Unit-XIV Musculoskeletal

dysfunctions in children
Presented By:
Junaid Zia
Akhtar Naveed
Awais Ahmad
Muhammad Asim
Arbaz Khan
 Objective
• At the end of the session the students will be able to discuss
the management of following disorders.
• Kyphosis
• Lordosis
• Scoliosis
• Types of common fractures in children.
• Rheumatoid arthritis
• Congenital hip dislocation
• Nursing care, child with cast and traction, rehabilitative care
and other medical and surgical management for the children
with such disorders
 Pediatric differences in the
Musculo-skeletal system

 Muscle tissue is almost completely developed at birth.

 The infant’s bones are neither as firm nor as brittle. Only 65%

ossified at eight months of age.

Skeletal growth is stimulated by pituitary growth hormone.

 Metaphysis: responsible for the growth until adult height is

reached.
 Pediatric differences in the
Musculo-skeletal system cont’d
 Growing bones heal quickly therefore less risk of fractures in
most children.
 The skull is not rigid during infancy and the sutures of the
cranium do not fuse until 12—18 months of age.
 Fractures
Definition of Fracture:
“A break in the continuity of the bone as a result of
trauma, twisting or bone decalcification”.
(Wong, 1999)

“A bone fracture (FRX or Fx or #) is a medical condition

in which there is a break in the continuity of the
bone”.
 Etiology:

 Infancy: Birth trauma, Injury, child abuse,

rough handling, twisting, pulling.
 Childhood: Fall, automobile accidents (most
common b/w 4-7 years)
 Certain medical conditions that weaken the
bones, such as osteoporosis, bone cancer
(termed a pathologic fracture).
 Fractures

Classification of Fractures:
 Closed fracture: No break in the skin.
 Open or compound fracture: An open wound through which the
bone has protruded.
 Comminuted fracture: Fragments of the fractured shaft lie in the
surrounding tissues.
Types of Fractures:
 Bends.
 Buckle fracture.
 Greenstick fracture.
 Complete fracture.
 Some fracture types are:
• Greenstick fracture: an incomplete fracture in
which the bone is bent. This type occurs most
often in children.

• Transverse fracture: a fracture at a right angle

to the bone's axis.
• Oblique fracture: A fracture in which the break
has a curved or sloped pattern.

• Comminuted fracture: A fracture in which the

bone fragments into several pieces.
• Impacted fracture(buckle fracture): is one
whose ends are driven into each other. This is
commonly seen in arm fractures in children

• Pathologic fracture, caused by a disease that

weakens the bones, and stress fracture.
 Care of a child with Fractures
cont’d---
Diagnostic Evaluation:
 Radiographic examination.
 Blood Studies:
CBC (decreased Hb. And elevated WBC’s)
Elevated enzymes due to muscle damage (alkaline
phosphatase, serum glutamic-oxaloacetic transaminase
(SGOT), lactic dehydrogenase (LDH)
 Symptoms
• Intense pain
• Numbness and tingling
• Limited mobility or inability to move a limb
• Out-of-place or misshapen limb or joint
• Swelling, bruising or bleeding
 Sign and symptoms on
assessment

 Assess extent of injury- 5- “P’s”:

Pain and point of tenderness.
Pulselessness (distal to fracture).
Pallor.
Paresthesia (sensation distal
to fractured site).
Paralysis (movement distal
to fractured site).
• Out-of-place or misshapen limb or joint
• Swelling, bruising or bleeding
 Nursing Assessment

 Determine the mechanism of injury.

 Assess the neurovascular status.
 Cover open wound with sterile or clean dressing.
 Ask the child to point the painful area and wiggle the
toes.
 Immobilize the limb and do not attempt to push or
reduce the protruding bone under the skin unless
properly splinted.
 Treatment
• The aim of treatment is to help the bone to
recover.
• Treatment options include setting the limb in
plaster or surgically pinning the bone ends
back together.
• Plaster of Paris is one of the most common
methods used to immobilize a limb.
 Treatment
 Reduction:
Restoring the bone to proper alignment.
Closed reduction: manual alignment of the
fragments, followed by immobilization.
Open reduction: surgical insertion of internal
fixation devices, such as rods or pins in order to
maintain alignment during healing process.

