MUSCULOSKELETAL SYSTEM PEDIATRICS

MUSCULOSKELETAL SYSTEM

Care of the child with a Cast

•            if cast is of plaster – will remain wet for at least 24 hrs

•            use only the flats of their hands to move children

•            casts must remain open to the air until dry

•            casted extremities are elevated to help blood return and reduce swelling

•            Initial chemical hardening reaction may cause a change in an infant’s body

•            Choose toys too big to fit down cast

•            do not use baby powder near cast – medium for bacteria

•            prepare for anticipated casting by having child help apply cast in a doll

Diagnoses and interventions:

1. Potential for alteration in tissue perfusion related to constriction of cast

•          Check color, sensation and motion distal to the cast every half hour

•          Check pedal or radial pulse

•          Check for tightness by slipping finger under edge; if impossible – cast is too tight

•          Ask child to move toes or fingers

•          Elevate casted extremity

2. Potential for alteration in skin integrity

•          Remove plaster flakes from skin

•          Handle wet cast carefully so as not to cause indentations

•          Expose wet cast to air to hasten drying

•          Support heavy cast with sling or pillow to decrease pressure of cast edges

•          Check cast for foul or musty odors

3. Potential for fear and loneliness

•          Encourage expression of feelings

•          Provide diversional play

•          Encourage friends and family to visit children as often

•          Provide educational opportunity for children confined for long periods

4. Potential for knowledge deficit of family

•          Encourage discussion of feelings and fears

•          Provide information and reassurance as appropriate

•          Involve family in child’s care in hospital

•          Prepare family for some emotional regression

CONGENITAL HIP DISLOCATION

•            displacement of the head of the femur from the acetabulum

•            present at birth although not always diagnosed

•            familial disorder

•            unknown cause; may be fetal position in utero

•            acetabulum is shallow and the head of femur is cartilaginous at birth

Assessment:

•            maybe unilateral or bilateral

•            limitation of abduction (cannot spread legs to change diaper)

•            Ortolani’s click

1. With an infant supine, bend knees and place thumb on bent knees,

            fingers at hip joint

2. Bring femur 90degrees to hip, then abduct
3. Palpable click – dislocation

•          Barlow’s test

1. With  infant on back, bend knees
2. Affected knee will be lower because the head of the femur dislocates

            towards the bed of gravity

•          additional skin folds with knees bent

•            when lying on abdomen, buttocks of affected side will be flatter

•            Trendelenburg test – if child can walk

1. Have child stand on affected leg only
2. Pelvis will dip on normal side as child attempts to stay erect

Management:

•          Goal : to enlarge and deepen the socket

•          Early treatment:  positioning the hip in abduction with the head of the femur in the acetabulum and maintaining it in position for several months

•          Traction and casting (hip spica)

•          Surgery

Nursing intervention:

•            Maintain proper positioning:  keep legs abducted

1. Use triple diapering
2. Use Frejka pillow splint (jumperlike suit to keep legs abducted)
3. Place infant on abdomen with legs in “frog” position
4. Use immobilization devices

•          Provide adequate nutrition

•          Provide sensory stimulation

•          Client teaching and discharge planning:

CLUBFOOT (Talipes)

•            abnormal rotation of foot at ankle

Varus – inward rotation; bottom of feet face each other

Valgus – outward rotation

Calcaneous – upward rotation; would walk on heels

Equinas – downward rotation; would walk on toes

Most common – talipes equinovarus

Assessment: 

•            foot cannot be manipulated by passive exercises into correct  position

Management:

•            exercises

•            casting

•            Denis Browne splint (bar shoe)

•            surgery and casting

Nursing Intervention:

•            perform exercises as ordered

•            provide cast care

•            child who is learning to walk must be prevented from trying to stand; apply restraints if necessary

•            provide diversional activities

•            provide skin care

•            client teaching

SCOLIOSIS

•            lateral curvature of  the spine

•            most commonly in adolescent girls

•            familial pattern; associated with other nueromuscular condition

•            idiopathic majority

Assessment:

•            failure of curve to straighten when child bends forward with knees straight and arms hanging down feet

•            uneven bra strap marks

•            uneven hips

•            uneven shoulders

•            asymmetry of rib cage

•            xray: reveals curvature

Management:

•            stretching exercises

•            Milwaukee brace – worn 23 hours/day for 3 years

•            plaster jacket vest

•            spinal fusion

•           

Nursing Intervention:

•            teach/encourage exercise

•            provide care for the child with Milwaukee brace

1. Child wears brace 23 hours/day
2. Monitor pressure points
3. Promote positive body image with brace

•          Provide cast care

•          Assist with modifying clothing for immobilization devices

•          Adjust diet with decreased activity

•          Provide client teaching and discharge instructions

1. Exercise
2. Cast care
3. Correct body mechanics
4. Alternative education for long term hospitalization
5. Availability of community agencies

JUVENILE RHEUMATOID ARTHRITIS

•            systemic, chronic disorder of connective tissue

•            autoimmune reaction

•            results from eventual joint destruction

•            affected by stress, climate and genetics

Types:

1. Monoarticular JRA

•          Fewer than 4 joints involved (usually legs)

•          Asymmetric

•          Good prognosis

•          Mild signs of arthritis

2. Polyarticular JRA

•          Multiple joints affected

•          Symmetrical

•          Involvement of TMJ

•          Remissions and exacerbations

•            poor prognosis

3. Systemic disease with polyarthritis (Still’s disease)

•          Fever, rash, LADP, anorexia, weight loss

•          Exacerbations and remissions

Assessment:

•          No specific diagnostic tests

•          ESR, ASO, RF- not specific

Intervention

•          Drugs: ASA, corticosteroids

•          NSAIDS

•          Physical therapy – strengthening muscles, preventing deformities

•          Splints – used for knees, wrists and hands – to reduce pain and prevent

            or reduce flexion deformities

Nursing intervention:

•            Assess joints for pain, swelling, tenderness

•            promote maintenance of joint mobility

            a.  ROM exercises

            b.  Isometric exercises

•            change position frequently; alternate sitting, standing, lying

•            promote comfort and relief

•            provide firm mattress

•            maintain proper body alignment

•            keep joints mainly in extension, not flexion

•            cold treatments: in acute episodes

•            focus on child’s strength