Musculoskeletal Deficits

Kimberly Ambruso, RN, MS NU 102 Fall 2012

Musculoskeletal A&P
Function of bones
Protect Stabilize Surface for muscles Reservoir for storage of minerals Hematopoesis

Pediatric Differences
Musculoskeletal development of neonates and infants is immature better chance of correcting or preventing further progression of abnormalities Periosteum: provides nourishment to the bone. Thicker in children faster healing

Musculoskeletal Assessment
X-ray Bone scan Electromyography Muscle or bone biopsy Arthroscopy

Fractures
Common in children Most frequently broken bone in child? Causes: Children Adults Methods of treatment different in pediatrics than in older adult population

Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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Types of Fractures
Compound or open Complicated Comminuted Greenstick

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Clinical Manifestations of Fracture

Generalized swelling Pain or tenderness Diminished functional use May have bruising, severe muscular rigidity, crepitus
5 Ps of Fractures Pain and point of tenderness Pulsedistal to the fracture site Pallor Paresthesiasensation distal to the fracture site Paralysismovement distal to the fracture site

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Cast Care
Drying time Turn Q2hrs while drying Handling wet cast Elevate casted extremity

Cast Care
Nursing care Skin Pain Neurovascular Compartment syndrome Eating/diet Body image and socialization

Splints
Purpose: Immobilization Support Allows more room for swelling Fewer complications

Braces
Purpose: Provide support Control movement Prevention of further injury

Reduction
Open
Fractures Followed by fixation ORIF

Closed
Fractures Dislocations Followed by immobilization

Traction
Traction: extended pulling force may be used to: Provide rest for an extremity Help prevent or improve contracture deformity Correct a deformity Treat a dislocation Allow position and alignment Provide immobilization Reduce muscle spasms (rare in children)

Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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Traction: Essential Components

Traction: forward force produced by attaching weight to distal bone fragment Adjust by adding or subtracting weights Countertraction: backward force provided by body weight Increase by elevating foot of bed Traction must be continuous Weights must hang freely
Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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Types of Traction
Skin traction Non-invasive Secured by straps and bandages Bucks: most common Skeletal traction Surgically inserted rods/bars into the bone, through the skin Serious potential for infection

Hip Replacement
Indications Osteoarthritis Rheumatoid arthritis Trauma Congenital abnormalities Procedure Titanium or cobalt ball and socket Socket is cemented into acetabulum

Pre-Op Assessing risks for complications Obesity Cardiac Age Varicose veins History of DVT, emboli

Total Hip Replacement

Hip Replacement Nursing Care

Post-op
Standard post-op Prevention of infection Hemodynamics DVT prophylaxis Wound drainage Positioning Abduction Flexion rotation Ambulation PT begins immediately

Patient Education Total Hip Precautions No bending No adduction Hip cannot flex past 90 degrees No internal rotation No external rotation

Complications
Skin
Skin Breakdown Nerve Damage
foot drop

Skeletal
Infection
osteomyelitis Shock

Circulatory impairment
DVT

Skin
Pin care

Nerve damage

Compartment Syndrome
Increased pressure within the muscle lack of oxygen to the tissues damage to blood vessels and nerve and muscle cells EMERGENCY!!

Compartment Syndrome
Remove cast!!! Elevate extremity Fasciotomy Dont forget to do neurovascular checks!!

Osteomyelitis
Causes: Extension of soft-tissue infection Direct bone contamination Bloodborne spread from another site of infection
Manifestations: localized pain, edema, erythema, fever, and drainage Interventions Promote nutrition

vitamin C and protein

Encourage adequate hydration Administer and monitor antibiotic therapy

Other Complications
Pressure Ulcers
Pressure on bony prominence under cast or brace Pain/tightness in area Warm sensation in area Foul odor, drainage Removal of cast

Disuse Syndrome
Resulting from immobility Muscle atrophy Isometric exercises Muscle setting exercises

Developmental Dysplasia of the Hip

The head of the femur is improperly seated in the acetabulum A&P: ball and socket More common in caucasians, females and first born children
Asymmetry of gluteal skin folds upon extension of legs
Ortolanis sign

Barlows sign
Limited ROM

Lop-sided
Gait changes

Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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Hip Dysplasia- Manifestations

Ortolani / Barlow

Pavlik Harness
Maintains flexion, abduction and external rotation Initially worn continuously Improper positioning avascular necrosis

Straps need adjustments at regular intervals Nursing care

Hip Dysplasia Management

-Bryants Traction
Purpose Nursing considerations -Spica Cast -Surgery Osteotomy, with possible tendon release

Scoliosis
Lateral curvature of the spine and spinal rotation Severity
Mild: 10-20 degrees Moderate: 20-40 degrees Severe: > 40 degrees

Etiology
Idiopathic Congenital Neuromuscular: Muscular Dystrophy, CP, Spina Bifida

Scoliosis
Screening Asymmetry of ribs, flanks upon exam Adams test Leg length discrepancy X-Rays on spine, thorax
Assessment

Management
Mild: wait and see Moderate: Milwaukee Brace / TLSO Purpose Nursing implications Severe: surgery Spinal fusion Harrington Rod Post-op

Milwaukee Brace

TLSO Boston Brace

Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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Nursing Considerations
Concerns of body image Concerns of prolonged treatment of condition Preoperative care Postoperative care

Mosby items and derived items 2007, 2003 by Mosby, Inc., an affiliate of Elsevier Inc.

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