Exam 11: Pediatric Musculoskeletal Conditions
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| Age-Specific Changes: Infants (Gross Motor) | Head control.
Head lag.
Rolling over.
Sitting.
Locomotion.
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| Age-Specific Changes: Infants (Fine Motor) | Prehension
Palmar grasp
Pincer grasp
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| Age-Specific Changes: Toddlers (Gross Motor) | Locomotion
Walking
Running
Up and down stairs
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| Age-Specific Changes: Toddlers (Fine Motor) | Increasing manual dexterity
Pincer grasp to throwing ball
Building towers
Drawing
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| Age-Specific Changes: Preschoolers (Gross Motor) | Walking, running, climbing, jumping well established
Refinement of eye-hand muscle coordination
Rides trike, skips, jumps rope
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| Age-Specific Changes: Preschoolers (Fine Motor) | Increasingly skillful manipulation
Drawing
Dressing self
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| Age-Specific Changes: School Age | More graceful
Posture improved
Double strength
Muscles immature
“age of loose tooth”
“ugly duckling stage”
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| Age-Specific Changes: Adolescents | Sexual maturation
Final 20-25% of height is achieved
Adolescent growth spurt
Characteristic sequence for growth
-Extremities and neck
-Hip and chest
-Shoulder width
-Trunk length
-Depth of chest
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| Name one age-specific change for the infant, toddler, preschooler, school-age child, and adolescent. | Lots
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| The most frequent reasons for immobility are... | Congenital Defects.
Degenerative disorders.
Integumentary system impairment d/t injury or infection.
Musculoskeletal system.
Neurological system.
Therapies (ie; traction)
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| Immobilization: Physiologic effects | a. Decreased muscle strength and mass
b. Decreased metabolism
c. Bone demineralization
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| Major musculoskeletal consequences of immobilization | a. Significant decrease in muscle size, strength, and endurance
b. Bone demineralization leading to osteoporosis
c. Contractures and decreased joint mobility
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| Psychologic Effects of Immobilization | -Loss of integral part of daily life
-Loss of instrument of communication
-Increased anxiety
-Loss of sensory input
-Diminished environmental stimuli
-Quest for mastery of development
-Depression
-Monotony of immobilization
-Punishment
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| Name four of the most frequent reasons for immobility. | Congenital defects, degenerative disorders, infections or injuries of skin, musculoskeletal system problems, neurologic system problems, therapies
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| Soft Tissue Injury | Injuries to the muscles, ligaments, and tendons are common in children. In young children, soft tissue injury usually results from mishaps during play.
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| Contusions | a. Damage to the soft tissue, subcutaneous structures and muscle—tearing of these tissues and small blood vessels and the inflammatory response lead to hemorrhage, edema, and associated pain. Ecchymosis is present.
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| Crush Injury | occur when children slam their fingers (in doors, etc) or hit their fingers (such as hammering).
Severe crush injury involves the bone, with swelling and bleeding beneath the nail (subungual) and sometimes laceration of the pulp of the distal phalanx.
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| Dislocations | force of stress on the ligament is so great as to displace the normal position of the opposing bone ends or the bone end to its socket.
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| Sprains | Occurs when trauma to a joint is so severe that a ligament is partially or completely torn or stretched by the force created as a joint is twisted or wrenched often accompanied by damage to associated blood vessels, muscles, tendons, and nerves
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| Strains | Microscopic tear to the musculotendinous unit and has features in common with sprains.
Area is painful to touch and swollen
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| Fractures | occur when the resistance of bone against the stress being exerted yields to the stress force. Fractures are a common injury at any age but are more likely to occur in children and older adults
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| Epiphyseal (or Physeal) Injuries | Weakest point of long bones is the cartilage growth plate, or epiphyseal plate.
Frequent site of damage during trauma
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| Types of Fractures | Plastic Deformation.
Buckle or torus.
Green stick.
Complete.
Incomplete.
Transverse.
Oblique.
Spiral.
Simple or closed.
Compound or Open.
