Pediatric Musculoskeletal Mobility

Mobility

• State or quality of being movable
• Exemplars include developmental dysplasia of the hip and scoliosis

Objectives

• Integrate principles of growth, development, and safety when caring for a child requiring braces, casts, traction, and surgery
• Identify clinical manifestations of conditions of the hip or spine that would impact a child’s mobility
• Devise an individualized nursing plan of care for a child with a musculoskeletal disorder of the hip or spine

Basic Pediatric Principles Related to Musculoskeletal Development

• Muscles:
  • Present at birth
  • Grow in length and mass
  • Muscle mass accounts for 25% of total body weight in infants
    • Adults muscle mass is 40% of TBW
  • Most rapid growth occurs during adolescence
• Ligaments and tendons:
  • Stronger than bone until puberty
  • Tendons grow in length as a result of pressure
    • Restricted mobility = restricted growth potential
• Bones:
  • All bones present at birth
  • Ossification continues throughout adolescence
  • Bones are more porous, pliable, and less dense
  • Cartilage is gradually replaced at the epiphysis
  • Growth happens at the epiphysis plate
  • Bone healing is rapid

Developmental Dysplasia of the Hip (DDH)

• Improper alignment of the femoral head and acetabulum creates instability in the hip
• Etiology:
  • Genetic predisposition
  • Can occur early during fetal development
  • Mechanical forces late in pregnancy:
    • Hip can only develop normally if the femoral head is properly maintained within the acetabulum
• Pathophysiology:
  • Hip instability
  • Subluxation
  • Complete dislocation
• Dysplasia of the hip:
  • Acetabulum is shallow or sloping
    • Continued dislocation or subluxation can lead to complications:
      • Avascular necrosis of the femoral head
      • Hip instability
      • Limited ROM
      • Palsy of the femoral nerve
      • Early onset of osteoarthritis
• Clinical manifestations:
  • Limited abduction
  • Asymmetry of the gluteal and thigh folds
• Diagnostic Testing:
  • Allis sign
  • Barlow and Ortolani maneuvers
    • Physical assessment of all newborns conducted to evaluate for hip instability
• Therapeutic Management:
  • Goal: Maintain the hip joint in reduction, allowing the femoral head and acetabulum to develop properly
• Clinical Therapy:
  • Newborn to 6 months:
    • Pavlik harness: Prevents extension and adduction

  • 6 months:

    • Bryant traction
    • Closed reduction and spica cast

Pavlik Harness Nursing Considerations

• Safety:
  • Neurovascular checks
  • No swaddling
  • Car seat safety:
    • Adjustments of straps by specialist only
• Perfusion:
  • Assess skin under straps
  • Assess skin folds
  • Keep skin clean and dry
• Skin integrity:
  • Onesie and knee/thigh socks under harness
  • Diaper under harness
• Growth & Development:
  • Move legs and arms freely
  • Encourage activity
  • Tummy time
• Education:
  • Keep harness on for prescribed hours/day
  • Straps adjusted by specialist every 1-2 weeks
  • Compliance and follow-up appointments

Spica Cast Nursing Considerations

• Pain:
  • Acetaminophen or ibuprofen
• Perfusion:
  • Neurovascular checks
• Skin integrity:
  • Cast care: petal/ soft edges
  • Handle with palms of hands
  • Keep skin clean and dry
  • Nothing in the cast
• Elimination:
  • Diaper under cast
  • Change diaper frequently
• Growth & Development:
  • Tummy time
  • Age-appropriate play
• Safety:
  • Car seat
  • Injury prevention

Scoliosis

• Complex deformity of the spine
  • Lateral S or C curvature
  • Greater than 10 degrees is abnormal
• Etiology:
  • Idiopathic:
    • Lateral curve with vertebral rotation
    • Occurs most often during adolescence
  • Congenital
  • Acquired
• Pathophysiology:
  • Structural changes occur as a result of curvature:
    • Ribs on the concave side are forced together
    • Ribs on the convex side separate
    • Narrowing of the vertebral canal
• Clinical Manifestations:
  • Truncal asymmetry
  • Uneven shoulder height
  • Prominent scapula
  • One-sided rib hump
• Diagnostic Testing:
  • Inspection:
    • Early detection lessens deformity
    • Goal: Stop progression of the curve
  • Scoliometer
  • X-ray:
    • Most definitive
  • Screenings:
    • Screened every 6-9 months

Scoliosis Clinical Therapy

• Mild: Curvatures of 10-20 degrees
  • Exercise
  • Follow-up evaluations
• Moderate: Curvatures of 20-40 degrees
  • Prevents further curvature
  • Boston brace
    • Biggest issue is 23 hours/day compliance
• Severe: Curvatures greater than 40 degrees
  • Surgery:
    • Spinal fusion: Harrington rod
      • Stabilizes the spine

Scoliosis Nursing Considerations

• Pre-operative:
  • Preparation for what to expect
• Post-operative:
  • Pain control
  • Neurovascular checks
  • Coughing and deep breathing
  • Position changes
  • Activity will gradually increase
  • Pre-medicate for activity

Review Questions

• A school health nurse is screening for scoliosis. Which finding would the nurse assess for? 1. Prominent scapula
• A young child has just returned from surgery in a spica cast. The priority nursing intervention would be which of the following? 2. Check circulation
• Which of the following is appropriate for the nurse to include in parental education regarding the Pavlik harness? Select all that apply. * 3. Check at least two or three times a day for red areas under the straps and 4. Place a diaper over the harness, preferably using a thin, superabsorbent, disposable diaper

This quiz addresses the principles of pediatric mobility related to musculoskeletal development. It focuses on clinical manifestations of hip and spine conditions and the nursing care needed for children with these disorders. Explore how growth and development impact treatment strategies for children requiring specialized care.