Musculoskeletal disorder - PowerPoint Presentation

Slide1

Musculoskeletal disorder

Islamic University Nursing College

Slide2

Musculoskeletal

The main organs and tissues that are part of the musculoskeletal system in humans arethe cartilagesthe bonesthe muscles

Slide3

Musculoskeletal

Main functions of MS are:

To support & protect vital organs (the brain, heart and lungs)

To keep structure and maintenance of the body spatial conformation.

Allows the body to move (walking, standing, bending).

Because soft tissues are

resilient (flexible)

in children, dislocations and sprains are less common than in adults

Nutrient storage (glycogen in muscles, calcium and phosphorus in bones)

Slide4

Musculoskeletal: Physical Assessment

Inspect child undressed

Observe child walking

Spinal alignment

ROM (range of movement)

Muscle strength

Reflexes

Assessment of

concerns

Slide5

Musculoskeletal: Physical Assessment

Assessment of concerns:

Pain or tenderness & Muscle spasm

Masses

Soft tissue swelling

Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones

. A child younger than 1 year with a fracture should be evaluated for possible physical abuse or an underlying musculoskeletal disorder that would cause spontaneous bone injury

assess injury site at the last

Slide6

Musculoskeletal: Neurovascular Assessment

Neurovascular checks should be done at least every 1 to 2 hours during the first 48 hours, and usually for as long as the child is in

traction

Pain:

(location, alleviated and aggravating factors; Does the pain become worse when fingers or toes are flexed)

Sensation

: Can the child feel/ touch on the affected extremity

Motion:

Can the child move fingers or toes below area of injury / nerve injury

Temperature

: Is the extremity warm or cool to touch

Capillary refill; Color; Pulses

(distal to injury or cast)

Slide7

Musculoskeletal: Diagnostic procedures

X-ray & Bone scan

Alkaline phosphatase (ALP): ALP is an enzyme found mainly in bone, liver, placenta, and kidney; levels may be elevated in bone disease, fractures, trauma, or liver disease and during periods of rapid growth

.

Electromyography

(EMG): studies the electrical activity of skeletal muscle and nerve

conduction.

Muscle or bone biopsy

Arthoscopy

: direct visualization of a joint with a

fiberoptic

instrument.

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Fracture

Causes of fracture:Birth trauma, child abuse & injury.Vehicle accident for children and rare in infantsFracture line can be transverse, oblique, or spiral, compound

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Fracture: Clinical Manifestations

Swelling, pain or tenderness

Diminished functional use of the affected part; inability to bear

weight.

Bruising, severe muscular rigidity

Sometimes

crepitus

.

Less frequent neurological and vascular damage (ischemia), which can be assessed using

5

Ps.

Pain

Pallor

Pulselessness

Parasthesia

Paralysis

Slide10

Fracture: Therapeutic Management

Cast:

fiberglass or plaster application to immobilize affected body part

Tractions

:Is the direct application of force to produce equilibrium at the fracture site

Distraction

: involves the use of an external device to separate opposing bones to encourage regeneration of new bone & used to immobilize fractures or correct defects when the bone is rotated or angled

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Fracture: Therapeutic Management

Internal Fixation External Fixation

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Fracture: Cast

Risk for altered tissue perfusion R/F pressure from cast

Keep extremity elevated to decrease edema.

assess circulation Q 15 minutes after applying the cast then hourly

assess skin warmth and

5 Ps

Risk for impaired skin integrity R/F pressure from cast

Cast edges must smoothed/covered

Cast remains in place for 4-8 weeks

Discourage itching under the cast

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Fracture: Cast

Possible

concerns:

Unusual odor under the cast

Drainage from cast

Tingling, numbness and swelling in the casted body part

Loose or cracked cast

Unexplained fever

Unusual

fussiness (carefulness)

or irritability and pain

Discoloration of finger or toes

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Fracture: Traction

Is the direct application of force to produce equilibrium at the fracture siteTypes of tractions Manual traction: applied by hand is used during cast Skin traction: pull applied directly to the skin surface and indirectly to the skeletal structure Skeletal traction: pull applied directly to the skeletal structure by a pin, wire, or tongs

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Fracture: Traction

Purposes

To realign bone fragments & treat dislocation

To provide rest for an extremity & help prevent or improve contracture deformity.

