Musculoskeletal Dysfunction
M. Rubolino-Gallego
Nursing 355
Musculoskeletal
- Affects muscles, bones, joints and tendons
- Rapid growth of the skeletal system
- Most musculoskeletal problems are short-term
Bones
- A surface for the attachment of muscles, tendons, and ligaments
- 206 bones
- Long bone consists of a shaft with an epiphysis
- Wide portion of the bone responsible for growth
- Periosteum covers the bone
Joints/Articular System
- Connective tissue and cartilage
- Connect bones to one another
- Immovable vs. slightly movable vs. Freely movable
- Ligament binds one bone firmly to another
Muscle
- Elongated fibers
- 3 types of muscles
Cartilage
- Dense connective tissue
- The skeleton of an embryo is mostly cartilage
Musculoskeletal History
- ______is leading cause of death in children over age 1 year
- Fractures in children under 1 year are uncommon
- Depends on developmental stage of the child in the injury and the physiologic response
- Leading causes of morbidity in children are medical problems resulting from injury at home
Musculoskeletal
- Skull is not rigid/fixed during infancy
- Sutures fuse ______months of age
- Soft tissues are resilient in children
Fractures
- Occur in children from:
- Increased mobility
- Immature motor and cognitive skills
- Trauma (falls, MVAs, child abuse, sports injuries)
- Ages 5-9 more likely to have Fx
- Dx: X-ray
Etiology of a Fracture
- In infancy more often result ______
- Any investigation of fx in infants should include r/o osteogenesis imperfecta
- Fx of forearm common childhood injuries
- Clavicle bone is most frequently broken bone in children
- Hip fx are rare
- Children fall from heights
Pathophysiology
- Adult bones – are strong, require a violent traumatic force to fx, injuring the soft tissue
- Children – bones are more easily injured, fx may result from falls or twists
Types of Fractures
- Complete – fracture fragments are separated
- Incomplete – fracture fragments remain attached
- Transverse
- Oblique
- Spiral
- Simple
- Compound
- Comminuted
- Greenstick
- Buckle
- Bends
Types of Fractures
Greenstick Fractures
- ______
- But only bows or buckles on the other side
Greenstick Fracture
Oblique Fracture
- Diagonal break that occurs between the horizontal and perpendicular planes of the bone
Oblique Fracture
Comminuted Fracture
- Bone is splintered into pieces
Comminuted Fracture
Salter-Harris Classification System
Assessment
- ABC’s
- Assess extent of injury – 5 “Ps”
- Pain and point of tenderness
- Pulselessness
- Pallor
- Paralysis
- Paresthesia
- Determine mechanism of injury
- History
- Observe for bruising, lacerations, swelling
Diagnostic Criteria
- Infants and toddlers are unable to clearly communicate the details
- Older children may not be reliable informants
- X-ray – most useful
Treatment – Casts/Traction
- Emergency -Move injured part as little as possible
- Immobilize limb
- Elevate limb if possible
- Apply cold to affected area
- Cover open wound with sterile or clean dressing
- Call EMS
Casts
- Provides support and maintains position
- Plaster of Paris is not water resistant, heavier, molds easily, takes 24+ hours to dry
- Synthetic casts more expensive, dry quickly, lighter weight, water resistant
Traction
- Force exerted on one part of the body
- Skin ______
- Counter-traction must be provided at the same time usually with the child’s weight
- Mattress should be firm
- Attached with adhesive material
- Limits of weight
- Skin breakdown may occur
Skeletal Traction
- Pull applied directly to the skeletal structure by a pin, wire, or tongs
- Greater force than skin traction
- Tolerated for longer periods of time
- Complication: Osteomyelitis
- ______
- Inserted into the diameter of the bone
- Stress placed on the bone
External Fixation Device
- Pins or wires inserted through the skin, soft tissue, and bone and secured on the outer limb surface to a metal frame
- Child is ______
- More common now
- Pin care is needed to avoid infection
Nursing Considerations
- Understand purpose of traction
- Maintain traction
- Maintain alignment
- Neuro status – every ______hours for the first 48 hours
- Care for skin traction
- Prevent skin breakdown
- Prevent complications
Consequences of Immobility
- Integumentary : red, irritated skin, ulceration or drainage
- Respiratory: Decreased or altered respirations, SOB, lying supine for prolonged periods, decreased breath sounds, pulmonary embolism
- GI: decreased # of bowel mvmts
- GU: Decreased UO, foul smelling urine
- Musculoskeletal: reduced strength, loss of muscle tone, muscle atrophy, limited ROM
Limb Defects
- Common in children
- Often resulting from birth anomalies and sometimes trauma
- Syndactyly (webbing)
- Polydactyly (extra digits)
- Genu Valgum (knock knees)
- Genu Varum (bow leg)
- Club Foot
Webbing
Polydactyly
Knock knees
Bow leg
Club Foot
Club Foot
- Malformation of the lower extremities
- Genetic
- 1.2 in every 1000 births in the US
- Boys more than girls
- Treatment started soon after birth
- Serial manipulation and casting for 3-6 months
- Surgery if casting fails
- Even with treatment, foot is often not completely normal
- Lifelong atrophy of the calf is common
Hip Dysplasia
- Head of the femur is improperly seated in the acetabulum of the pelvis
- Can be present at birth
- May develop after birth
- Genetic
- African American and Asian less common
- More common in girls
Hip Dysplasia
- Infants beyond newborn exhibit asymmetry of the gluteal skinfolds when lying down
- Limited ROM of the affected hip
- Asymmetric abduction when child is supine with knees and hips flexed
- Dx: exam, ultrasound, CT, MRI
- Tx: depends on age and severity
