musculoskeletalmusculoskeletal elisa mancuso, rnc-nic, ms, fns professor of nursing
TRANSCRIPT
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MusculoskeletalMusculoskeletalMusculoskeletalMusculoskeletal
Elisa Mancuso, RNC-NIC, MS, FNSElisa Mancuso, RNC-NIC, MS, FNS
Professor of NursingProfessor of Nursing
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Anatomic Differences
• Child's skeleton contains growth cartilage
• √ Injury = widening of growth plate
• Physis = growth plate. – cartilaginous disq btwn epiphysis and
metaphysis
• Growth plate FX need ↑ follow-up – Growth disturbances– Non-union – Deformity if not healed properly
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Pediatric Fractures• Seldom complete breaks• Buckle or bend RT flexibility of
bones– ↑ thicker periosteum– ↑ amounts of immature bone
• Fractures RT direct force to bone• FX <1 year are always suspicious
– R/O Intentional (Child Abuse) vs. Accidental
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Fracture -Clinical Signs
• Pain @ site with guarding• Tenderness• Edema• Ecchymosis• Impaired ROM• Deformity• Crepitus• Neurovascular status impaired
– Distal to site RT compression
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Neurovascular Check
“Five P’s”1.Pain2.Pallor3.Pulselessness4.Paresthesia5.Paralysis
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Diagnosis• X-ray
– √ R & L extremities– Comparison– Oblique FX→
• CT scan• Bone Scan• MRI
– √ ligament damage
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TherapyRICE• Rest• Ice• Compression• Elevation
Surgery- ORIFOpen Reduction Internal Fixation
Casting- Closed Reduction– Fiber glass – Plaster
• Neurovascular √’s• Pain medication
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Complications
Compartment Syndrome• Surgical Emergency!• ↑ Pressure to FX site• ↓ Circulation• ↑ Risk for infection• ↑ Pain• Tenseness with palpation• Motor weakness• ↓ ROM
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Traction
• Immobilize fracture• Realign bone fragments• ↓ Muscle spasms and pain• Applies pull in 1 direction
– Against counter pull in opposite direction
• Body wt is counter traction• External fixation = ↑ mobility
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Skin Traction• Buck’s
– Leg extended. – 1 line of horizontal - pull.
• Russel’s– Leg extended & knee flexed.– 2 lines of pull; – 1 horizontal & 1 vertical.
• Bryant’s– Hips flexed @ 90 degrees– Buttocks off bed – Both legs extended vertically
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Skeletal Traction
• Pin or wire directly inserted into bone.
• For complicated fx of femurs >6 years
• Complications– Osteomyelitis.
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Immobility Complications
• Skin integrity• Atelectasis• Renal calculi• Constipation• Infections• Osteoporosis-bone demineralization• Fat Embolism
– Female adolescents in 1st 24 hours (Femur Fx)
– Sudden chest pain– SOB– Impending doom! – Tx like PE!
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Nursing Interventions
• √ lab values-– ↑ Ca+, ↑BUN, & ↓ H and H – √ bleeding
• ↑ Hydration (2-3 L/day) – Prevent hypercalcemia & renal
calculi• ↑ Nutrition & Protein
– Small frequent meals• Exercise to help prevent
osteoporosis
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Osteomyelitis
• Infection –– Bacteria invading metaphysis – Forming abscess and local bone
destruction
• Males at ↑ risk at 5-14 years• Causes:
– Trauma or penetration injury – Invasion during surgical procedure– Systemic infection
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Clinical Signs
• ↑ Temp• Erythema and warmth• Pain
– Abrupt onset with ↑ intensity• Non-weight bearing• ↓ ROM• Irritability• Septicemia
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Diagnosis
• CBC ↑ WBC with shift• BC• ↑ ESR• X-ray maybe negative at first• Bone scan
– Show ↑ uptake @ site of infection• Bone Biopsy
– Identify organism and degree of damage
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TherapyIV antibiotics • Long term 4 – 6 weeks
– PICC line• Meningitic dose• Surgery I & D• Nutrition
– ↑ calories, ↑ protein and ↑ fluids
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Osteogenisis Imperfecta OI
• Congenital connective tissue disorder – Defect in synthesis of collagen– Incomplete development of :
•bones, teeth, ligaments and sclera
• Brittle bones and ↑ risk for fractures• Autosomal Dominant-mild-Type I • Autosomal Recessive-severe-Type II • Intrauterine fx and death
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Clinical Signs• Depends on type of OI• Short stature• Fractures from minimal trauma “brittle
bones”• Progressive bone deformities and bowing of
lower limbs• Blue, purple or gray sclera. • Hearing loss by 20-30 years• Thin skin • Bruise easily• Hypoplastic teeth
– Yellow or grayish blue – W shaped – ↑ dental = more severe skeletal
deformities
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Therapy • Prevent fractures-
– Lift gently and avoid jarring movements
– Provide padded and soft environment
• Encourage walking• No contact sports, and no
strenuous activity• Preventative dental caries• Diet ↑ Calcium, ↑ Vit D and ↑C • Maintain healthy weight
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Muscular DystrophyDuchenne’s
• Duchenne muscular dystrophy (DMD) – X-linked recessive disorder, – DMD occurs in 1 in 3000 male
infants.
