuver

ChildrenLimited ROMShort femurGait

Diagnostic Tests:UltrasoundCT and MRIX-ray

Treatment: Splinting of hip - Pavlik

harnessHip maintained in flexion

and abductionDeepens acetabulum

from pressure of femur head

Treatment cont’d.Skin Traction

Relocates femoral head while stretching restrictive soft tissue

Surgical Treatment & Spica Cast: Release muscles and tendonsApplication of body spica cast

Promoting Developmental Needs

BondingEnvironment

Activity

?????A parent asks why her infant must wear a Pavlik

harness. The nurse responds that the purpose of this device is to:

A. provide comfort and support.B. shorten the limb on the affected side.C. maintain the femur within the acetabulum .D. provide outward displacement of the

femoral head.

Cast Care & AssessmentUse palms to handle wet castElevate extremity & change position Keep cast clean & dryPetal castBar between the legs is not a handle!Assess CMS (circulation, movement,

sensory); bleeding, temperature, skin integrity.

Complications Associated with Casts

Compromise to circulation and innervation

Compartment SyndromeParathesiaPainPressurePallor **Paralysis **Pulselessness **

Nursing Management for the Casted Child

Encourage cuddlingTeach parent application of harnessDevelopmental needs

Bring environment to childProtect skinDietSafety

?????An 18 month old is scheduled for application of a

plaster cast to correct a clubfoot. The post-op plan should include which of the following measures?a. Elevate the cast above the level of the heartb. Handle cast with fingertipsc. Reposition the child every 2 hoursd. Spray the cast with an acrylic protectant

Fractures Occur as a result of direct force

Greenstick fracture MVA

Repeated stress on the bone

Pathologic conditions

Patho-physiologyEpiphyseal platePliable and porousHealing is Rapid in children

Approximately 1 week for every year of life up to 10 years of age

AssessmentPain TendernessEdemaLimited movementDistortion of limb

TreatmentCasting

Traction

Surgical intervention

Complications associated with orthopedic trauma:

Fat EmbolismParticles of fat are carried through circulation and lodge in

lung capillaries causing:Pulmonary edemaRespiratory distress with hypoxemia and respiratory

acidosisTreatment

Increase in IV fluidsRespiratory support and adequate oxygenation

Legal & Ethical implications when caring for a child with a fracture:

All fractures entering the hospital via ER require social service consult for documentation of suspected abuse or neglect.

The nurse must report all suspected abuse to the appropriate authority.

Do not discuss the possibility of abuse with the parents or guardians!! Do not attempt to prove or disprove abuse.

ScoliosisLateral “S” or “C” curvature of the spine

> 10°Structural

Idiopathic (70-80% of all cases)Congenital Neuromuscular

PoliomyelitisCerebral palsyMuscular dystrophy

Scoliosis

ManifestationsScreening

5th & 7th gradesClassic Signs:

Truncal asymmetryUneven shoulders and hipsA one-sided rib bumpProminent scapula

Treatment of ScoliosisMild 10-20°

Exercises improve postureModerate 20-40°

Bracing maintains existing curvatureSevere 40° or >

Spinal fusion(> 80% = compromised respiratory function)

Goal: limit or stop progression of curvature

????The school nurse would screen an adolescent

for scoliosis by instructing him/her to:A. Bend forward at the waist, holding hands

togetherB. Lie prone on an examination tableC. Stand with shoulders placed against the

wallD. Sit on a chair and raise shoulders

BracingUsed for skeletally immature http://milwaukee.brace.nu/

????

An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen?

A. Discourage participation in ADL’s.B. Teach appropriate application, removal and care of

skin and brace.C. Discourage sports like golf and tennis encourage

sedentary activities.D. Teach non-weight bearing techniques.

Rods:

Recommended for curves > 40 degreesGoal: fuse spine to prevent progression

Surgical CarePre-op

Mentally prepareDemonstrate incentive spirometer, TCDB, log rollPCA pump

Post – opPain managementMonitor neurovascular statusMonitor H&HLog Roll, sit, ambulateROMDressing changes

What would you teach a child to expect in the immediate post-op period?

a. Frequent neurovascular assessmentsb. Need to CT&DB every 2 hours (IS)c. Possibility of IV, chest tubesd. Use of post-op analgesia

Discharge TeachingNo heavy lifting, bending or twisting at the

waist. Brace applicationFollow-up X-rays Once fused may resume normal activity

levels, skiing, sports, etc…

Muscular DystrophyMuscle fiber degeneration and muscle

wasting.Duchennes

Onset of symptoms 3-4 years of lifeTerminal disorder

Clinical Manifestations & DiagnosisS/S

Delayed walking, frequent falls, tire easily, toe walking, hypertrophied calves, waddling gait, lardosis, + Gower’s maneuver, mental retardation

Dx:Muscle biopsy (↓ distrophin)↑ Serum enzyme CKElectromyogramEEG (75% are abnormal)

Prognosis: 1:3500 children effected

Ability to walk lost by age 9-12

Death occurs 9-10 years after diagnosis

Nursing Care:Promote optimal healthGoal: keep child ambulatory Assess muscle weaknessRespiratory functionNutritional statusOT, PT, RT

Psychological ImpactWhat are some psychological

issues that may affect a family caring for a child with muscular dystrophy?

Family Centered Care:Financial resourcesCommunity resourcesCultural influences Support groups

Please contact me if you have any questions or concerns regarding this presentation.

Marlene Meador RN, MSN, CNEmmeador@austincc.edu