The Musculoskeletal System

Musculoskeletal System

• Supports the body and provides movement
• Systems work for sitting, standing, walking, and upright posture
• Muscles move air in/out of lungs, blood through vessels, food through digestion, and produce heat
• Bones are levers for support
• Red blood cells produced in marrow; minerals stored here

Fetal Development

• Musculoskeletal system arises from mesoderm
• Skeletal growth: prominent from fourth to eighth fetal weeks
• Limbs elongate; muscle masses form in extremities
• Ballard scoring system measure neuromuscular maturity
• Reflex testing provides further measure

Locomotion

• Develops gradually and systematically in growing children
• Deceleration signals need for investigation

Child vs Adult Musculoskeletal Systems

• Pediatric bones are not fully ossified
• Epiphyses are present
• Periosteum is thicker
• Child bones produce callus more quickly

Bone Characteristics

• Lower mineral content
• Greater porosity
• Increased strength
• Rotational/angular forces impact ligaments inserting at epiphyseal bone area
• Injury to epiphysis affects bone growth

Fracture Healing

• Bone overgrowth: common in children under 10 due to epiphysis and hyperemia
• Exact alignment not needed in fracture reduction for children under 10
• Bone overgrowth and accelerated growth occur for 6-12 months post-injury
• Fractures at or near bone growth plate need careful treatment and monitoring
• Thoracic and sacral spine areas are convex at birth
• Spinal curves change as child sits/stands

Assessment of Musculoskeletal System

• Nurse must understand effect of growth, neuro development, and motor milestones at various ages to find deviations
• Newborn hip has limited ROM for internal rotation
• Legs are flexed; lower leg has internal rotation due to uterine positioning (lasting 4-6 months)
• Newborn spine has C-shape curvature that changes with motor skill mastery, becoming double S-curve
• Newborn feet turn inward/outward but self-corrects when sole of foot is stroked
• Toddler feet appear flat because of fat pad.
• Neuro development delays cause motor skill delays can alter skeletal growth

Physical Assessment

• Includes observation, palpation, ROM, and gait assessment

Delayed Walking

• Children not walking independently by 18 months need healthcare referral

Observation of Gait

• Gait: person's walking style
• Toddlers have wide, unstable gait; arms do not swing
• 18 month olds: narrowing base and more stable walk
• 4 year olds: hop on one foot; arms swing with walking
• 6 year olds: Adult-like gait, equal stride lengths, and arm swing
• Trunk centered over legs, movement symmetrical
• Favoring one side could indicate pain; toe walking post 3 years can indicate muscle problem
• In-toeing often resolves by 4 years old, but can cause tripping. Teaching proper sitting/turning helps

Skeletal Growth

• Skeletal growth is most rapid during infancy and adolescence; assessment is vital
• Child bones are more resilient, bend more, and deform before breaking
• Bone blood supply is rich; healing occurs faster because the periosteum is thick and has high osteogenic activity
• Epiphyseal plate fractures may disrupt bone growth
• Musculoskeletal problems are often growth-related
• Rapid skeletal frame growth can cause severe deformities

Assessing Alignment in Children

• Body mechanics are treatment of choice
• Ballet and in-line skating enhance hip flexibility
• The prescription of a brace may occur if the problem does not resolve
• Failure to treat can result in hip, knee, or back problems in adulthood
• Children appear bowlegged (genu varum) or knock-kneed (genu valgum) until age 5
• Bowing is seldom pathological
• Ligaments supporting the arch are not mature before age 6
• Orthotics can be prescribed if the condition interferes with walking
• If flatfoot is painful, refer immediately

Assessing Muscle Tone

• Assess symmetry of movement
• Assessing the strength and contour of the body and extremities is key
• Test the strength of extremities by having the child push away from hands/feet

Neurological Examination

• An assessment is a vital part of a muscular skeletal exam
• Reflexes, sensory function, and spasms should be noted

