MODULE 7: CARE OF THE CHILD WITH MUSCULOSKELETAL SYSTEM CONDITIONS

Plan
 MSK – health issues
 S&S
 Testing
 Nursing care and interventions
Bone Growth
- Long bones: rapid grow from childhood to adolescents
- Growth plate – physis: area of cartilages where new bone tissues are made
- Thigh bone grows 10mm/ year and ankle bone grows 4mm/ year in children
- Grow spurts is rapid bone growth happens in preteen or early teenage years. Growth will slow
down when bone reaches skeletal maturity: 14 for girls, 16 for boys.
--> Grow spurts and grow rate are different for every child and can be influenced by many factors: age,
sex, family history and maturity
- Limb deformities: when one or more long bones have a different length or angle from what is
typical for your age
- Limb length discrepancy: different in length between 2 limbs on either side. Affect by different
grow rate between both limbs, congenital condition (hemimelia), injury or infection in the
growth plate
- Angular deformity: bone grow at the wrong angle, caused by narurally at birth, congenital
disease condition (Rickets), injury causes bone or grow plate to tilt from its normal angle
--> over time leads to joint problem or arthritis

Pediatric MSK differences

 Damage to epiphyseal plate can disrupt bone growth
 Deformities
 Bones are pliable – more bendy, hard to break
 Dislocation and sprains not common
 Rapid growth of skeletal frame

Assessment findings
 A few normal findings to keep in mind:
o Neonates have C-shaped spine
o Toddlers have a wide gait – because they have a big head
o Knock knees are normal until 2 -3 ½ years of age
o Bowlegs are normal during the first year
o Radial head subluxation (pulled elbow) due to picking up or swinging them by the arms

How would you assess MSK in children?

 Inspect
 Watch child move
 Palpate joints for heat, tenderness and swelling

Cla Diagnostic tests

ssi  X-ray
fica  Bone scan
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  Computed tomography
 Magnetic resonance imaging
 Ultrasounds
 Barlow's Test - for hip dislocation

Club Foot
 Also called Talipes Equinovarus – TEV - feet cannot be straighten out
 One of the most common deformities of the skeletal system
 Foot is generally adducted and there is a short or tight Achiles’ tendon
 True clubfoot does not respond to simple exercise

Clubfoot: Diagnosis & Treatment

 Cause: unknown but appears to have a familial tendency, 50/50 for boy and girl
 Possibility of arrested or abnormal fetal development during the 9 & 10 week of gestation when
feet are formed
 Leads to abnormal muscles and joints and leads to contractures of soft tissue
 Early medical intervention has good results:
o Early intervention important to prevent bones and muscles from continuing to develop
abnormally
o Passive massage and stretching exercises
o Serial Casting
o Splinting
o Special boots
o Surgical Intervention
Patient teaching
 Skin integrity: keeping things clean
 How to support the kid
 Circulation – capillary refills
 Sensation

Development Hip Dysplasia

 Abnormality of the hip joints which can develop in utero, infancy or childhood
 Untreated subluxation or dislocation can lead to permanent disability
 Assessment
 Observe the buttock for variation in size when infant is prone.
 The legs of the infant should be equal in length.
 The infant should kick both legs, not just one.
 The depth and number of skin folds of the infant’s upper thighs should be symmetrical.
 Observe posture and gait in older children.
--> Look for any discrepancy between the legs (if one is longer or more abducted than the other)
 Diagnosis
Usually discovered at birth or periodic health exam during 1st/2nd month of life
 Ortolani’s sign (click heard birth to 3 months)
 Observe symmetry of gluteal folds
Cla  Shortening of leg
ssi  Child may have difficulty walking, weight bearing, may limp or toe walk
fica  X-rays unreliable until child is 3- 6 months of age
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  CT scan can show position of femoral head
 Ultrasound used
 Nursing diagnosis: Skin integrity, tissues perfusion, impaired mobility

 Treatment (early detection important):

Non-surgical:
o Splinting Pavlik harness
o Bryant’s traction, hips are in flexed 90-degree position with buttocks synthe bed for 2-3
weeks followed by hip spica cast
Surgical intervention:
o Closed reduction under G.A. (manipulation and hip spica cast application for 5-9 months
and changed every 4-6 weeks)
Pediatric Trauma
 Soft tissue injuries
o R. I. C. E (30min intervals)
 Traumatic Fractures
o Simple (no broken skin)
o Compound (broken skin)
o Greenstick (bent bone)
o Spiral (rarely accidental)
Fracture treatment
 Cast
 Plaster or Fiberglass
 Patient teaching of cast care and removal
What should the nurse assess when a patient has a cast? - proper p/t teaching: not to put
anything in the cast
Big risk when kid have a broken bone is compartment syndrome (emergency) – increase in pressure
inside a muscle --> restricts blood flow --> edema --> extreme pain

