Musculoskeletal Rounds 2: Acquired Musculoskeletal disorders


Slipped Capital Femoral Epiphysis


Slipped Capital Femoral Epiphysis
Spontaneous displacement of the proximal femoral epiphysis
Considered an emergent condition as eary diagnosis and treatment increase the likelihood of a satisfactory resolution
Often occurs before or after a period of rapid growth during adolescence
Most frequently in males
Obesity is a contributing factor

Clinical Manifestations:
Limp
*Vague complaints of hip, thigh or knee pain with may be continuous or intermittent
Diagnosis confirmed by x-ray

Nursing care / interventions:
Emergent treatment to prevent further slippage, presurgery bedrest and traction
Surgical treatment to include placement of pins, screws or osteotomy
Postsurgical care nonweight bearing crutch ambulation until painless ROM

Osteomyelitis


Infectious process in a bone
Acute hematogenous - blood borne bacterium causes infection in bone. Tonsillitis, otitis media, impetigo - bacteria travels to the capillaries in the bone causing obstruction
Exogenous - direct injury to bone or adjacent tissues
Subacute - less virulent walled off infection
Chronic - dead bone, bone loss, sinus drainage

Manifestations:
History of trauma to bone
Ill, irritable child
Fever, restlessness
Elevated temperature, rapid pulse
Dehydration
With redness, tenderness, swelling over bone, muscles tense and painful movement

Treatment in response to offending organism from blood cultures

Nursing interventions:
Pain management, comfort positioning, possible splinting
Antibiotic therapy * Be sure blood cultures have been obtained prior to initiation of antibiotic therapy
Standard precautions
Note intake and output
Drainage from site
*Cast care if appropriate
Limited weight bearing then physical therapy

Skeletal Tuberculosis
Not common in US
Tuberculosis can affect any joint or bone
Most commonly affects spine
Insidious symptoms of joint pain, swelling, stiffness

Nursing Treatment/ Interventions
Antituberculin drug administration - isoniazid, rifampin, or pyrazinamide
Care depends on site with the spine or hip often needing immobilization, casting and fusion like osteomyelitis and septic arthritis

Septic Arthritis
Bacterial infection in a joint
Fluid is aspirated and cultured
Surgery may be required

Nursing interventions:
Pain management
Medication administration
Post surgical care or cast care if needed
Physical therapy
Treatments similar to osteomyelitis


Nursemaids Elbow






Dislocation - displacement of a bones (or bones) from its articulation with a joint
Subluxation - incomplete or partial dislocation of the articular surfaces of a joint.
Dislocations or subluxation common in fingers and elbows of children.
Nursemaids elbox subluxation of the radial head typically in children younger than 5
Dislocations associated with pain and damage to ligament and joint capsule
Normal contour of joint may be affected or length of an extremity
Treated with closed manual reduction and splinted, casted or in a sling for 3 weeks

Overuse syndromes
(Sport) occurs due to athletes training earlier, longer and harder. ..shin splints, plantar faciitis, Osgood –Schlatter, Severies disease
Stress fractures may not show up on x-ray until callus formation noted.
Stay mobile without weight bearing, ice, taping, bracing, splinting,
NSAIDS.
Caution parents against over committing

Sprains and Strains
Sprain is a twisting injury to a joint - ligaments are stretched or torn
Strains are excessive stretching of a muscle/tendon group
Sprains and strains are graded according to severity
Manifestations will depend on it muscle or tendon
May hear a pop and muscles are vascular so they will bruise
X-rays to rule out fracture

Goal:
Keep pain free and return to function

Management:
RICE
Ice 3xs a day for 30 minute intervals
Acetaminophen or Ibuprophen
Treated with casting, bracing, complete tears - surgery
Monitor neurovascular status - pulses distal to injury, pink, capillary refill

Musculoskeletal Injuries
*RICE
Rest, Ice, Compress, Elevate
*With possible musculoskeletal injuries - Observe for the 5 P's*
Pain
Pulse
Pallor
Paresthesia - sensory impairment
Paralysis - movement impediment

Crutches for non weight bearing injury




External Fixation - displaced hospital and at home traction
Stable unilateral fixator along outer aspect of leg
Pins are attached to bone through skin
Clean with 1/2 strength hydrogen peroxide at pin site (pin care)
High rate of infection
Internal Fixation surgery and use of nails
Crutches for non weight bearing injury