Diagnostic Studies

• Radiographs: Confirm suspected pathological condition and the affected area is compared with the unaffected area
• Bone scans: Helps to identify pathological conditions not clear on x-rays
• CT: a cross-section picture of bone and relationships to structures in the area
• MRI: No radiation. Detailed pictures of the brain, spinal cord, soft tissue lesions, and slipped femoral epiphysis
• Ultrasound: no radiation; rules out foreign bodies in soft tissues, joint effusions, and developmental dysplasia of the hip.
• CBC and ESR: Rule out septic arthritis or osteomyelitis. Rheumatoid factor diagnosed rheumatological disorders
• Detailed history: Necessary to determine the basis for musculoskeletal problems which are often insidious
• Arthroscopy may be performed for sports injuries
• Bone biopsy: May show malignancy
• Muscle biopsy; May detect muscular dystrophy

Treatments

• Traction, casting, splints, or surgery is used in accordance with the patient's needs
• Immobility from these causes deceleration in body metabolism
• ROM exercises and trapezes prevents muscle atrophy
• Increased roughage intake stimulates digestion and prevents constipation
• Respiratory exercises prevent pneumonia
• This prevents child from being hospitalized longer

Soft Tissue Injuries in Pediatric Trauma

• Soft tissue injuries usually accompany traumatic fractures in the child at play or sports activity that include:
• Contusion: tearing of subcutaneous tissue that has hemorrhage, edema, and pain with it; blood that has escaped into soft tissue is called a hematoma or a "black and blue mark"
• Sprain: The ligament is torn or stretched away from the bone; damage to blood vessels, muscles, and nerves results; Swelling, disability, and pain are major signs
• Strain: Microscopic tear to the muscle or tendon and results in long term edema and pain

Treating Soft Tissue Injuries

• Limit damage from edema and bleeding
• Cold pack and elastic wrap reduce edema, bleeding, and pain; alternating 30-minute intervals or ischemia can occur
• Elevate the extremity heart to reduce edema
• Neurovascular checks ensure adequate tissue perfusion

Managing Soft Tissue Injuries

• Rest
• Ice
• Compression
• Elevation

Prevent Pediatric Trauma

• Prevent morbidity and mortality
• Injury can cause permanent disability or premature death
• Safety practices that include pedestrian safety, car seat restraints, helmets, pool fences, window bars, deadbolt locks, and locking cabinets, can prevent injuries
• Support laws that will maintain a safe environment

Traumatic Fractures

• It is a break in a bone from accidents
• Pain, tenderness on movement, and swelling are characteristics. Discoloration, limited movement, and numbness may also occur
• Simple fractures: The bone is broken, however the skin over the area is not
• Compound fractures: A wound in the skin accompanies the broken bone; there is added danger of infection
• Greenstick fractures: An incomplete fracture where one side of the bone is broken while the other is bent; bones are soft, flexible, and more likely to splinter
• Complete fracture: The bone is entirely broken across its width
• Signs of child abuse are suspected if fractures are at various stages of healing
• A child's periosteum is stronger and thicker which makes them heal more rapidly
• Fat embolism can occur within hours of fractures of long bones or multiple injuries when fat particles escape from the site and into the lung

Fractures for the Femur in Childhood

• The femur is the largest and strongest bone; suggests a nonaccidental injury if any fracture is suggested
• A forceful twisting motion of the femur causes a spiral fracture; The child has complains of pain and is tender when the leg is moved, the clothes are removed to confirm diagnosis

Traction Treatment

• Used when surgical intervention isn't available
• Bryant Traction: used for fractures of the femur in children younger than 2 years of age or lighter than 9.09kg to 13.64kg (20 to 30lb), weights and pulleys extend the limb as in the Buck's extension but the legs are suspended vertically(weight of child is the countertraction)
• Traction in the older child: Used when cast cannot maintain alignment of 2 bones(skeletal muscles act as a splint). Skeletal muscles align the injured bones by using weights and counter traction
• Buck skin traction: used for femur fractures and in hip, as well as knew contractures; pulls hip and leg into extension while the child's body supplies countertraction

Russell Traction

• Similar to Buck's extension
• Uses a sling under the knee to suspend distal thigh. Pull is in 2 directions, vertically from the knee sling, and longitudinally from the footplate
• Skeletal traction carries the risk of infection by bacteria

