Musculoskeletal+Rounds+2


 * Musculoskeletal Rounds 2: Acquired Musculoskeletal disorders **

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 * 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

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 * <span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Osteomyelitis **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Infectious process in a bone <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">//Acute hematogenous// - blood borne bacterium causes infection in bone. Tonsillitis, otitis media, impetigo - bacteria travels to the capillaries in the bone causing obstruction <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">//Exogenous// - direct injury to bone or adjacent tissues <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">//Subacute// - less virulent walled off infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">//Chronic// - dead bone, bone loss, sinus drainage

<span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">History of trauma to bone <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Ill, irritable child <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Fever, restlessness <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Elevated temperature, rapid pulse <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Dehydration <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">With redness, tenderness, swelling over bone, muscles tense and painful movement

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment in response to offending organism from blood cultures

<span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing interventions: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pain management, comfort positioning, possible splinting <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Antibiotic therapy * Be sure blood cultures have been obtained prior to initiation of antibiotic therapy <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Standard precautions <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Note intake and output <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Drainage from site <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Cast care if appropriate <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Limited weight bearing then physical therapy

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Not common in US <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Tuberculosis can affect any joint or bone <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Most commonly affects spine <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Insidious symptoms of joint pain, swelling, stiffness
 * <span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Skeletal Tuberculosis **

<span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing Treatment/ Interventions <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Antituberculin drug administration - isoniazid, rifampin, or pyrazinamide <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Care depends on site with the spine or hip often needing immobilization, casting and fusion like osteomyelitis and septic arthritis

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bacterial infection in a joint <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Fluid is aspirated and cultured <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Surgery may be required
 * <span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Septic Arthritis **

<span style="color: #e02929; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing interventions: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pain management <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Medication administration <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Post surgical care or cast care if needed <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Physical therapy <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatments similar to osteomyelitis

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 * <span style="color: #23b83e; font-family: 'Times New Roman',Times,serif; font-size: 23px;">Nursemaids Elbow **

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<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Dislocation - displacement of a bones (or bones) from its articulation with a joint <span style="color: #e01c4b; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Subluxation <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">- incomplete or partial dislocation of the articular surfaces of a joint. <span style="color: #e61439; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Dislocations <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;"> or subluxation common in fingers and elbows of children. <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Nursemaids elbox subluxation of the radial head typically in children younger than 5 <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Dislocations associated with pain and damage to ligament and joint capsule <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Normal contour of joint may be affected or length of an extremity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Treated with closed manual reduction and splinted, casted or in a sling for 3 weeks

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">(Sport) occurs due to athletes training earlier, longer and harder. ..shin splints, plantar faciitis, Osgood –Schlatter, Severies disease <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Stress fractures may not show up on x-ray until callus formation noted. <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Stay mobile without weight bearing, ice, taping, bracing, splinting, <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">NSAIDS. <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Caution parents against over committing
 * <span style="color: #23b83e; font-family: 'Times New Roman',Times,serif; font-size: 23px;">Overuse syndromes **

<span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 21px;">Sprains and Strains <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Sprain is a twisting injury to a joint - ligaments are stretched or torn <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Strains are excessive stretching of a muscle/tendon group <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Sprains and strains are graded according to severity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Manifestations will depend on it muscle or tendon <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">May hear a pop and muscles are vascular so they will bruise <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">X-rays to rule out fracture

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Goal: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Keep pain free and return to function

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">RICE <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Ice 3xs a day for 30 minute intervals <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Acetaminophen or Ibuprophen <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Treated with casting, bracing, complete tears - surgery <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Monitor neurovascular status - pulses distal to injury, pink, capillary refill

<span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Musculoskeletal Injuries <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*RICE <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rest, Ice, Compress, Elevate <span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 20px;">*With possible musculoskeletal injuries - Observe for the 5 P's* <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Pain <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Pulse <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Pallor <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Paresthesia - sensory impairment <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Paralysis - movement impediment

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Crutches for non weight bearing injury media type="youtube" key="mPeNOb2eIyA" width="504" height="377"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">External Fixation - displaced hospital and at home traction <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Stable unilateral fixator along outer aspect of leg <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Pins are attached to bone through skin <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Clean with 1/2 strength hydrogen peroxide at pin site (pin care) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">High rate of infection <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Internal Fixation surgery and use of nails <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Crutches for non weight bearing injury

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<span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 20px;">Fractures <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">In young children ligaments and tendons are stronger than bone so fracture more common than strains <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Most common upper extremity injuries: fingers, hand, clavicle (collarbone), humerus, elbow, distal radius (wrist) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Most common lower extremity injuries: pelvic, tibial, femur, metatarsal/phalanx, tibia, ankle, femoral neck <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Femoral shaft most common

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Fractures classified as: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Closed (skin intact) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Open <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Plastic (bowing, bending) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Buckle (torus) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Greenstick <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Complete (transverse) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Comminuted (multiple fractures, pieces) <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Physeal (across the growth plate) - classified with the Salter-Harris system I-IV, wrist is the most common

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Signs and symptoms depend on location: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Pain <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Edema <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Decrease ROM <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Deformity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Crepitus grating sound <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Functional use decreased <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Xrays unless cartilage the US, CT or MRI <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Closed reduction or Open reduction?

<span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 20px;">*Cast care* <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Often injuries involving bones and joints must have surgery and are placed in casts. <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">It is imperative that the nurse observe these extremities and teach cast care to the parents as well <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Keep the cast elevated on a pillow <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Use palms not hands to avoid compressing the cast <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Observe the casted extremity for evidence of swelling or discoloration <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Check movement, sensation and temperature of extremity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Encourage rest <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">ROM of joints above and below cast <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Do not allow the child to put anything in the cast <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Provide a clear path for ambulation <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Crutches for non weight bearing injury <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Obseve for Compartment syndrome from massive edema or to restrictive cast, splint *5P's <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Cutting the cast off can be frightening

media type="youtube" key="167xqGKS9hk" width="560" height="315" <span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Physiology of bone healing media type="youtube" key="qVougiCEgH8" width="504" height="377"

<span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 160%;">*Purposes of Traction <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To fatigue the muscles so that realignment can occur <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To reduce muscle spasm <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To position bones for proper healing <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To immobolize the site until realignment or healing has been initiated, until casting or splinting is achieved <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To prevent contracture <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">To immobolize

<span style="color: #db1f1f; font-family: 'Times New Roman',Times,serif; font-size: 160%;">*Types of Traction* <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">For every action must be an equal and opoosite reaction <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Skin traction - uses ace bandages, boots or belts, attached to weights <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Used less as costly <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Dunlop's Traction - arm (humerus) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Milwaukee Brace - Scoliosis <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Russell's Traction - Knee contractures <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bryant's Traction - fracture or infant's with Congenital hip dysplasia (CHD) (with elevation of hips off the bed) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Buck's Traction - Hip fracture

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*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.

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 17px;">References: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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..

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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..

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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.

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Videos:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">slipped femoral head located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/ICojcqlCm1o

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Osteomyelitis https://youtu.be/pnJWLDwkdr4

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

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursemaids Elbow https://youtu.be/-0ROu4hCXwQ https://youtu.be/3XcDUQ7s62s <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sprain and strain explanation located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/mPeNOb2eIyA

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sprains and strains assistance video located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/WyJiV5Cgoaw

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Types of fractures located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/mL0SsSwccdQ

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

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bone Healing located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/qVougiCEgH8

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Traction located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/OLiqFD4khIo