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| Plastic deformation Fx | bone bent but not broken, will not completely straighten on own
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| Buckle, or torus Fx | produced by compression of the porous bone, appears as raised or bulging projection at the fracture site
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| Greenstick Fx | occurs when a bone is angulated beyond the limits of bending, tension side fails, causing an incomplete fracture
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| Complete Fx | divides the bone fragments, often remain attached by periosteal hinge
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| Incomplete Fx | fracture is not completely through the bone and fragments remain attached.
-proximal Fragment.
-Distal Fragment.
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| Proximal fragment Fx | fragment closer to the midline
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| Distal fragment Fx | fragment farther from the midline
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| Transverse Fx | crosswise, at right angles to the long axis of the bone
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| Oblique Fx | slanting but straight, between a horizontal and perpendicular direction
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| Spiral Fx | slanting and circular, twisting around the bone shaft
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| Simple or closed Fx | fracture does not produce a break in the skin
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| Compound or open Fx | bone protrudes through skin
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| Therapeutic Management Goals of Fx | a. Regain alignment and length of the bony fragments (reduction)
b. To retain alignment and length (immobilization)
c. To restore function to the injured parts
d. To prevent further injury
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| 5 P's | i. Pain and point of tenderness
ii. Pulse—pulse distal to the fracture site
iii. Pallor
iv. Paresthesia—sensation distal to the fracture site
v. Paralysis—movement distal to fracture site
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| Explain the acronym RICE. | Rest, ice, compression and elevation to reduce edema, bleeding and pain.
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| What things need to be included in the assessment of a child with a suspected fracture? | The 5 P’s: pain, pallor, pulselessness, paresthesia, paralysis.
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| Purposes of traction | -Fatigue involved muscles
-Reduce spasms
-Position distal and proximal bone ends
-Immobilize fracture site
-Help prevent or improve contracture deformity
-Provide immobilization of specific areas of body
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| Traction | forward force is produced by attaching weight to the distal bone fragment
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| Counter-traction | backward force is produced by the body’s weight
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| Friction | patient’s contact with the bed constitutes frictional force
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| Types of Tractions | Manual Traction- Skin- Skeletal- Bryant- Buck Extension- Russell- Balanced suspension- Cervical
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| Manual Traction | applied to the body part by the hand placed distal to the fracture site, used to apply cast or closed reduction
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| Skin Traction | applied directly to the skin surface and indirectly to the skeletal structures, pulling mechanism is attached to the skin with adhesive material or an elastic bandage
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| Skeletal Traction | 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
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| Bryant Traction | type of running traction where the pull is only in one direction, skin traction applied to the legs, flexed at 90 degrees at hips
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| Buck Extension Traction | type of traction with the legs in an extended position; used for dislocated hips, Legg-Calve-Perthes disease, accomplished with either skin straps of special foam boot designed for traction
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| Russell Traction | skin traction on the lower leg and padded sling under the knee, two lines of pull, one along the longitudinal line of the lower leg and one perpendicular to the leg
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| Balanced Traction | may be used with or without skin or skeletal traction, suspends the leg in a desired flexed position to relax the hip and hamstring muscles, does not exert traction directly on a body part.
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| Thomas splint | Extends from the groin to midair above the foot
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| Pearson Attachment | Supports lower leg.
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| Cervical Traction | vulnerable site for flexion and extension
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| Halo brace or vest | consists of steel halo attached to the head by four screws inserted into the outer skull, several rigid bars connect the halo to a vest that is worn around the chest to hold head in alignment with spine
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| Crutchfield, Barton, or Gardner-Wells tongs | inserted through burr holes in the skull with weights attached to the hyperextended head, as the neck muscles fatigue with constant traction pull, the vertebral bodies gradually separate so that the cord is no longer pinched between the vertebrae
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| What are three things that can be done to prevent skin breakdown in a child in traction? | Provide alternating pressure mattress under the hips and back, Inspect pressure points daily or more often if breakdown is observed, Change position at least every 2 hours to relieve pressure.
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| developmental dysplasia of the hip (DDH) | a spectrum of disorders related to abnormal development of the hip that may occur at any time during their fetal life, infancy or childhood.
