Musculoskeletal disorders in children

Common disorders
• Sprains • Slipped capital femoral
• Strains epiphysis
• Contusions • Legg Calve Perthes
• Fractures disease
• Osteomyelitis • Juvenile rheumatoid
arthritis
• Congenital hip
dislocation • Muscular dystrophy
• Scoliosis
• Osgood Schlatter’s
Other less common disorders

Club feet
Polydactyly
 Common injuries-Sprains
• More common in adolescents
• Due to athletic injuries, falls • May need surgical
correction
• Complaints • Air cast for 4-5 weeks
• Swelling
• Tenderness
• Ecchymosis
• Reduced ROM
• May have instability with higher
degree
• Usual management
• Rest
• Ice
• Compress
• Wrap with ACE bandage
• Elevate
• Parent education
• Temporary use of NSAIDs
• Ice therapy
 Fractures
• Most are trauma
induced
• Other things that are
considered
• Child abuse
• Osteogenesis imperfecta
• Nutritional deficiencies
• Vitamin D
• Calcium
 Nursing interventions
• Emergency room
• Assess injury
• Swelling
• Break in skin
• Assess for the 5 Ps
• Pain
• Paresthesia
• Pallor
• Pulse
• Paralysis
• Immobilize/splint injury
• Elevate, ice
• Control bleeding if present
• Prepare for open or closed reduction
• Pain management
 Inpatient interventions
• Pain management
• Skin integrity • IV antibiotics for
• Keep clean and dry
• Pillows for support/comfort
prophylaxis
• Traction care-less & less • Incentive
common spirometer
• Wound care if ORIF
• Elevate
• Neurovascular checks
• Q 2 hours • Ambulate with
• Bowel and bladder needs PT when
• Fluids
• Stool softeners appropriate
• Nutrition
• Play therapy
• Parent/patient education
 Osteomyelitis
• Infection of bone and
• Analgesics
surrounding soft tissue
• Monitor temperature and
• Can cause sepsis, death if not
signs of infection after
caught early enough
antibiotics/surgical
• Difficult to treat 2° to poor blood debridement
supply to bone
• Should see
• Diagnostics
• X ray
improvement within 48
• CBC
hours
• • Wound care
• Drain care
 Juvenile Rheumatoid Arthritis
• Autoimmune phenomenon
• Perhaps triggered by infection?
• Girls > boys
• The earlier it occurs the more likely to affect G&D
• Intermittent joint pain lasting > 6 weeks
• Afternoon fevers, swelling, erythematous joints
• Rash, lymphadenopathy, chest pain, anemia possible if
systemic type
• http://www.youtube.com/watch?v=yJBvbFbbrGs&feature=related
 Nursing interventions
• Careful assessment of the full body
• Positioning
• Elevate with pillows
• Pain meds prior to movement
• Nutrition
• Pain management
• NSAIDs
• Steroids
• Prednisone
• DMARDs
• Methotrexate
 Interventions
• Parent and patient education
• Monitor joint status
• Pain
• Swelling
• Mobility
• Warmth
• Mobility
• Need ROM
• Proper positioning
• Medications
• Diet- fiber, protein, fluids, calcium especially since
weight bearing activities are 
• Activities for normal G&D
 Osgood Schlatter’s Disease
• Problem from overuse
• Usually occurs in early adolescents
• Common in athletes
• Pain with activity
• Swelling of tibial
• Patellar tendon tears away from bone
• Rest
• NSAIDs
• Patient/parent education
• Tincture of time!
• Activity restrictions
 Scoliosis
• Lateral curvature of spine
• Check alignment
• C or S curve
of neck, shoulders,
• Occurs in adolescence & hips
90% (10% congenital or
• Rib or scapula
other forms)
hump, leg length
• Compensatory curve to discrepancy,
maintain balance unequal shoulders
• School nurse begin • Curvature > 40°
screening about age 9 requires treatment
• Mild cases wait and
watch approach so
recheck every six
months
Treatment modalities
• Exercise
• Bracing
• 18-23 hours per day
• Mild cases-wait and watch, recheck 6
months
• 18-23 hours per day
• For milder cases
• Surgical repair
• Spinal fusion and rod placement
• Delay until growth completed
Hip Dysplasia
• Dislocated-femoral head completely out of
socket
• Leg length difference
• Asymmetric thigh folds
• Relatively uncommon at birth
• Dislocatable
• Hip resting in socket; can be pushed completely
out by maneuvering; + Barlow sign
• No leg length difference, no thigh fold
asymmetry
• Subluxatable
• Hip feels loose; can partially move but not
completely out of socket; most common
situation
• No thigh fold asymmetry
 Congenital Hip Dysplasia
• Barlow’s sign-downward
pressure
• Ortolani sign-
abduct/adduct
• Asymmetric gluteal and
thigh folds
• Leg length discrepancy
• If hip dislocated, see
limited abduction by 4-5
mos. of age
• Older children
• Limping gait
• Stiff hip when trying to
abduct Breech hips-  risk
• X rays more valuable in this
group
 Hip dysplasia

• If detected in nursery, Ortho

consult before discharge
• Ultrasound or x ray for diagnosis
• Pavlik harness
• Teach parents how to use
• Straps need to be secure
Galleazi sign of dislocated hips
enough to keep hips flexed
• Wear 23 hours/day
• Skin assessment & protection
• Diapers under harness
• Hip spica cast
Surgical correction
• If after 6 months harness
unsuccessful or if not detected
early enough
• Pre op teaching
• Procedure
• IV fluids
• Pain
• Hip spica cast
• Post op care
• Neurovascular checks
• IV fluids
• Nutrition
• Cast care
• Monitor for infection
Discharge planning
• Cast care
• Diapering/hygiene
• Transportation
• Wagon
• Cushion with pillow
• Seat belts
• Clothing
• Cut seams and Velcro
• Diet
• Limit foods that cause
diarrhea
 Muscular dystrophy
• Progressive degeneration of skeletal muscle
• Most common form-Duchenne
• Sex linked recessive; only in boys
• 1 in 3500 males
• Usually detected by 3-5 years old
• Motor milestones reached but delayed then decline
• Calf muscles or pelvis affected first
• Lack ability to produce dystrophin a protein needed
for muscle
• Replaced by fat and connective tissue
 Diagnostic testing

• Elevated CK levels early

• EMG (electromyography)
• CK levels  as muscle is
wasted
• Muscle biopsy
 Muscular Dystrophy
• Increasing weakness, affects
• Speech
• Swallowing
• Walking-long bone muscle tension; short tendons; toe
walk
• Cardiac muscle weakness- CHF
• Respiratory-
• Pneumonia
• Complete respiratory failure
• Fractures from excessive LE muscle tension
• Contractures
Management of DMD
• Maximize potential
• Prednisone
• May improve muscle strength
• May delay progression
• Assistive devices for mobility
• Cane, walker, wheel chair
• Release of contractures
• Routine post surgical care
• Increased risk of respiratory
compromise
• Physical therapy
 Nursing interventions
• Maximize potential for
ADLs as long as possible
• Safety precautions
• Skin integrity
• Transfer from bed to chair
• Bowel and bladder care
• Monitor for respiratory
distress
• Diet
• High protein, high fiber
• Low calorie