To allow preoperative or postoperative positioning and alignment.

To provide immobilization of affected body part

To fatigue the involved muscle and reduce muscle spasm so that bones can be realigned (Fatiguing of muscle is accomplished by applying constant stress to the muscle so that the buildup of lactic acid will produce muscle relaxation)

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Fracture: Traction

Nursing Care

Regular assessment of 5 Ps

Skeletal traction is never released by the nurse (do not move the weights)

Assess blood pressure

Skin care for the child’s back, elbows and

heels.

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Fracture: Complications

Circulatory impairment:

Careful assessment of the pulses, skin color, and temperature is crucial

Nerve compression syndromes

(e.g., carpal tunnel syndrome, tarsal tunnel syndrome)

Sensory testing with touch and pinprick

evaluating motor strength by asking the child to move the unaffected joint distal to the injury

Slide18

Fracture: Complications

Compartment syndromes

is a tissue ischemia due to a compression of

nerves, blood vessels, and muscle

inside a closed space (compartment) within the body due to increased pressure in that part

The most frequent causes are:

tight dressings or casts, hemorrhage, trauma, burns, and surgery

Signs & symptoms include:

motor weakness and pain that does not decrease with medication

the muscle may feel tight or full

Burning sensation

Slide19

Fracture: Complications

Epiphyseal

damage:

leads to unequal growth

Infection

:

osteomyelitis

(potential problem in open fractures, from pressure ulcers, or when bone surgery)

Pulmonary emboli

: blood, air, or fat emboli may produce a life-threatening vascular obstruction and ischemia.

Primary symptom is shortness of breath and chest pain.

Interventions should include:

Place patient in high fowlers

Administer O2 and check chest X-ray

Slide20

Sprained ankle

A soft tissue injury

Management ( in the first 6 to 12 hours)

controlling the swelling and reducing muscle damage by “RICE”

Rest

Ice

Compression

Elevation

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Kyphosis

Is an abnormally increased convex angulation in the curvature of the thoracic spineIt can occur secondary to disease process such as tuberculosis, chronic arthritisTreatment Postural exercises Bracing (Milwaukee) for more marked deformity

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Lordosis

Is an accentuation (stress) of the lumbar curvature beyond physiologic limitsIt may be a complication of a disease process, the result of trauma or idiopathicLordosis is a normal observation in toddlersIn older children is often seen in association with flexion contractures of the hip, obesity, congenital dislocated hip and slipped femoral capital epiphysis.

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Scoliosis

Is a spinal deformity which may involve lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. It is the most common spinal deformity. It can be congenital, or it can develop during infancy or childhood, but it is most common during adolescence (peaks between 8-15 years) It may be genetic and transmitted as an autosomal dominant traitIt may be multifactorial

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Scoliosis: Types

Functional scoliosis

caused by a secondary problem such as unequal leg length.

The curve tends to be

a

C-shaped curve

can be treated by treating the primary cause first

Structural scoliosis

the cause is idiopathic with a positive family history in some cases

It involves a permanent curvature of spine accompanied by damage to the vertebral.

The curve tends to be

S-shaped curve

.

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Scoliosis: Clinical Manifestation

From standing position ( feet together and arms at sided)Unequal shoulders levelCurved spinal columnUneven level of the elbowsFrom bending position ( child bends and touch his toes):Rotation of the spine becomes more prominent.Hump (bulge) in the backOne shoulder blade is more prominent than other isIn some cases there are back pain, fatigue and dyspnea

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Scoliosis: Management

Non-surgical management aimed to :

promoting self-esteem and positive body image

maintain spinal stability

prevent further progression of deformity until bone growth is complete and surgical repair can be performed

mild cases (less than 20%), observation and exercises- swimming is advised &

Long-term monitoring.

