Pediatric Nursing
Musculosketal Disorders
__________
Remedios H. Fernando, EdD RN LPT
St. Luke’s College of Nursing
The musculoskeletal system
Anatomy & Physiology
Assessment
A. Structure
B. Function
C. Developmental Differences in
Musculoskeletal Response
1.Damage to the epiphyseal plate can disrupt
bone growth
- area of bone weakness
2. Because child is still growing some bony
deformities that have resulted from injury can
be remodelled or straightened over time, but
can also causes deformities.
3. Because child’s bone are more pliable than an
adult’s bone, more force is required to fracture a
bone specific forces may produce different types of
fracture.
4. A child’s bone generally heal much faster than
those of an adult, so the time required for
immobilization after injury may greatly reduced.
5. Dislocation and sprains are less common in
children than adults because soft tissues are resilient.
Assessment:Cardinal Signs
I. Health History: Cardinal signs
Delayed walking or other motor
developmental abnormalities
Pain, stiffness or both
Physical limitation, lifestyle alterations r/t
immobility, limited ROM
b. Explore prenatal, personal and family history
for risk factors
Prenatal Risk Factors :
- maternal infections
- use of substances or medications
- position in utero or fetal hypoxia
Personal Risk Factors:
- multiple birth - perinatal trauma
- type of delivery - use of mobility aids
- genetic disorders - sports participation
- low birth weight - safety measures used
- obesity - use of steroids
- delayed growth or puberty
Family Risk Factors
- history of musculoskeletal or
neuromuscular ds.
- osteogenesis imperfecta
- JRA
- Scoliosis
PE
a.Vital signs
measure height and weight for signs of growth
abnormalities
b.Inspection
inspect for posture and gait
inspect for body symmetry of shape and movement including
active ROM
observe for structural abnormalities (club foot, etc)
c. Palpation
palpate bony structure for tenderness, masses
and lesions
Palpate the joints for ROM (passive), tenderness
and warmth (signs of inflammation)
Palpate the spine to assess the curvature
Assess muscle mass, tone and strength
Labs and Diagnostics
Radiograph
Ultrasound
Blood studies – CBC
Alkaline Phosphatase – enzyme elevated in
bone ds and fracture
Creatinine Kinase – enzyme elevated in trauma
and muscular dystrophy (MD)
Arthroscopy
Arthrography
Bone Scans
Computed tomography scans
MRI
Joint aspiration
Nursing Diagnosis
Risk for peripheral neurovascular dysfunction
Risk for injury
Activity intolerance
Impaired skin integrity
Constipation
Impaired urinary elimination
Ineffective breathing pattern
Risk for deficient fluid volume
Acute or chronic pain
Imbalanced nutrition: less than or more than
body requirements
Delayed growth and development
Planning and Outcome
The child will remain free from signs and
symptoms of neurovascular compromise.
The child will remain free from injury and maintain
muscle strength, endurance and flexibility
The child will maintain normal skin integrity
The child will maintain normal cardiopulmonary
pattern
The child will remain pain free
The child will remain well hydrated and well
nourished
The child will maintain age appropriate
autonomy, interact with peers and family and
express fears and concerns.
Congenital Hip dislocation
a.k.a Developmental Dysplasia of the hips
A group of disorders related to abnormal
development of the hips.
Refers to variety of conditions in which the
acetabulum are improperly aligned
Congenital Hip dislocation
Etiology: unknown
attributed to prenatal condition
(e.g position, maternal hormone relaxin
and estrogen –cause laxity of the hip
joint and capsule)
Pathophysiology:
HIP DISLOCATION/DYSPLASIA
Subluxation – incomplete contact between
articular surfaces of the acetabulum and
femoral head
Dislocation –there is full loss of contact
between articular surfaces of the acetabulum
and femoral head
Clinical manifestations:
Newborn Assessment:
1. Shortening of the affected limb.
2.Decreased sensation on affected leg (decreased ROM)
3.Alli’s sign – child in supine, flexed thigh to a 90 degrees
angle towards the abdomen, unequal knee
height.
4. Unequal gluteal folds
5.Restricted abduction on affected leg (6-10 weeks of age)
6.Positive ortolani or barlow signs up to 2 – 3
months.
7. History of delayed walking.
8. Trendelenburg sign
ORTOLANI TEST
ALLIS/GALEAZZI
Priority Nursing Diagnoses:
1.Knowledge deficit
2. Impaired physical mobility r/t pressure from casts and
braces
3. Risk for impaired skin integrity r/t pressure from cast
and braces.
4. Risk for altered tissue perfusion (peripheral) r/t
pressure from casts and braces
5. Risk for altered growth and development r/t limited
mobility and potential decreased exposure to stimulation.
Planning and Implementation:
1.Correction involves positioning the hip into a flexed
, abducted (externally rotated).
2.For infants less than 3 months, most common
treatment is the use of pavlik harness
3. For infants older than 3 months, the most common
treatment is the use of skin traction followed by spica
cast application.
4. Correction in the child older than 18 months
requires traction, operative reduction and
rehabilitation.
PAVLIK HARNESS
HIP SPICA CAST
BRYANT’S TRACTION
Club Foot
used to describe a common deformity in which the
foot is twisted out of its normal shape or position.
Types:
a. Talipes equinus – plantar flexion in which
the toes are lower than the heel
b. talipes calcaneus – dorsiflexion in which the toes
are lower than the heel
c. talipes varus – an inversion or bending inward
d. talipes valgus – an eversion or bending outward
EQUINOVARUS
Etiology:
1.Unknown
2. Abnormal intrauterine position
3.Neuromuscular or vascular problems
4. Strong familial tendency
Incidence: 1-2: 1000 live births
Priority Nursing Diagnoses:
1. Impaired physical mobility r/t to cast wear.
2. Altered parenting r/t emotional reaction
following the birth of an infant with a physical
defect.
3. Risk for impaired skin integrity r/t cast wear.
4. Knowledge deficit; deformity, treatment and
home care.
Planning and implementation:
1.Correction is achieved best if is begun in the
newborn period as the small bones begin to
ossify after birth.
2. Manipulation and series of casting should
begin immediately and continued for 8 -12
weeks. Cast are changed Q 1 – 2 weeks.
3. Parents then need to perform passive ROM.
4. May use Denis Browne splints.
5. Surgery.
LEG CASTING
Thank You!