Cast assessment
Used to determine tissue perfusion of affected extremity.
 Pain
o Pain that does not respond to medication maybe be a sign of a serious complication
called compartment syndrome.
 Pulselessness/Capillary Refill
 Paresthesia
 Pallor or Cyanosis
 Paralysis
 Pressure
Traction
 Reduction of fracture
 Surgery is preferred, but may not be available in all countries
 Bedrest required
The main purposes of the traction are:
Cla  Fatigue muscle to reduce spasm for realignment
ssi  Align bone fragments
fica  Immobilize fracture until realignment is achieved
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  Allow for preoperative and postoperative positioning and alignment
Newer technology has produced orthopedic fixation devices that allow for mobility
What complications can arise from Bedrest?
--> Risk for: impaired mobility, skin integrity, perfusion issues

Osteomyelitis
 Infection of the bone --> cause sepsis b/c bone makes blood
 < 1yr age and between 5 and 14 years
 Staphylococcus aureus 85% of cases - MRSA
 Hemophilus influenzae cause in younger children
 How can we prevent osteomyelitis? Vaccine, hand hygiene, don’t kiss the baby, complete your
antibiotics course

Osteomyelitis
 Common Sites:
 Foot
 Femur
 Tibia
 Pelvis
 Signs and Symptoms
o 2-to-7-day history of pain – very painful
o Warmth
o Tenderness
o Decreased ROM
o Fever
o Irritability
o Lethargy
Diagnosis, Treatment, nursing care
 C & S (done on the blood) of aspirated exudate - to confirm the diagnosis
 Cultures of blood, joint fluid and infected tissue samples
 Bone biopsy
 Lab values: CBC, increase WBC, decreased RBC, decreased hematocrit,
 CT scan
 MRI
 IV antibiotics - diarrhea, IV burns, phlebitis, IV infection, erythema, edema
 Affected joint may be drained for pus
 Joint immobilization may use cast
 ROM
 Positioning
 Avoid weight bearing
 May have temporary cast
 Turning carefully
 Vital signs
 Antipyretics
Cla
ssi
fica Muscular Dystrophy - NO curable - life span of p/t is 18 – 20 years
tio  Progressive muscle degeneration
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  Sex-linked inherited disorder on X chromosome
 Almost exclusively found in boys
 Early weakness between 3 and 7 years
 History of delayed motor development
 Calf muscles become hypertrophied
 Progressive weakness – frequent falls, clumsiness, contractures of ankles and hips
Muscular Dystrophy
 Waddling gait, frequent falls
 Gower sign: rising from the floor by using hands and arms due to lack of thigh and hip muscle
strength
 Lordosis – arch back gait (opposite with kyphosis)
 Enlarged muscles, especially of thighs and upper arms
 Profound muscular atrophy in later stages
 Cognitive impairment common
 No effective treatment established
Primary goal: maintain function in unaffected muscles for as long as possible
 Keep child as active as possible
 Range of motion, bracing, performance of activities of daily living, surgical release of
contractures prn
 Genetic counselling for family
Juvenile Idiopathic Arthritis (JIA)
 Inflammatory diseases of joints, connective tissues and viscera – cause unknown.
 No known cure
 Reduce joint pain
 Promote mobility
 NSAIDS – cannot have ASP --> cause Reye’s syndrome --> severe inflammation of the liver
 Methotrexate
 Oral or injectable gold therapy, sulfasalazine and others
Family Centered care
 What would you do to support Peter and his family using the spheres of caring? Having
therapeutic support: asking open ended question, social work, support groups, asking how’s the
p/t doing
 What would be your nursing interventions?

Scoliosis
 Refers to lateral-S shaped curvature of spine
 Thoracic vertebrae are affected
 In severe cases, the abdominal organs may be compressed, and the expansion of the rib cage
during inhalation may be impaired
 Function Scoliosis: usually caused by poor posture, not a spinal disease. The curve is flexible and
easily correctable.
 Structural scoliosis is caused by changes in the shape of the vertebrae or thorax.
Cla
ssi Nursing Interventions
fica  Teaching child and family about scoliosis and brace
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  Emotional support, allow child and family to express feelings, encourage normal routines and
activities
 Support and encouragement through possible exercise program
 Teaching about braces
 Pre and post operative teaching and care: no weight baring, signs of infection, pain (big one),
vital signs, BP, hypovolemia, RR, LOC
 Junior high kids: Support self-esteem, support mental aspect

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