MUSCULOSKELETAL DISORDERS

Revised, summer 2007

Talipes Equinovarus (Clubfoot)Adduction and supination of forefoot with

an inversion (varis) of the heel and fixed plantar flexion.

Etiology unknown

75% of abnormalities of the foot (1:1000)

Clinical Manifestations Focus on early detection

Rocker bottom foot Fixed position

Diagnostic tests Ultrasound CT MRI

Treatment

Corrective casting every 3-14 days

Dennis Browne splints- horizontal bar attached to foot plates

Nursing Care

Care of Casts

CMS assessment Keep dry/clean Assess placement

Evaluation:

Regular check-ups

Prognosis

ROM after removal of casts

?????

An 18 month old is scheduled for application of a plaster cast to correct a clubfoot. The post-op plan should include which of the following measures?a. Elevate the cast above the level of the heartb. Handle cast with fingertipsc. Reposition the child every 2 hoursd. Spray the cast with an acrylic protectant

Congenital Dislocation of Hip

Malrotation of the hip at birth

Improper formation or function of acetabulum

Clinical Manifestations

Gluteal folds

Ortolanis sign

Shorter femur

Prominence of femur

Clinical Manifestations cont…

Limited abduction

Barlow Maneuver

Signs and Symptoms in older child

Diagnostic Tests:

Ultrasound

CT and MRI

X-ray

Surgical Treatment:

Release muscles and tendons

Application of body- spica cast

Treatment with Spica Cast

For complex cases and older children

Dislocated -some closed and open reductions

Spica cast

Spica Cast Care

Use palms to handle cast Bar between the legs is not a handle! Use pillows for positioning Keep cast clean & dry

Nursing Management

Case finding and referral Teach parent application of harness Protect skin Bring environment to child Safety

Developmental dysplasia of the hip Head of femur is unstable Subluxation of the hip occurs Dislocation of the hip can be in late

stage of development

Treatment

Splinting of hip- Pavlick harness

Hip maintained in flexion and abduction

Deepen acetabulum from pressure of femur head

Pavlik harness

?????

A parent asks why her infant must wear a Pavlik harness. The nurse responds that he purpose of this device is to:

A. Provide comfort and support

B. Shorten the limb on the affected side

C. Maintain the femur within the acetabulum

D. Provide outward displacement of the femoral head.

Nursing Management

Case finding and referral Teach parent application of harness Protect skin Bring environment to child Safety

Fractures

Greenstick fracture- most common type in kids < 3 years

MVA -frequent cause of bone injury in 4-7 year olds

Pathophysiology

Epiphyseal plate

Pliable and porous

Fractures

Occur as a result of direct or indirect force

Repeated stress on the bone

Pathologic conditions

Healing

Rapid in children Good rule of thumb:

one week for every year

of life up to 10 yrs

Assessment

Pain (PROM) Tenderness

Edema

Limited movement

Distortion of limb

Nursing Care

Casting

Tractionhttp://www.dhmc.org/webpage.cfm?site_id=2&org_

Compartment syndrome

Surgical intervention

Muscular Dystrophy

Duchennes- 13 types

Onset of symptoms

Duchenne’s (D M D)

Duchenne’s characteristics

Prognosis

Ability to walk lost by age 9-12

Death occurs 9-10 years after diagnosis

1:3500 children effected

Diagnosis/Treatment

Muscle biopsy **Serum enzyme CK Electromyogram ECG Rehab Corticosteroid therapy

Nursing Care

Promote optimal health Goal: keep child ambulatory Assess muscle weakness Respiratory function Nutritional status OT, PT

Scoliosis

Curve greater than 25 degrees Functional

Postural Compensatory

Structural Idiopathic (70-80% of all cases) Congenital Neuromuscular

– Poliomyelitis– Cerebral palsy– Muscular dystrophy

????

The school nurse would screen an adolescent for scoliosis by instructing him/her to:

A. Bend forward at the waist and allow upper extremities to dangle

B. Lie prone on an examination table

C. Stand with shoulders placed against the wall to check evenness

D. Sit on a chair and raise shoulders

Manifestations

Progression- 1 degree per month

Observation of curves Texas response to funding issues 6th & 8th grades

Bracing

Used for skeletally immature http://milwaukee.brace.nu/

????

An adolescent must wear a Milwaukee brace. Which of the following actions would the nurse take to promote optimal functioning for the teen?

A. Discourage participation in ADL’s.B. Teach appropriate application, removal and

care of skin and brace.C. Discourage sports like golf and tennis

encourage sedentary activities.D. Teach non-weight bearing techniques.

Rods:

Recommended for curves >40 degrees Goal: fuse spine to prevent progression Why is surgery the recommended

treatment for progressive curvature?

Post-op Care

Pain management Monitor Neurovascular status Monitor H&H Log Roll, sit, ambulate Dressing changes Report vomiting WHY???

What would you teach a child to expect in the immediate post-op period?

Frequent neurovascular assessments Need to CT&DB every 2 hours (IS) Possibility of IV, chest tubes Use of post-op analgesia

Discharge

As sited in text No contact jarring activities for 6-12

months X-rays q 1-2 years until bone solidly

fused Once fused may resume normal activity

levels, skiing, sports, etc…