Nursing Care Responsibilities

• Ropes are intact, pulleys are grooved to the body
• Body in alignment
• Legs at right angles and sufficiently to clear bed
• The elastic bandages avoid being too tight or loose Children is encouraged to drink to keep stool sot
• Diversional therapy should be enacted

Neurovascular Checks

• Priority nursing duty Assess Neuro/vascular checks and report abnormalities for early intervention
• Peripheral pulse rate and quality
• Color
• Warmth
• Movement and sensation

Managing Pain

• Control strategies and medication use as quickly as possible
• May need surgical procedure for increased pressure

Elevating and Neurovascular Checks

• Extremity on a pillow + frequent neurovascular checks
• The nurse should be taught safe transfer from bed to wheelchair and to use crutch-walking techniques. The child should use weights only used on hands.

Cast Care

• The child should be prepared for cast removal because the cast cutter can appear and sound threatening; use lotion and soothing baths
• This includes body care, skin protection, as well encouragement of school progress to prevent long lasting affect.

Osteomyelitis

• A bone infection that usually occurs in children under 1 and from. 5 to 14
• The inflammation produces an exudate under the marrow and cortex of the bone

Causes

• Staphylococcus aureus is the organism often responsible in older children with MRSA accounts for nearly 50% of these cases in children
• Diagnosed by elevation in WBC and ESR but MRI will provide precise detail

Treatment

• IV antimicrobial therapy, a high amount, for up to 6 weeks
• Monitor children and ensure long term compliance
• Bed rest followed by wheelchair access is used, but weight is avoided
• Passive ROM and PT is important, a ESR is predictive of healing

Duchenne's Muscular Dystrophy

• Group of genetic disorders of progressive muscle degeneration
• Only occurs in boys and has an incidence in 3,600 lived male infants

Characteristics

• Dystrophin is usually absent in protein of muscle tissue
• Pseudophertophic muscle is present in the calf Gower's maneuver may be used

Labs and Diagnosis

• Show marked levels in serum creatine phosphokinase
• Myleogram shows a graphic record of electrical stimulation showing decreases motor unit potential
• Muscle biopsy shows degeneration and is considered diagnostic, A blood PCR for the genetic mutations shows if they have muscular dystrophy

Treatment

• Mainly supportive to prevent muscle mass and to maintain life
• Respiratory assistance is common
• Patient may appear passive and/ depressed
• Early depression is common because the child cannot compete with peers

Slipped Femoral Capitis

• Can displace femoral epiphysis and can occur during growth with high rates by obesity causing the widening to displace
• X-ray will confirm The child will need traction and surgery

Legg Calvé Perthes Disease

• Blood supply to the epiphysis will be disrupted leading necrosis, affecting development of the head of the femur more than likely unilateral Signs and Symptoms
• Thigh and knee pain along with limitation of motion

Treatment

• The goal is to preventing weight bearing while keeping femoral head in place with brace

Osteosarcoma

• Causes Malignant tumor of long bones with those ages 10- 15 at highest risk, and the patients are usually tall
• Metastasis occurs and may affect the brain and bones Signs and Symptoms
• Pain and swelling at the point
• May have to less by flexing that extremity

Treatment

• Consists of surgery, chemo, resections of the bone that will allow them to grow
• Problems with body image are apparent so the patient will face anger, etc.

Ewing's Sarcoma

• Malignant growth in the marrow the patients should not want weight in those areas
• Amputation not needed due to radiation

Juvenile Idiopathic Arthritis (JIA)

• Common condition, systemic auctomic that can involve multiple genes Signs and Symptoms
• Have distinct classifications
• Oligo Arthritis- is four joints being effected
• Poly arthritis Effects is five joints causing issues to 10 %

Treatment

• Goal is to reduce swelling, promote mobility etc There may be periods of reminiscence that can lead to child stress

Torticollis ( Wry Neck )

• In this condition the neck motion is limited with the spine being shorted from the sternocleidomastoid that can cause injuries from births- or acquired.

Scoliosis

• Is a shape curvature to the spine, scoliosis affects more adolescent girls than others.
• Functional scoliosis involves posture not spinal disease Signs and Symptoms
• Symptoms can go undetected