 Retention: Application of traction or cast

 Traction

“The direct application of forces having both direction

and magnitudes to produce equilibrium at a fracture
site”.
(Wong, 1999).
Purpose of traction:
 To reduce muscle spasm so that the bone can be
realigned.
 To position the distal and proximal bone ends in
desired realignment.
 To immobilize the fractured site until sufficient
realignment and healing takes place.
 Types of traction:

 Manual traction
 Skin traction
 Skeletal traction.
 Modern techniques
• Russell's traction: an orthopedic mechanism
that combines suspension and traction to
immobilize, position, and align the lower
extremities in the treatment of fractured
femurs, hip and knee.
• Dunlops traction:
• An orthopedic mechanism that helps
immobilize the upper arm in the treatment of
supracondylar fracture of the elbow.
• The mechanism uses a system of traction
weights, pulleys, and ropes and may be
accompanied by skin traction.
• Buck's traction: one of mechanisms by which
pull is exerted on the lower extremity with a
system of ropes, weights, and pulleys.
• It is used to immobilize, position, and align the
lower extremity in the treatment of
contractures and diseases of the hip and knee.
• The Milwaukee brace, also known as a
cervico-thoraco-lumbo-sacral orthosis or
CTLSO, is a back brace used in the treatment
of spinal curvatures (such as scoliosis or
kyphosis) in children.
 Nursing care of client with traction:

 Maintain functional capacity of traction

 Assess functions of all components including;
frames, ropes, pulleys and weight.
 Ropes should be in center tract of pulley, knots tied
securely
 Pulleys should be in original position it should not
slid from original site
 Wheels should be freely moveable.
 Check weights for correct amount and Hang freely.
 Provide analgesics and muscle relaxants.
 Prevent urinary tract infections and constipation
(assess intake and output for adequate fluid intake).
Nursing care of client with traction:

 Observe for signs of complication; i.e., circulatory

impairment, fracture site problems and bone
infections.
 Check pin sites frequently for signs of bleeding,
inflammation or infection.
 Cleanse the pins with pyodine and cover ends of pins
with protective gauzes.
 Assess Neurovascular status.
 Provide comfort with pillows, rolls or foam.
 Maintain skin integrity with change of position 2h.
 Cast

 Made of plaster or fiberglass to promote

immobilization of bones and joints after fracture or
injury.
 There are 4 major categories of casts:
Upper extremity: wrist or elbow.
Lower extremity: ankle or knee.
Spinal and cervical: spine.
Spica cast: hip and knee.
 Nursing care of child with cast:

 Assess the cast for swelling and neurovascular

complications
 Assess (5 P’s) such as; pain, pallor, Pulselessness,
Paresthesia, and paralysis.
 Observe for bleeding for the first few hours after
surgery.
 Encourage frequent rest and leg elevation during rest.
 Do not allow child to put anything inside cast.
 Prepare for cutting the casts in case of circulatory
impairment.
 Instruct the parents and child to keep the cast clean
and dry.
 Nursing care of child with cast:

 Avoid allowing the affected limb to hang down or standing for

more than 30 min.
 Instruct parent to keep a clear path for ambulation by
removing toys or other items.
 Instruct child and parent to avoid
placing the cast in water
 If experience an itch, don’t poke
anything between the cast and your limb
(such as a pencil).
 Surgery
• Operation procedures depend on the location and
severity of the fracture, for example:
• Closed or simple fractures ­– the two ends of the
broken bone are lined up and held in place.
• Open or compound fractures – these have to be
thoroughly cleansed in the operating room to
remove debris to avoid the risk of infection. And
then is repair.
• Long bones – long bones are generally treated by
internal nailing
 Nursing intervention.

• Provide adequate pain relief medication.

• Assess for swelling of the limb.
• Assess fro the sign of infections.
• Administer prescribed antibiotics to prevent
infection.
• Parent education of how to keep the wound clean and
dry.
• Report any sign of swelling, blueness or loss of
movement of the fingers or toes, numbness or
increased pain.
 Kyphosis

• “Kyphosis is a curving of the spine that causes a

bending or rounding of the back, which leads to a
slouching posture.”
 Causes

Kyphosis can occur at any age.

• Adolescent kyphosis, also known as Scheuermann's
disease, is caused by the wedging together of several
bones of the spine. Unknown cause.
• Degenerative diseases of the spine (such as arthritis)
• Fractures caused by osteoporosis.
• Injury (trauma)
• Slipping of one vertebra forward on another
(spondylolisthesis)
 Tuberculosis
 Symptoms

• Difficulty breathing (in severe cases)

• Fatigue
• Mild back pain
• Round back appearance
• Tenderness and stiffness in the spine
 Tests
• Physical examination
• Spine x-ray
• Pulmonary function tests (if kyphosis affects
breathing)
• MRI (if there may be a tumor, infection, or
neurological symptoms)
 Treatment
Treatment depends on the cause of the disorder:
• Congenital kyphosis requires corrective surgery at
an early age.
• Scheuermann's disease is treated with a brace and
physical therapy.
• The osteoporosis needs to be treated to help prevent
future fractures..
• Kyphosis caused by infection or tumor needs to be
treated with surgery and medications.
 Complications

• Decreased lung capacity

• Disabling back pain
• Neurological symptoms including leg
weakness or paralysis
• Round back deformity
 Lordosis

• Lordosis is an increased curving of the spine.