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| cause of DDH | unknown, but certain factors are believed to affect the risk of DDH:
1. Gender
2. Birth order
3. Family history
4. Intrauterine position
5. Delivery type
6. Joint laxity
7. Postnatal positioning
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| DDH: Physiologic factors | include maternal hormone secretion and intrauterine positioning
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| DDH: Mechanical Factors | include breech presentation, multiple fetus, oligohydramnios, large infant size
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| DDH: Genetic Factors | entail a higher incidence (6%) of DDH in siblings of affected infants and an even greater incidence (36%) of recurrence if a sibling and one parent were affected
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| Hip Dysplasia; Major Groups | Typical-infant is neurologically intact
Teralogic-involves a neuromuscular defect such as arthrogryposis or myelodysplasia, usually occur in utero and are much less common
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| Three degrees of DDH | Acetabular dysplasia (or preluxation).
Subluxation.
Dislocation.
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| Acetabular dysplasia (or preluxation) | mildest form, neither subluxation nor dislocation, delay in acetabular development evidenced by osseous hypoplasia, femoral head remains in acetabulum.
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| Subluxation | implies incomplete dislocation of the hip; regarded as an intermediate state in the development from primary dysplasia to complete dislocation; the femoral head remains in contact with the acetabulum, but femur head is partially displaced
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| Dislocation | femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim
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| Talipes varus | an inversion, or bending inward
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| Talipes valgus | an eversion, or bending outward
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| Talipes equines | planter flexion, in which the toes are lower than the heel
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| Talipes calcaneus | dorsiflexion, in which the toes are higher than the heel
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| Talipes equinovarus (TEV) | composite deformity, in which the foot is pointed downward and inward in varying degrees of severity, most cases of clubfoot are a combination of these positions
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| Positional clubfoot | also called transitional, mild, or postural clubfoot, believed to occur primarily from intrauterine crowding and responds to simple stretching and casting
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| Syndromic or Teratologic clubfoot | associated with other congenital anomalies such as myelomeningocele or arthrogryposis and is more severe form and often resistant to treatment
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| Congenital clubfoot | also called idiopathic, may occur in an otherwise normal child and has a wide range of rigidity and prognosis
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| Osteogenesis Imperfecta (OI) | heterogeneous, autosomal dominant disorder characterized by fractures and bone deformity.
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| Osteogenesis Imperfecta (OI): Clinical Features | a. Varying degrees of bone fragility, deformity and fractures
b. Blue sclera
c. Hearing loss
d. Dentinogenesis imperfecta (discolored teeth)
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| Why would a Pavlik harness be used on a newborn? | The Pavlik harness is used on newborns to help splint their hips in a safe position with the femur centered in the acetabulum. The harness is worn continuously until the hip is proved stable on examination.
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| What things should a nurse do to help prevent fractures while caring for a child with Osteogenesis Imperfecta? | These children require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved and held.
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| Legg-Calve-Perthes Disease | a self-limiting disorder in which there is aseptic necrosis of the femoral head.
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| Legg-Calve-Perthes Disease: Pathophysiology | Disturbance of circulation to the femoral capital epiphysis that produces an ischemic aseptic necrosis of the femoral head
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| Legg-Calve-Perthes Disease: Stage I | initial or avascular stage
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| Legg-Calve-Perthes Disease: Stage II | fragmentation or revascularization stage
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| Legg-Calve-Perthes Disease: Stage III | reossification or reparative stage
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| Legg-Calve-Perthes Disease: Stage IV | residual or regenerative stage
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| What two major factors are considered when planning nursing care? | The age of the child and the type of treatment.
