Module 8

Musculoskeletal system is composed of the bones muscles joints tendons ligaments cartilage

Long bones- tibia, fibula, femur, humerus, ulna

Sort bones- such as those in wrist and ankle

Flat bones- skull, sternum, ribs Irregular bones- pelvis, vertebrae,

scapula

Skeletal (striated)- voluntary muscles; deltoid, biceps, gluteal, etc..

Smooth (short-fibered)- involuntary muscles; GI tract, lungs, pupils, etc..

Cardiac (striated, special function)

Fibrous membrane still exists between the cranial bones (fontanels)

Posterior closes between 2-3 months, anterior stays open until approx. 18 months of age to allow for brain and skull growth

Secondary ossification occurs as the long bones grow

Calcium intake during childhood and adolescence is essential for bone density

Growth takes place in the epiphyseal plates, injury in this portion is of concern in childhood

Rapid bone growth facilitates healing after a fracture

Can have growing pains because of rapid growth as well

Long bones are porous and less dense; bones can bend, buckle or break

In utero thoracic and sacral spine are convex curves (rounded)

Cervical region becomes concave as baby can hold head up

When learning to stand, the lumbar region becomes concave

Abnormalities can occur- scoliosis, lordosis, kyphosis

Muscular system is almost completely formed at birth

The length and circumference grow, but not the number

Maximum diameter for girls 10 years of age; 14 in boys

Strength continues to increase until 25-30 yrs

Almost completely formed at birth Muscles don’t increase in number, just

length and circumference Fibers reach maximum diameter around

10 years of age for girls and 14 yrs in boys

Strength continues until 25-30 yrs of age Until puberty, ligaments and tendons are

stronger than bone

Ligaments are the structural support connecting bones

Tendons connect bones to muscles

Cervical and lumbar areas become concave

Bowed legs (genu varum) in infant Knock knees (genu valgum) in

preschool child Resolve with growth

Developmental dysplasia of the hip Scoliosis, kyphosis, lordosis

Femoral head and acetabulum are improperly aligned Hip instability Dislocation Subluxation Dysplasia of

acetabulum

Figure 28–10 The asymmetry of the gluteal and thigh fat folds is easy to see in this child with developmental dysplasia of the hip.

Left hip more often than right Maternal estrogen may be a link to

laxity of joint, especially in females Possible cultural factors Assessment

Limited abduction of affected hip Asymmetric gluteal and thigh folds Allis’ sign; Ortolani-Barlow maneuver

Treatment Pavlik harness Skin traction- Bryant’s traction Casting Pain control Prevent complications from immobility Promote normal growth and development

Figure 28–11 The most common treatment for DDH in a child under 3 months of age is a Pavlik harness. A shirt should be worn under the harness to prevent skin irritation (it was omitted for clarity in this photograph).

Figure 28–12 For infants older than 3 months of age, skin traction is commonly used for treatment of DDH

Abnormal curvature of the spin Congenital Idiopathic Acquired

Can be structural or compensatory More often in girls than boys Ages 10-13 is highest incidence

Figure 28–15 A child may have varying degrees of scoliosis. For mild forms, treatment will focus on strengthening and stretching. Moderate forms will require bracing. Severe forms may necessitate surgery and fusion. Clothes that fit at an angle, such as this teenage girl’s shorts, and anatomic asymmetry of the back provide clues for early detection.

Most commonly right thoracic, left lumbar Ribs forced closer together Uneven shoulders Uneven hips, one-sided rib hump Prominent scapula X-ray Can also us CT, MRI, bone scan for

degree of curvature

Limit or stop the progression Rehab Bracing- Boston brace Spinal fusion

Nursing concerns? Nursing consideration? Nursing diagnoses? Nursing interventions?

Juvenile Rheumatoid Arthritis- Chapter 17 Chronic autoimmune inflammatory disease More common in girls Ages 2-5, or 9-12 Can enter into remission, or become chronic Joint inflammation

Decreased mobility Swelling pain

Figure 17–5 Joint inflammation and destruction in rheumatoid arthritis

Diagnosis made by jistory and assessment findings

Onset before 17 yrs of age, persisting for >6weeks

Pain Impaired mobility Interference with

growth and development

Fever Rash Lymphadenopathy

Splenomegaly Hepatomegaly Limp Favor one extremity Slow or uneven

growth Pain Swelling

Pauciarticular- knees, ankles, elbows, more common in girls

Systemic arthritis- males and females equally; high fever, polyarthirits and rheumatoid rash; affects internal organs and joints

Polyarticular arthritis; many joints (5 or more), particularly small joints (hands, fingers, hips, knees feet, ankles and neck)

May occur for a limited time and them improve, may recur periodically, or may last for 3-6 months or longer

No specific lab test, but can run Rheumatoid factor Human leukocyte antigen B27 Antinuclear antibody (ANA) ESR

Drug therapy Physical therapy Surgery Relieve pain Prevent contractures Aspirin or NSAIDS Steroids

Pain relief Promoting mobility Adequate nutrition Promotion of growth and development Prevent contractures

Break in bone integrity Result from direct trauma-falls, sports

injuries, abuse, MVA Result from bone diseases-

osteogenesis imperfecta Occur frequently in children because

bones are less dense and more porous

Pain Abnormal positioning Edema Immobility or decreased ROM Ecchymosis Guarding Crepitus

Common sites Clavicle Tibia Ulna Femur Distal forearm of ulna and radius most

common

X-ray Examination and palpation

Good hx, identify cause of injury Pain management Cast care Traction Internal vs. external fixation Care post realignment

Open reduction Closed reduction

Complications Pain Infection Vascular injury Malunion Non union Fat or bone embolus

Assessment for compartment syndrome

Delayed G & D Neurovascular

assessment Pain Pulses Paraesthesias

Maintain proper alignment Monitor neurovascular status Promote mobility Home care teaching Pain management Prevention of infection

Diagnoses Considerations Priorities Medications

Analgesics Antibiotics Muscle relaxers