Moderate (20-40%), exercises, traction, bracing. Bracing (

Milwaukee brace

)

is successful in halting or slowing the progression of curvatures

Severe (more than 40%), bracing until the skeletal system mature and then surgical intervention

Surgery includes realignment and straightening of the spine with internal fixation

Slide27

Developmental/congenital hip dysplasia/dislocation (DDH/CHD)

Improper formation and function of the hip socket. Cause of DDH is unknown, but there are predisposing factors such as:Genetic factors & birth orderPhysiologic factors: maternal hormoneMechanical factors: intrauterine position (breech), oligohydraminos, twining and fetus size, delivery type, postnatal positioning DDH occurs more commonly in females.

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DDH/CHD: Degrees

Acetabular dysplasia (or preluxation)SubluxationDislocation

Slide29

DDH/CHD: Degrees

Acetabular dysplasia (or preluxation)The mildest form The femoral head remains in the acetabulum

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DDH/CHD: Degrees

SubluxationAccounts for the largest percentage of DDH. It implies incomplete dislocation The femoral head remains in contact with the acetabulum, but a stretched capsule and ligamentum tears cause the head of the femur to be partially displaced.Dislocation Femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim

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DDH/CHD: diagnosis

Ortolani testAbduction of the thighs with external rotation. If the femoral head can be felt to slip forward into the acetabulum on pressure from behind, it is dislocated (positive Ortolani sign)Sometimes an audible “clunk” can be heard.Barlow testPressure from the frontIf the femoral head is felt to slip out over the posterior lip of the acetabulum and immediately slips back in place when pressure is released, there is dislocation or “unstable” (positive Barlow sign)

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DDH/CHD: diagnosis

Other signs of DDH are: Shortening of the limb on the affected side (limping and toe walkingPositive Trendelenburg sign or gait)Asymmetric thigh and gluteal foldsBroadening of the perineum(in bilateral dislocation)Ultrasounds

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DDH/CHD: Management

Newborn to six monthsPavlik harnessThe harness is used to maintain the infant’s hips in flexion and abduction and external rotation Pavlik harness device is to be worn continuously.The child in a Pavlik harness needs special attention to skin care because the infant’s skin is sensitive and the harness may cause irritation.6-8 months: Gradual reduction by traction is used for approximately 3 weeks. If the hip is not reducible, an open operative reduction is performed. Following reduction the child is placed in a hip spica cast for 2-4 months

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DDH/CHD: Management

Older child: Operative reductionAfter cast removal and before weight bearing is permitted, range-of-motion exercises & rehabilitative measures The former practice of double-or triple-diaper for DDH is not recommended because it promotes hip extension, thus worsening proper hip development

Slide35

DDH/CHD: Nursing Diagnosis & Management

Knowledge deficit

regarding care of harness or cast

Impaired

physical mobility

Risk for

impaired skin integrity

related to pressure from casts or braces

Risk for altered

skin perfusion

due to casts or braces

Risk for altered

growth and development

due to limited mobility

Nursing Management

Compliance with corrective devices by parents

Not removed for bathing

Prevent skin irritation

Cast care & Diaper area

Because DDH may reoccur it is important to

follow-up until the child reaches skeletal maturity

Slide36

Congenital clubfoot (Talipes)

Deformity of the ankle and footCategories of TalipesPositional clubfoot (transitional, mild or postural), may occur from intrauterine crowding responds to simple stretching and casting.Syndromic (tetralogic ) clubfootassociated with other congenital abnormalities such as myelomeningocele, more severe form of clubfoot that is often resistant to treatment.Congenital clubfoot (idiopathic ) has a wide range of rigidity and prognosis

Slide37

Congenital clubfoot: Management

goal of management: is

Correction of the deformity & Maintenance of the correction until normal muscle is gained

Management

Casts

begin immediately or shortly after birth and continue until marked overcorrection is reached.

Weekly manipulation and cast changes proceed for the first 6 to 12 weeks of life.

Surgery

If casting and manipulation are not successful

Followed by brace and cast

Slide38

Congenital clubfoot: Management

Nursing Care

Observation of skin and circulation (particularly important in young infants because of their normally rapid growth rate): swelling in the toes, foot temperature

Parents need to understand the diagnosis, the overall treatment program, the importance of regular cast changes

Slide39

Juvenile Rheumatoid Arthritis (JRA)

Is an inflammatory disease of the body joints and sometimes affects blood vessels and connective tissue

Unknown cause but a slight tendency to occur in families

Peak ages : 2 – 5 years and between 9 - 12 years of age

JRA is similar to the adult disease with some distinguishing features

onset before puberty

a negative rheumatoid factor (RF).