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| Scoliosis | a complex spinal deformity in three planes, usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis
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| Scoliosis: Pathophysiology | -Most common spinal deformity
-Classified according to age of onset
-Can be associated with other conditions
-May be genetic component
-Curves of less than 10 degrees
-Curves of less than 20 degrees
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| Boston and Wilmington braces | are underarm orthoses customized for patient from prefabricated plastic shells
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| TLSO (thoracolumbosacral orthosis) | underarm orthosis made of plastic custom molded to the body and then shaped to correct deformity
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| Milwaukee brace | individually adapted brace that includes a neck ring used to treat kyphosis more than scoliosis
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| Charleston nighttime bending brace | worn only when child is in bed, prevents walking
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| How is scoliosis classified and what is the most common? | Classified by age and adolescent is the most common
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| Osteomyelitis | infectious process in the bone, can occur at any age but most frequently is seen in children 10 years of age or younger
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| Acute hematogenous osteomyelitis | results when a bloodborne bacterium causes an infection in the bone
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| Exogenous osteomyelitis | acquired from direct inoculation of the bone from a puncture wound, open fracture, surgical contamination, or adjacent tissue infection
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| Subacute osteomyelitis | has a longer course and may be caused by less virulent microbes with a walled-off abscess or Brodie abscess, typically in the proximal or distal tibia
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| Chronic osteomyelitis | is a progression of acute osteomyelitis and is characterized by dead bone, bone loss, and drainage and sinus tracts
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| Osteomyelitis: Exogenously acquired | direct inoculation of bone from trauma or surgery, usually foot or hand
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| Osteomyelitis: Hematogenously acquired | seeded by organisms from a preexisting infection; usually in metaphyses of long bones
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| How long is the course of antibiotics for osteomyelitis? | 4 weeks IV, may need 6-8 weeks
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| Osteosarcoma | most common bone cancer in children.
Also known as osteogenic sarcoma.
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| Osteosarcoma: Pathophysiology | Peak incidence
Bone-forming mesenchyme
Primary tumor sites
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| Osteosarcoma: Therapeutic Management | Optimum treatment is surgery and chemotherapy
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| Ewing sarcoma | as a primitive neuroectodermal tumor (PNET), is the second most common malignant bone tumor in childhood. 1. Arises in the marrow spaces of the bone rather than from osseous tissue.
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| Ewing sarcoma: Therapeutic management | Surgical amputation not routinely recommended
Treatment of choice
-Intensive radiotherapy
-Combined with chemotherapy
Chemotherapy varies widely
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| When is Ewing's sarcoma most likely to occur? | Between age 4 and 25.
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| Juvenile idiopathic arthritis | Chronic autoimmune inflammatory disease causing inflammation of joints
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| Juvenile idiopathic arthritis: Pathophysiology | Starts before 16 years of age.
Chronic inflammation of the synovium with joint effusion, erosion, destruction, and fibrosis.
Adhesions between joint surfaces.
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| Juvenile idiopathic arthritis: Clinical Manifestation | Arthritis wax and wane.
30% have progressive arthritis into adulthood.
Significant joint deformity.
Significant functional disability.
Chronic and acute uveitis can cause permanent vision loss.
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| Types of Juvenile idiopathic arthritis | Systemic arthritis
Oligoarthritis
Polyarthritis
Psoriatic arthritis
Enthesitis-related arthritis
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| Systemic arthritis | arthritis in one of more joints associated with at least 2 weeks of fever, rash, lymphadenopathy, hepatosplenomegaly, and serositis
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| Oligoarthritis | arthritis in one to four joints for the first 6 months of disease, it is subdivided to persistent oligoarthritis if it remains in four joints or less or becomes extended oligoarthritis if it involves more than four joints after 6 months
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| Polyarthritis rheumatoid factor negative | affects five or more joints in the first 6 months with a negative rheumatoid factor
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| Polyarthritis rheumatoid factor positive | affects five or more joints in first 6 months, but these children have a positive rheumatoid factor
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| Psoriatic arthritis | arthritis with psoriasis or an associated dactylitis, nail pitting or onycholysis or psoriasis in a first-degree relative
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| Enthesitis-related arthritis | arthritis and/or enthesitis (inflammation at the tendon insertion site) associated with at least two of the following: sacroiliac or lumbosacral pain, arthritis in males older than 6.
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| Arthritis can cause significant joint deformity and functional disability perhaps requiring what three items? | Medication, physical therapy, future joint replacements
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| Chemotherapy Drugs | a. Vincristine
b. Actinomycin-D
c. Cyclophosphamide or Ifosfamide
d. Etoposide
e. Doxorubicin
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| Arthritis can cause significant joint deformity and functional disability perhaps requiring what three items? | Medication, physical therapy, future joint replacements.
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| is responsible for determining the type and amount of activity the child should perform? | The physical therapist.
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