Fractures
In young children ligaments and tendons are stronger than bone so fracture more common than strains
Most common upper extremity injuries: fingers, hand, clavicle (collarbone), humerus, elbow, distal radius (wrist)
Most common lower extremity injuries: pelvic, tibial, femur, metatarsal/phalanx, tibia, ankle, femoral neck
Femoral shaft most common

Fractures classified as:
Closed (skin intact)
Open
Plastic (bowing, bending)
Buckle (torus)
Greenstick
Complete (transverse)
Comminuted (multiple fractures, pieces)
Physeal (across the growth plate) - classified with the Salter-Harris system I-IV, wrist is the most common

Signs and symptoms depend on location:
Pain
Edema
Decrease ROM
Deformity
Crepitus grating sound
Functional use decreased
Xrays unless cartilage the US, CT or MRI
Closed reduction or Open reduction?

*Cast care*
Often injuries involving bones and joints must have surgery and are placed in casts.
It is imperative that the nurse observe these extremities and teach cast care to the parents as well
Keep the cast elevated on a pillow
Use palms not hands to avoid compressing the cast
Observe the casted extremity for evidence of swelling or discoloration
Check movement, sensation and temperature of extremity
Encourage rest
ROM of joints above and below cast
*Do not allow the child to put anything in the cast
Provide a clear path for ambulation
Crutches for non weight bearing injury
*Obseve for Compartment syndrome from massive edema or to restrictive cast, splint *5P's
*Cutting the cast off can be frightening


Physiology of bone healing



*Purposes of Traction
To fatigue the muscles so that realignment can occur
To reduce muscle spasm
To position bones for proper healing
To immobolize the site until realignment or healing has been initiated, until casting or splinting is achieved
To prevent contracture
To immobolize

*Types of Traction*
For every action must be an equal and opoosite reaction
Skin traction - uses ace bandages, boots or belts, attached to weights
Used less as costly
Dunlop's Traction - arm (humerus)
Milwaukee Brace - Scoliosis
Russell's Traction - Knee contractures
Bryant's Traction - fracture or infant's with Congenital hip dysplasia (CHD) (with elevation of hips off the bed)
Buck's Traction - Hip fracture

*Long term traction has decreased due to advances in technology. Traction is often used to initially stabilize or align and then newer fixation devices which allow for more movement and flexibility are placed.

References:
Axton, S. E., & Fugate, T. (2003). Chapter 8: Care of Children with musculoskeletal dysfunction. In M. Connor & Y. Kopperman (Eds.), Pediatric nursing care plans (2nd ed., pp. 187-216). Upper Saddle River, New Jersey: Prentice Hall Pearson Education, Inc..

Axton, S. E., & Fugate, T. (2003). Chapter 9: Care of children with neurological/neuromuscular dysfunction. In M. Connor & Y. Kopperman (Eds.), Pediatric nursing care plans (2nd ed., pp. 217-252). Upper Saddle River, New Jersey: Prentice Hall Pearson Education, Inc..

Wilson, D. (2005). The child with musculoskeletal or articular dysfunction. In M Hockenberry, D. Wilson & M. Winkelstein (Eds.), Wong's essentials of pediatric nursing (7th ed., pp. 1147-1186). St. Louis, Missouri: Elsevier Mosby.

Videos:

slipped femoral head located at
http://youtu.be/ICojcqlCm1o

Osteomyelitis
https://youtu.be/pnJWLDwkdr4

Halo Skeletal traction:
https://youtu.be/qCx6pHnBLGk

Nursemaids Elbow
https://youtu.be/-0ROu4hCXwQ
https://youtu.be/3XcDUQ7s62s
Sprain and strain explanation located at
http://youtu.be/mPeNOb2eIyA

Sprains and strains assistance video located at
http://youtu.be/WyJiV5Cgoaw

Types of fractures located at
http://youtu.be/mL0SsSwccdQ

Cast removal
https://youtu.be/167xqGKS9hk

Bone Healing located at
http://youtu.be/qVougiCEgH8

Traction located at
http://youtu.be/OLiqFD4khIo