• Absence or deficiency of dystrophin a skeletal protein product
• Onset @ the fourth year • Often causes death by age 20.
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Signs and Symptoms• Delay in motor development:
– Waddling gait, prolonged lordosis and ↑ falls
• Gower’s sign– Hands push self up from floor when
rising from sitting or supine position• Proximal limb weakness • Pseudohypertrophy of the calves. • Myocardium is affected • Severely disabled by the age of 10.
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DiagnosisMuscle biopsy identifies type of
dystrophy• Absence or deficiency of dystrophin • Degeneration of muscle fibers• Fibrosis and fat present
(Pseudohypertrophy)
• ↑↑ CPK • ↑↑SGPT &↑↑SGOT• EMG (electromyography)-
– ↓↓ Electrical activity in muscles
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Therapy• Genetic counseling • Maintain function in unaffected
muscles as long as possible– ROM, Braces,– ↑ top sneakers to prevent foot drop
• ✔ Respiratory function-– Mobilize secretions, CDB, PD & C
• Promote independence • ↑ Fluids and fiber to prevent
constipation• Anticipatory grieving
– (cardiomyopathy is main cause of death)– Make will & funeral arrangements
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Congenital Hip Dysplasia
Head of femur improperly seated in acetabulum
• Shallow acetabulum– Mildest form
• Subluxation– Incomplete dislocation. – Displaced laterally.
• Dislocation– Femoral head out of acetabulum. – Displaced posteriorly
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Etiology
•↑↑ Maternal estrogen = ↑ relaxation of joints
•Positive family history•Breech presentation•Females 6x > males•Bilateral 20%
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Clinical signs• Asymmetry of gluteal folds• Unequal limb length• Trendelenburg sign
Ortolani test• Flex hips @ 90 degree angle• Adduct hips and apply gentle pressure with
thumbs. • Feel “Click” from femoral head moving out of
acetabulum
Barlow’s• Abduct hips and feel “clunk” of dislocated
femoral • head moving back into acetabulum• Sonogram or x-rays confirm diagnoses
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Interventions• Pavlik Harness
– Newborn to 6 months– Skin care– Must remain on 24 h/day
• Hip Spica Cast– 6-18 months– Change q 4-6 weeks for growth
• Skeletal Traction
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Congenital Clubfoot Talipes Equinovarus
• Most common congenital foot deformity• Boys 2x > girl • Unilateral more common
• Abnormal intrauterine position• Oligohydramminos • Muscular atrophy or dystrophies
• Inversion and lateral border convexity• Plantar flexion-toes lower than heels• Medial adduction of toes and fore
foot
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3 Stage Therapy• Correction of deformity
– Manipulation and casting
• Maintenance of correction – Until normal balance is regained– Follow-up observation
• Surgery by 3-6 months – Manipulation is ineffective with
casting – Unable to maintain position
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Prognosis
• Variable
• Correct foot maybe ½ size smaller– Need 2 different shoe sizes
• Calf is 10% smaller
• Observe the foot closely for several years – Prevent deformity from recurring
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Legg-Calve-Perthes Disease
• Avascular necrosis of femoral head • Causes ↓ circulation to femoral
epiphysis• Ischemia and necrosis to femoral head• Painful limp that is ↑ by activity• Self-limiting• Idiopathic• Trauma• Inflammatory• Boys 4-8 years @ ↑ risk• White 10X > blacks
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5 stages1-Onset-
Epiphysis begins to show ischemia & necrosis
2-Necrosis-Bone weakens and diesCollapse of femoral head
3-Fragmentation-Avascular bone is reabsorbed & healing occurs
4-Reossification-Femoral head and neck re-form
5-Reconstitution- Final healing occurs
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Treatment• Containment of femoral head in
acetabulum – Prevent further stress and damage– 1-2 year healing process
• Blood supply takes long time to reestablish.
• Immobilization-– Casting or brace for 1 ½ years!!
• No Weight Bearing!• Surgery- Latest approach!
– Minimizes immobilization time.– Cast for six weeks – Wheelchair additional 4 weeks