- Newborn: splinting the hips with a Pavlik harness
- After newborn period: traction or surgery
Osteogenesis Imperfecta
- Most common osteoporosis in children, brittle bone disease
- Inherited syndrome: FX and bone deformity
- Clinical features: bone fragility, deformity, fracture, blue sclerae, hearing loss, discolored teeth, skin transparent, frequent fractures
- Dx: X-rays, genetic testing
- TX: supportive, prevention of more fractures
- Patho: biochemical defect in the synthesis of collagen
- Abnormal collagen results in incomplete development of bones, teeth, ligaments and sclerae
Osteomyelitis
- Bacterial Infection of the bone involving the cortex or marrow
- Acute vs. chronic (longer than 1 month)
- Occurs more in children 10 years of age or younger
- ______#1 causitive agent, B strep (newborns), E. coli
- Results from a blood borne bacteria causing an infection in the bone
- Causes: large amount of organisms, foreign body, bone injury, immunosupression, malnutrition
- Bacteria adheres to bone
- 1 in 500 children younger than 13 years old
- Infants: blood vessels cross the growth plate into the epiphysis and joint space, allowing infection to spread into the joint
- Children: infection is contained by the growth plate, joint infection is less likely
- S/Sxs: severe pain, fever, irritability, tenderness, without local signs of infection, tender extremity
- Dx: organism ID, cultures from blood, joint fluid, and infected skin, bone changes may not be evident on x-ray until 10 days after onset
- Tx: IV antibiotics – clindamycin, or vanco for at least 4 weeks, surgery
- Nursing: affected limb will cause discomfort to the child
- Child positioned comfortably with limb supported
- Poor appetite leading to vomiting, high calorie liquid foods encouraged
Juvenile Arthritis
- Autoimmune, inflammatory disease
- No known cause
- May or may not have a + rheumatoid factor
- Chronic disease, is the leading cause of blindness and disability in children
- Unknown etiology: infection, trauma, emotional stress cited as triggers
Juvenile Arthritis
- 1 in 1000 children in the US
- Before 16 years of age
- Sxs: intermittent joint pain lasting longer than 6 weeks in more than 1 joint
- Joint may appear stiff, swollen, warm, limited ROM
- Dx: History, rheumatoid factor, ANA, elevated ESR, + C-reactive protein
Juvenile Arthritis
- Tx: supportive, NSAIDs, steroids, gold salts, methotrexate
- PT/OT treatment
Scoliosis
- Complex spinal deformity in three planes
- Most common spinal deformity
- Lateral curvature of the spine
- Affects 10% of the population
- congenital or develop during infancy or childhood
- May be genetic or multifactorial
- Rarely apparent before age 10
- Rarely has discomfort and few outward signs in the beginning
- Dx: standing child, wearing only underwear, viewed from behind
- X-ray
- Screening is controversial
- Tx: observation, bracing, spinal fusion surgery, based on magnitude, location and type of curve
- Must promote self-esteem
Lordosis
- Accentuation of the lumbar curvature beyond physiologic limits
- Idiopathic, trauma, secondary complication
- Normal in toddlers
- Teens: more in girls, in obese children; the wt. of the abdominal girth alters the center of gravity
- Pain
- Tx: manage predisposing cause, postural exercises
Kyphosis
- Abnormally increased convex angulation in the curvature of the thoracic spine
- Can occur secondary to diseases
- Postural kyphosis in 4% of healthy adolescents
- Dx: visual exam
- Tx: postural exercises, sports
Muscular Dystrophy
- Inherited disease
- Duchenne’s MD recessive disorder affects only males – females are carriers and pass the defect onto their male children
- Muscle fibers degenerate and are replaced by fat and connective tissue causing weakness and atrophy
- 1 in 3000 male children
- Increasing disability/deformity
- Usually 3-7 years old, must use Gowers maneuver to rise from floor (child puts hands on knees and moves the hands up legs until standing erect)
- Labs: Serum Creatine Kinase - CK levels elevated in early stages
- TX: maintain ambulation and independence
Cardiopulmonary complications most common cause of death
Goals: Prompt attention to infection
- Respiratory
-Obesity prevention
Legg-Calve-Perthes
- Self-limited disorder
- Avascular necrosis of the femoral head
- Disorder of growth
- 1 in 20,000, more in boys
- Affects boys 4-8 years, average onset 6 years
- Cause unknown
- S/Sxs: intermittent, painful limp, hip soreness, ache or stiffness, pain along hip or entire thigh, limited ROM
- Tx: keep head of femur contained in the acetabulum as it regenerates, and reduce the risk of permanent stiffness, surgery, adductor brace for 18 months
Slipped Capital Femoral Epiphysis
- Affects the upper femoral growth plate
- Hip disorder, during rapid growth ie. Adolescence
- Cause: Unknown
- 2 per 100,000, average age 12 years for girls and 13.5 years for boys
- Usually exceed the 90th percentile for height and weight
Slipped Capital Femoral Epiphysis
- Sxs: limp, pain (groin, thigh, knee), abnormal gait
- Dx: History, x-rays
- Tx: pin or screw inserted into the growth plate securing the femur head, with diagnosis, leads to admission to the hospital and bed rest
Osgood-Schlatter Disease
- Related to repetitive stress from sports-related injuries, combined with overuse of immature muscles and tendons over an extended period of time
- Exacerbated by exercising
- Occurs between ages 8-16 yrs, knee pain
- Inflammation of the tibial tubercle
- Without tx, tubercle enlarges and can cause functional and cosmetic problems
- Dx: x-ray, clinical picture
- Tx: avoid exercising x 6 weeks, wrapping the knee, PT, ice, heat, NSAIDs