• Inward curvature of a portion of the lumbar and
cervical vertebral column”
• curve has convexity anteriorly and concavity
posteriorly
 Cause

• The cause of lordosis is unknown

• Associated factors include tight low back muscles,
excessive visceral fat, and pregnancy.
• Other causes include Rickets, a vitamin D deficiency.
 Secondary to trauma.
 Associated with obesity, congenital dislocated hip.
 Diagnosis

• Physical examination
• X-ray
• MRI
 Treatment of lordosis

• Specific treatment for lordosis depend on child's age,

overall health, and medical history
• The extent of the condition
• The goal of treatment is to stop the progression of the
curve and prevent deformity.
• Surgical correction.
• Bracing .
 Weight loss
 Postural exercises to relieve symptoms
 Support garments
 Scoliosis
Definition:
“It is a complex spinal deformity involving lateral
curvature of spinal with rotary deformity (spine, chest
and pelvis)(Wong, 1999)
• The bones of the spine twist on each other, forming a
"C" or an "S" shape spine
 Causes

• Idiopathic.
• Genetic and transmitted as an autosomal dominant trait.
• infantile scoliosis: age 3 and younger
• juvenile scoliosis: age 4 – 10
• adolescent scoliosis: age 11 – 18
• Congenital scoliosis: when the baby’s ribs or spine bones
do not form properly.
• Neuromuscular scoliosis: is caused by a nervous system
problem that affects your muscles, such as muscular
dystrophy.
 Symptoms

• May be no symptoms.
• Sometime low-back pain
• Tired feeling in the spine after sitting or
standing for a long time
• Uneven hips or shoulders
• Spine curves more to one side
 Diagnostic tests

• Physical examination.
• One shoulder is higher than the other
• The pelvis is tilted.
• X-ray of the spine.
• MRI of the spine.
 Treatment

• Treatment depends on the cause, location, size of

scoliosis
• Idiopathic scoliosis may not need treatment.
• If still growing, the doctor might recommend a back
brace
• Sometimes surgery is needed.
• Scoliosis surgery involves correcting the curve as
much as possible.
• After surgery using a brace for a little while to keep
the spine still.
 Complications

Complications of scoliosis may include:

• Breathing problems (in severe scoliosis)
• Low back pain
• Lower self-esteem
• Persistent pain if there is wear and tear of the
spine bones
• Spinal infection after surgery
• Spine or nerve damage from an uncorrected curve
or spinal surgery
 Scoliosis cont’d---
Nursing Management:
 Encourage for bracing and exercise.
 Assess environment for hazards to prevent from injury.
 Examine skin surface in contact with brace for the sign of
irritation.
 Verbalize the feelings regarding body image disturbance .
 Encourage the child to participate in social activities.
Surgical Management:
 Spinal Realignment and straightening with internal fixation
and instrumentation combined with bony fusion of the
realigned spine.
 May require use of tractions before and after Surgery
 Scoliosis cont’d---

Post-operative care:
 Assessment: wound, circulation, V/S, Neurological
status (esp. extremities).
 Changing the position of patient.
 Encourage for exercise of thigh and calf muscle.
 NG tube insertion.
 Assess the level of pain and provide pain
management (analgesics, epidural infusions)
 Encourage physiotherapy (ROM)
 Involve family in providing care to the patient.
 Congenital Clubfoot
(Talipes Equinovarus)
Definition:
“It is a complex deformity of the ankle and foot. Also
referred to as Talipes Equinovarus”.
(Wong, 1999).
Characteristics of the deformity:
 Fixed plantar flexion (equinus) of
the ankle, and inability to bring
The foot to a standing position.
This is caused by a tight Achilles
tendon.
 Cont…

Characteristics of the deformity:

 Adduction (varus), or turning in of the heel.
Causes:
 Congenital or idiopathic
 Abnormal development of the muscles, tendons, and
bones during the first trimester of pregnancy (about
the 8-12 week) or abnormal positioning in utero.
 Certain Neurogenic conditions (Spina bifida,
cerebral palsy etc.).
 Cont…
Diagnostic Evaluation:
 Physical assessment
 Radiographic examination.
Management:
Regular passive exercises
 Manipulation and application of
cast series for the first 6-12 wks.
of life soon after birth.
 Surgical intervention involves;
pin fixation and release of tight joints
and tendons.
 Cont…

Nursing Considerations:
 Neurovascular assessment.
 Pain management
 Range of motion passive exercise
 Instruct parents about cast care and the signs of
neurovascular impairment.
 Use of braces, special shoes to ensure continual
growth.
 Congenital Hip Dislocation

Definition:
“It is an abnormal formation of the hip joint. The ball at the
top of the thighbone (femoral head) is not stable in the
socket (acetabulum). Also, the ligaments of the hip joint
may be loose and stretched”.
(Pediatric Orthopedic Society of North America, June 2004)

Incidence:
It occurs once in every 1,000 live births.
(Pediatric Orthopedic Society of North America, June 2004)
 Congenital Hip Dislocation

Causes or Risk factors for CHD:

 Family history.
 First-born babies are at higher risk since the uterus
is small and there is limited room for the baby to
move.
 Twin or large infant size.
 Position of the baby in the uterus, especially with
breech presentations.
 Association with other orthopedic problems that
include; clubfoot deformity, congenital conditions,
and other syndromes.
 Congenital Hip Dislocation

Clinical Manifestations:
 Shortening of the affected limb.
 Restricted abduction of the
affected leg.
 The Gluteal folds in the skin of the
thigh or buttocks may appear
uneven.
 The space between the legs may look wider than
normal
 Congenital Hip Dislocation

Diagnostic Evaluation:
 X-Rays.
 Ultrasound.
 MRI.
 CT-Scan.
 Juvenile Rheumatoid Arthritis

Auto immune, inflammatory disease (Wong, 2005)

Affect body's connective tissue; multisystem disoder.
“Juvenile Arthritis (JA) refers to a number of
.
different conditions, all of which strike children of 16
years of age or less and have pain, tenderness and
joint inflammation and stiffness(of one of more
joints). The condition is also referred to as Juvenile
Rheumatoid Arthritis”.

Encyclopedia of Children's Health (2007)

 Cont…

Onset:
The two peak ages:
2-5 years.
9-12 years.
Epidemiology
 Overall prevalence of juvenile
rheumatoid arthritis is estimated
to be from 30 - 150 per 100,000
children.
(Encyclopedia of Children's Health, 2007)
 Juvenile Rheumatoid Arthritis.
Cont’d---
Causes:
• Unknown
• Genetic: (specific genetic marker has not been
identified yet).
• Immunologic: Disease process involves loss of
tolerance towards auto-antigens  chronic synovitis;
Production of auto-antibodies
• Environmental Factors: Viruses.
 Cont…

Pathophysiology:
 Chronic inflammation of the synovium with joint
effusion and eventual erosion, destruction and
fibrosis of the articular cartilage.
 Cont…

Clinical Manifestations:
 Stiffness, Swelling and loss of motion
of affected joint.
 Edema, joint effusion.
 Pain and tender joint.
 Morning stiffness.
 Fever and rash.
 Systemic involvement.
(e.g., heart and lungs).
Clinical Manifestations of JRA
 Cont…

Diagnostic Evaluation:
 Symptoms last for >6 months.
 Radiographic examination.
 Increase ESR.
 Elevated white blood cell count.
 Elevated C-reactive protein.
 Juvenile Rheumatoid Arthritis.
Cont’d---
Medical Management:

Oral
Corticosteroids

Cytotoxic Drugs

Slow-acting
Anti-Rheumatic Drugs

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

 Juvenile Rheumatoid Arthritis.
Cont’d---
Surgical Management:
• Open biopsy or soft tissue release (tenotomy)
• Joint replacement (successful in older children).
 Cont…
Nursing management:
 Relieve pain: Non-pharmacological modalities.
 Promote general health:
Well-balanced diet.
Discourage increase periods of
rest to avoid weight gain.
Posture and body mechanics. (prone position is
encouraged)
Firm mattress and use of splints to maintain good
alignment.
 Cont…
Nursing management (cont’d---):
 Encourage heat, rest and exercise spaced throughout
the day:
 Encourage for Swimming activity.
 Play therapy (throwing or kicking a ball, riding a
tricycle with a seat raised).
 ROM exercises when disease is disappeared.
 Encourage patient for socialization
 Share concerns from the families regarding disease
process.
Thanks