Module 8 MUSCULOSKELETALMOBILITY OVERVIEW Musculoskeletal bones muscles joints

Module 8 MUSCULOSKELETAL/MOBILITY

OVERVIEW Musculoskeletal bones muscles joints tendons ligaments cartilage system is composed of the

TYPES OF BONES Long bones- tibia, fibula, femur, humerus, ulna Sort bones- such as those in wrist and ankle Flat bones- skull, sternum, ribs Irregular bones- pelvis, vertebrae, scapula

TYPES OF MUSCLES Skeletal (striated)- voluntary muscles; deltoid, biceps, gluteal, etc. . Smooth (short-fibered)- involuntary muscles; GI tract, lungs, pupils, etc. . Cardiac (striated, special function)

PEDIATRIC DIFFERENCES Fibrous membrane still exists between the cranial bones (fontanels) Posterior closes between 2 -3 months, anterior stays open until approx. 18 months of age to allow for brain and skull growth Secondary ossification occurs as the long bones grow Calcium intake during childhood and adolescence is essential for bone density

PEDIATRIC DIFFERENCES Growth takes place in the epiphyseal plates, injury in this portion is of concern in childhood Rapid bone growth facilitates healing after a fracture Can have growing pains because of rapid growth as well Long bones are porous and less dense; bones can bend, buckle or break

PEDIATRIC DIFFERENCES In utero thoracic and sacral spine are convex curves (rounded) Cervical region becomes concave as baby can hold head up When learning to stand, the lumbar region becomes concave Abnormalities can occur- scoliosis, lordosis, kyphosis

PEDIATRIC DIFFERENCES Muscular system is almost completely formed at birth The length and circumference grow, but not the number Maximum diameter for girls 10 years of age; 14 in boys Strength continues to increase until 25 -30 yrs

MUSCULAR SYSTEM Almost completely formed at birth Muscles don’t increase in number, just length and circumference Fibers reach maximum diameter around 10 years of age for girls and 14 yrs in boys Strength continues until 25 -30 yrs of age Until puberty, ligaments and tendons are stronger than bone

Ligaments are the structural support connecting bones Tendons connect bones to muscles

PEDIATRIC DIFFERENCES Cervical and lumbar areas become concave Bowed legs (genu varum) in infant Knock knees (genu valgum) in preschool child Resolve with growth

STRUCTURAL DEFORMITIES Developmental dysplasia of the hip Scoliosis, kyphosis, lordosis

DDH Femoral head and acetabulum are improperly aligned Hip instability Dislocation Subluxation Dysplasia of acetabulum Figure 28– 10 The asymmetry of the gluteal and thigh fat folds is easy to see in this child with developmental dysplasia of the hip.

DDH Left hip more often than right Maternal estrogen may be a link to laxity of joint, especially in females Possible cultural factors Assessment Limited abduction of affected hip Asymmetric gluteal and thigh folds Allis’ sign; Ortolani-Barlow maneuver

DDH Treatment Pavlik harness Skin traction- Bryant’s traction Casting Pain control Prevent complications from immobility Promote normal growth and development

DDH Figure 28– 11 The most common treatment for DDH in a child under 3 months of age is a Pavlik harness. A shirt should be worn under the harness to prevent skin irritation (it was omitted for clarity in this photograph).

DDH Figure 28– 12 For infants older than 3 months of age, skin traction is commonly used for treatment of DDH

SCOLIOSIS Abnormal curvature of the spin Congenital Idiopathic Acquired Can be structural or compensatory More often in girls than boys Ages 10 -13 is highest incidence

SCOLIOSIS Figure 28– 15 A child may have varying degrees of scoliosis. For mild forms, treatment will focus on strengthening and stretching. Moderate forms will require bracing. Severe forms may necessitate surgery and fusion. Clothes that fit at an angle, such as this teenage girl’s shorts, and anatomic asymmetry of the back provide clues for early detection.

ASSESSEMENT Most commonly right thoracic, left lumbar Ribs forced closer together Uneven shoulders Uneven hips, one-sided rib hump Prominent scapula X-ray Can also us CT, MRI, bone scan for degree of curvature

SCOLIOSIS TREATMENT Limit or stop the progression Rehab Bracing- Boston brace Spinal fusion

SCOLIOSIS Nursing concerns? Nursing consideration? Nursing diagnoses? Nursing interventions?

CHRONIC CONDITIONS Juvenile Rheumatoid Arthritis- Chapter 17 Chronic autoimmune inflammatory disease More common in girls Ages 2 -5, or 9 -12 Can enter into remission, or become chronic Joint inflammation Decreased Swelling pain mobility

JRA Figure 17– 5 Joint inflammation and destruction in rheumatoid arthritis Diagnosis made by jistory and assessment findings Onset before 17 yrs of age, persisting for >6 weeks

JRA ASSESSMENT Pain Impaired mobility Interference with growth and development Fever Rash Lymphadenopathy Splenomegaly Hepatomegaly Limp Favor one extremity Slow or uneven growth Pain Swelling

JRA Pauciarticular- knees, ankles, elbows, more common in girls Systemic arthritis- males and females equally; high fever, polyarthirits and rheumatoid rash; affects internal organs and joints Polyarticular arthritis; many joints (5 or more), particularly small joints (hands, fingers, hips, knees feet, ankles and neck)

DIAGNOSIS May occur for a limited time and them improve, may recur periodically, or may last for 3 -6 months or longer No specific lab test, but can run Rheumatoid factor Human leukocyte antigen B 27 Antinuclear antibody (ANA) ESR

TREATMENT Drug therapy Physical therapy Surgery Relieve pain Prevent contractures Aspirin or NSAIDS Steroids

NURSING CARE Pain relief Promoting mobility Adequate nutrition Promotion of growth and development Prevent contractures

ACUTE FRACTURES Break in bone integrity Result from direct trauma-falls, sports injuries, abuse, MVA Result from bone diseases- osteogenesis imperfecta Occur frequently in children because bones are less dense and more porous

FRACTURE SX Pain Abnormal positioning Edema Immobility or decreased ROM Ecchymosis Guarding Crepitus

Common sites Clavicle Tibia Ulna Femur Distal forearm of ulna and radius most common

TYPES OF FRACTURES

DIAGNOSIS X-ray Examination and palpation

NURSING CARE Good hx, identify cause of injury Pain management Cast care Traction Internal vs. external fixation Care post realignment Open reduction Closed reduction

Complications Pain Infection Vascular injury Malunion Non union Fat or bone embolus Assessment for compartment syndrome Delayed G & D Neurovascular assessment Pain Pulses Paraesthesias

NURSING CARE Maintain proper alignment Monitor neurovascular status Promote mobility Home care teaching Pain management Prevention of infection

SKELETAL TRACTION

SKIN TRACTION

EXTERNAL FIXATION

SPICA CAST

NURSING-FRACTURES Diagnoses Considerations Priorities Medications Analgesics Antibiotics Muscle relaxers