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Juvenile Rheumatoid Arthritis (JRA): Courses

Pauciarticular Polyarticular Systemic

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Juvenile Rheumatoid Arthritis (JRA): Pauciarticular

4

or fewer joints are affected

The most common form of JRA; about half of all children with JRA have this type

Affects large joints, such as the knees

Girls under age 8 are most likely to develop this type of JRA.

Some

children have special kinds of antibodies in the blood.

Antinuclear antibody (ANA)

Rheumatoid factor

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Juvenile Rheumatoid Arthritis (JRA): Pauciarticular

Eye disease

affects about 20 to 30% of children with

pauciarticular

JRA

Up to 80% of those with eye disease also test positive for ANA

The disease tends to develop at a particularly early age in these children

Regular examinations by an ophthalmologist are necessary to prevent serious eye problems such as

iritis

or

uveitis

Some children with

pauciarticular

disease

outgrow

arthritis by adulthood, although eye problems can continue and joint symptoms may recur in some people

Slide43

Juvenile Rheumatoid Arthritis (JRA): Polyarticular

30% of all children with JRA have

polyarticular

disease

5

or more joints are affected. The small joints (hands and feet) are most commonly involved, though large joints may be affected

symmetrical; that is, it affects the same joint on both sides of the body

Some children have an antibody in their blood called

IgM

rheumatoid factor (RF)

These children often have a

more severe

form of the disease

Slide44

Juvenile Rheumatoid Arthritis (JRA): Systemic (Still’s disease)

Joint swelling, &

fever

and a light

skin

rash

May also affect

internal organs

such as the heart, liver, spleen, and lymph nodes

Almost all children with this type of JRA test

negative

for both RF and ANA

Affects 20% of all children with JRA. A small percentage of these children develop arthritis in many joints and can have severe arthritis that continues into adulthood.

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Juvenile Rheumatoid Arthritis (JRA): Clinical Manifestations

Joint swelling

Stiffness

that typically is worse in the

morning or after a nap

Pain

may

limit/loss

movement of the affected joint

Commonly affects the knees and joints in the hands and feet

One of the

earliest signs

of JRA may be

limping

in the morning because of an affected knee.

Besides joint symptoms, children with

systemic JRA

have

A high

fever

and a light skin

rash

. The rash and fever may appear and disappear very quickly.

Swelling in the

lymph nodes

located in the neck and other parts of the body

In some cases (< 50%),

internal organs

(heart and, very rarely, the lungs) may be involved.

Slide46

Juvenile Rheumatoid Arthritis (JRA): Clinical Manifestations

Eye inflammation

Sometimes occurs in children with

pauciarticular

JRA.

Not present until some time after a child first develops JRA

Typically, there are periods when the symptoms of JRA are better or disappear (remissions) and times when symptoms are worse (flare-ups).

Growth problems

Depending on the severity of the disease and the joints involved it may cause joints to grow unevenly or to one side. causing one leg or arm to be longer than the other.

Overall growth may also be slowed.

Slide47

Juvenile Rheumatoid Arthritis (JRA): Diagnosis

Diagnosis of JRA is based on:

Age of onset

Arthritis in one or more joints for

6 weeks or longer

Exclusion of other etiologies.

Laboratory tests-- Blood may be taken to test for

RF

and

ANA

, and to determine the Erythrocyte

Sedimentation Rate (

ESR

).

positive RF is detected in just 10% of the cases. The RF test helps the doctor tell the difference among the three types of JRA.

ANA is found in the blood more often than RF, and both (ANA & RF) are found in only a small portion of JRA

patients.

ESR indicates inflammation in the body. Not all children with active joint inflammation have an elevated ESR.

