Musculoskeletal Rounds:

Congenital disorders:

Clubfoot:
Complex deformity of the ankle and foot
Bilateral in 50% of cases
Cause: Arrested development or in utero positioning

Positional responds to stretching and casting
Syndromic is associated with other anomalies such as spina bifida
Congenital idiopathic, has a wide range of severity

Nursing Interventions:
Correction, maintenance and follow-up
Cast care and or surgery
Parental education





Developmental Dysplasia of the Hip (DDH)
Spectrum of congenital hip disorders
Left hip 60% cases, also 60% of cases involve girls

Predisposing factors:
Physiological factors - maternal hormones, intrauterine positioning
Mechanical factors such as breech presentation, oligohydramnios
Genetics

Typical - infant is neurologically intact or teratologic (< common)
*Culture - cultures that tightly swaddle infants or carry them on cradle boards have a greater prevalence than cultures which carry infants on their hips

Nursing interventions:
*Observation/detection - shortened limb on affected side, unequal gluteal folds, restricted abduction/click
Parental education about the Pavlik harness -

  • do not adjust harness
  • will need to be assessed each week due to rapid growth
  • wear a t-shirt under the harness to prevent rubbing
  • place diaper under harness
  • gently rub skin under harness at least once a day
  • Encourage parents to hold and nurture infant dispite the harness

If surgery and cast is necessary, cast care would need to be taught


Detection of DDH after one year usually requires surgery.



Legg-Calve-Perthes Disease (Perthes Disease)
Coxa plana or osteochondritis deformans juvenilis - asceptic necrosis of the femoral head
Mainly boys between 4-8
Etiology unknown but a circulation disturbance is suspected
Insidious appearance - parents may note a limp that increases with activity, pain worse at start and end of day
Younger children with more cartilage heal quicker and children diagnosed before destruction

Radiographic Stages: (diagnosis x-ray and MRI)
  • flattening of the femoral head due to necrosis
  • fragmentation/revascularization
  • reossification/reparative
  • residual/regenerative stage

Nursing Interventions:
Goal is to rest the hip and restore
Parental education especially regarding appliances, rest
Surgery is often necessary also









Scoliosis, Torticollis, Kyphosis, Lordosis



Halo Traction




For Scoliosis: 3 options
*Monitor - if the curve does not progress and remains below 40 degrees

*Brace - started early while child still growing, customized, recommended to prevent further progression
Boston brace mid back
Milwaukee (high curves)
Charleston (bending brace) - for small flexible curves, only worn at night
*Bracing for scoliosis is not curative. It slows the progression of curvature to allow for growth.

*Surgery on children and teens curve greater than 45-50,
spinal fusion with autologenous bone grafts from child or Harrington or Cotrel Dubousset

Complications:
No treatment can affect ADL, respiratory function, eating, digestion,


Post Op Care: nursing management includes:
Log roll to prevent damage to surgical site and internal fusion
Observe wound site, circulation and vital signs
* Neurological assessments of extremities very important
*Pain management
Physical therapy

This animated video demonstrates a posterior spinal fusion for the treatment of scoliosis





Osteogenesis Imperfecta

*Must rule out nonaccidental injuries through history and presence or lack of soft tissue damage
Most common osteoporosis syndrome in childhood
Autosomal dominant disorder
Six types which vary in degrees and presentation (type I-VI) Type II (10% of all cases) is lethal, type III severe and progressive
Faulty bone mineralization
*Goal is to prevent positional contractures, deformity, muscle weakness, malalignment of extremities through bracing, physical therapy, surgery


Nursing Interventions:
Parental education about activities, development
Genetic counseling
Assistive organizations
*Turn carefully, changing a diaper can cause a fracture
Bisphosphonate therapy with IV pamidronate to increase bone density
Experimental bone marrow transplants for severe cases






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:
Congenital club foot video located at
http://youtu.be/vxkMnJ7WcEQ
https://youtu.be/nxG6mR1ElXA
DDH video located at
http://youtu.be/mOga_tDqyXo

DDH video 2 is located at
http://youtu.be/ysn4xfxbuqs

Perthes disease video at
http://youtu.be/oyUoSRndbho
https://youtu.be/2ClXbRh8Dxg
https://youtu.be/imbdyrafIxQ
Scoliosis information located at
http://youtu.be/1FeU07brzB4

Scoliosis
https://youtu.be/qCx6pHnBLGk

Scoliosis spine fusion located at
http://youtu.be/OfWQr_2yF9g

Osteogenesis imperfecta video located at

https://youtu.be/oK7Vd5WM_3A

http://youtu.be/Z7d27bBwX3E