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