Lab. tests may include elevated

WBCs

Slide48

Juvenile Rheumatoid Arthritis (JRA): Therapeutic Management

Slide49

Juvenile Rheumatoid Arthritis (JRA): Treatment

NSAIDs:

Aspirin, ibuprofen; may cause Reye’s Syndrome

Disease-modifying anti-rheumatic drugs (DMARDs):

most given in combination with NSAIDs to

slow the progression of JRA

Corticosteroids:

to control severe symptoms; can

interfere with a child's normal growth, a round face, weakened bones, and increased susceptibility to infections.

Biologic agents:

Etanercept

(

Enbrel

) blocks the actions of tumor necrosis factor, a naturally occurring protein in the body that helps cause inflammation

Physical therapy

:

Exercise to maintain

muscle tone and preserve and recover the range of motion of the joints; rest of affect body part and heat application

Slide50

Juvenile Rheumatoid Arthritis (JRA): Side effect of Aspirin

Bleeding

Stomach upset

Liver problems

Reye’s Syndrome:

Is sudden (acute) brain damage (encephalopathy) & liver function problems

Abnormal accumulations of fat begin to develop in the liver and other organs of the body, along with a severe increase of pressure in the brain

Without proper treatment death is common within a few days

Slide51

Juvenile Rheumatoid Arthritis

During painful episodes of the disease

Proper positioning is important to support and protect affected joints. Isometric exercises and passive range-of-motion exercises will prevent contractures and deformities

. Swimming in warm water provides

strengthening and range-of-motion exercises while protecting the joints.

After discharge

routine ophthalmologic

examinations

Swimming

Slide52

Cerebral palsy (CP)

It is a group of non-progressive disorders

(meaning the brain damage does not worsen, but secondary orthopedic difficulties are common)

of

motor neuron

impairment that result in

motor dysfunction

may

be accompanied by perceptual problems, language deficits, and intellectual involvement.

The disabilities usually result from injury to the

cerebellum, basal ganglia, or motor cortex.

The exact cause is unknown; it may results from injury to the brain before, during, or shortly after birth

Slide53

Cerebral palsy (CP)

Risk factors include:

Prematurity

LBW

Asphyxia

Infections (meningitis, encephalitis)

Head injuries

Metabolic problems such as

hyperbilirubinemia

and hypoglycemia

Sever dehydration

Slide54

Cerebral palsy (CP): Types

Spastic Dyskinetic/ athetoidAtaxic Mixed type/dystonic

Slide55

Cerebral palsy (CP): Types

Spastic : (most common type)

May involve one or both sides

Hypertonicity

with poor control of posture, balance, and coordinated motion (rigid & jerky movement).

Impairment of fine and gross motor skills

Dyskinetic

/

athetoid

:

Abnormal involuntary movement

Slow, wormlike, writhing (rolling & twisting) movements that usually involve the extremities, trunk, neck, facial muscles, and tongue.

Involvement of the pharyngeal, laryngeal, and oral muscles causes drooling and

dysarthria

(imperfect speech articulation)

Involuntary irregular jerking movements

Slide56

Cerebral palsy (CP): Types

Ataxic

Rapid, repetitive movements performed poorly.

Disintegration of movements of the upper extremities when the child reaches for objects

Mixed type/

dystonic

:

Combination of spasticity and

athetosis

.

Slide57

Cerebral palsy (CP): Clinical Manifestations

Delayed

gross motor development.

Alteration in

muscle tone

: increased or decreased resistance to passive movements.

Abnormal posture

:

opisthotonic

postures (exaggerated arching of the back) and may feel stiff on handling or dressing

Reflex abnormalities

: persistence of primitive infantile reflexes is one of the earliest clues to CP

Possible Associated

disabilities

and problems:

Convulsion/seizure

Visual and hearing impairments

Communication and speech difficulties

Some may have varying levels of mental retardation.

Slide58

Cerebral palsy (CP): Treatment

Goals of treatment:

Establish locomotion, communication and self-help.

Gain optimum appearance and integration of motor functions.

Correct associated defects.

Adaptation.

Management:

Provide safe environment to prevent injury.

Prevent physical deformities by using braces and provide ROM exercises.

Appropriate motor activities.

Medications such as sedatives, muscle relaxants, anticonvulsants.

Encourage ADLs.

Occupational to improve small muscles development

Speech therapy