Musculoskeletal+Rounds


 * Musculoskeletal Rounds: **


 * Congenital disorders: **

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

//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 media type="youtube" key="vxkMnJ7WcEQ" width="560" height="315"

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

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Predisposing factors: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">//Physiological factors// - maternal hormones, intrauterine positioning <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">//Mechanical factors// such as breech presentation, oligohydramnios //<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Genetics //

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Typical - infant is neurologically intact or teratologic (< common) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Culture - cultures that tightly swaddle infants or carry them on cradle boards have a greater prevalence than cultures which carry infants on their hips

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing interventions: <span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Observation/detection - shortened limb on affected side, unequal gluteal folds, restricted abduction/click <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Parental education about the Pavlik harness -


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">do not adjust harness
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">will need to be assessed each week due to rapid growth
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">wear a t-shirt under the harness to prevent rubbing
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">place diaper under harness
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">gently rub skin under harness at least once a day
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Encourage parents to hold and nurture infant dispite the harness

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">If surgery and cast is necessary, cast care would need to be taught

media type="youtube" key="mOga_tDqyXo" width="420" height="315" <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">Detection of DDH after one year usually requires surgery. media type="youtube" key="ysn4xfxbuqs" width="560" height="315"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Coxa plana or osteochondritis deformans juvenilis - asceptic necrosis of the femoral head <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mainly boys between 4-8 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Etiology unknown but a circulation disturbance is suspected <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Insidious appearance - parents may note a limp that increases with activity, pain worse at start and end of day <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Younger children with more cartilage heal quicker and children diagnosed before destruction
 * <span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Legg-Calve-Perthes Disease (Perthes Disease) **

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Radiographic Stages: (diagnosis x-ray and MRI)
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">flattening of the femoral head due to necrosis
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">fragmentation/revascularization
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">reossification/reparative
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">residual/regenerative stage

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 17px; line-height: 25px;">Nursing Interventions: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%; line-height: 25px;">Goal is to rest the hip and restore <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%; line-height: 25px;">Parental education especially regarding appliances, rest <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%; line-height: 25px;">Surgery is often necessary also

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 * <span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Scoliosis, Torticollis, Kyphosis, Lordosis **

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

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<span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Monitor - if the curve does not progress and remains below 40 degrees
 * <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">For Scoliosis: 3 options **

<span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Brace - started early while child still growing, customized, recommended to prevent further progression <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Boston brace mid back <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Milwaukee (high curves) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Charleston (bending brace) - for small flexible curves, only worn at night <span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Bracing for scoliosis is not curative. It slows the progression of curvature to allow for growth.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Surgery on children and teens curve greater than 45-50, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">spinal fusion with autologenous bone grafts from child or Harrington or Cotrel Dubousset

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Complications: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">No treatment can affect ADL, respiratory function, eating, digestion,

<span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Post Op Care: nursing management includes: <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Log roll to prevent damage to surgical site and internal fusion <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Observe wound site, circulation and vital signs <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Neurological assessments of extremities very important <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Pain management <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Physical therapy

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">This animated video demonstrates a posterior spinal fusion for the treatment of scoliosis

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<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 170%; line-height: 0px; overflow: hidden;">media type="youtube" key="oK7Vd5WM_3A" width="560" height="315" <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Must rule out nonaccidental injuries through history and presence or lack of soft tissue damage <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Most common osteoporosis syndrome in childhood <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Autosomal dominant disorder <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Six types which vary in degrees and presentation (type I-VI) Type II (10% of all cases) is lethal, type III severe and progressive <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Faulty bone mineralization <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Goal is to prevent positional contractures, deformity, muscle weakness, malalignment of extremities through bracing, physical therapy, surgery
 * <span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Osteogenesis Imperfecta **

<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing Interventions: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Parental education about activities, development <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Genetic counseling <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assistive organizations <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Turn carefully, changing a diaper can cause a fracture <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Bisphosphonate therapy with IV pamidronate to increase bone density <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Experimental bone marrow transplants for severe cases

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<span style="color: #c42121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">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: 17px; line-height: 25px;">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: 130%;">Videos: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Congenital club foot video located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/vxkMnJ7WcEQ https://youtu.be/nxG6mR1ElXA <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">DDH video located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/mOga_tDqyXo

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">DDH video 2 is located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/ysn4xfxbuqs

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Perthes disease video at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/oyUoSRndbho https://youtu.be/2ClXbRh8Dxg https://youtu.be/imbdyrafIxQ <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Scoliosis information located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/1FeU07brzB4

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Scoliosis https://youtu.be/qCx6pHnBLGk

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Scoliosis spine fusion located at <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/OfWQr_2yF9g

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Osteogenesis imperfecta video located at

https://youtu.be/oK7Vd5WM_3A

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/Z7d27bBwX3E