Musculoskeletal Assessment
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Musculoskeletal Assessment
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Inspection Walks, moves in bed, performs any physical activity Look for foot dragging, limping, shuffling, and the position of the trunk in relation to the legs. Ask about usual physical activity Range of motion, muscle strength and tone. Factors affecting musculoskeletal Heavy alcohol, smoking, constant dieting, Hx fractures, excessive caffeine intake, long term corticosteroid use, aluminum-containing antacids, phenytoin, menopause <45, and post menopause
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Older Patients
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Muscle mass and strength and atrophy of muscles. Mobility, range of motion, flexibility, coordination and stability. Change of gait. Posture and stature changes. Increased brittleness of bones. Deterioration of joint capsule components. Kyphosis of the dorsal spine.
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Common Postural Abnormalities
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Scoliosis Lordosis Kyphosis Perry and Potter page 1426 Table 46-1
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What is kyphosis?
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Kyphosis is an excessive convex curvature at the thoracic level of the spine. Curvature greater than 45 degrees is generally considered excessive.
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Kyphosis Etiology
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Congenital Failure of formation or segmentation of the vertebral structures in uterus. Postural Tends to occur in preadolescent years. Secondary Cerebral palsy, tuberculosis, spinal muscle atrophy, muscular dystrophy, and metabolic disorders.
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What are the symptoms of kyphosis?
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Difference in shoulder height The head bends forward compared to the rest of the body Difference in shoulder blade height or position When bending forward, the height of the upper back appears higher than normal Tight hamstrings (back thigh) muscles
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Kyphosis Diagnosis
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Visualizing the spine and scapular area from the side with the child bending 90 degrees at the waist. X-ray Bone Scans CT Scans MRI This test is done on kyphosis patients to rule out any associated abnormalities of the spinal cord and nerves.
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Treatment of kyphosis:
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Child's age, overall health, and medical history The extent of the condition Severity of deformity & amount of pain. Conservative treatment Exercise regimen and anti-inflammatory agents Still growing - brace >75 degrees, surgery with fusion
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What is lordosis?
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A normal spine, when viewed from behind appears straight. However, a spine affected by lordosis shows evidence of a curvature of the back bones (vertebrae) in the lower back area, giving the person a "swayback" appearance.
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What causes lordosis?
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Normal in toddlers Should disappear as the child grows in height Often observed in girls, during growth. Obesity Flexion contractures of the hip Developmental dysplasia of the hip Slipped capital epiphysis
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What are the symptoms of lordosis?
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Prominence of the buttocks. Protruding chest and abdomen Complaints of: Lower back pain, hip pain, and fatigu
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How is lordosis diagnosed?
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Visualization of the spine and radiographs X-ray Bone scans CT MRI
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Treatment of lordosis:
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The goal of treatment is to stop the progression of the curve and prevent deformity. Management of lordosis will depend upon the cause of the lordosis. Simple exercises may be sufficient if lordosis is associated with poor posture. However, lordosis occurring as a result of a hip problem may be treated as a part of the hip problem.
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3 What causes lordosis? Normal in toddlers Should disappear as the child grows in height Often observed in girls, during growth. Obesity Flexion contractures of the hip Developmental dysplasia of the hip Slipped capital epiphysis What are the symptoms of lordosis? Prominence of the buttocks. Protruding chest and abdomen Complaints of: Lower back pain, hip pain, and fatigue How is lordosis diagnosed? Visualization of the spine and radiographs X-ray Bone scans CT MRI Treatment of lordosis: The goal of treatment is to stop the progression of the curve and prevent deformity. Management of lordosis will depend upon the cause of the lordosis. Simple exercises may be sufficient if lordosis is associated with poor posture. However, lordosis occurring as a result of a hip problem may be treated as a part of the hip problem. What is scoliosis?
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Four common types of curve patterns seen in scoliosis are: thoracic - 90 percent of the curves occur on the right side. lumbar - 70 percent of the curves occur on the left side. thoracolumbar - 80 percent of the curves occur on the right side. double major - curves that occur on the right and left side.
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What causes scoliosis?
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Congenital spinal column abnormalities Neuromuscular Muscular dystrophy, cerebral palsy, spina bifida and radiation Idiopathic Infantile, juvenile, and adolesce
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Congenital Scoliosis
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Failure of the vertebrae to form normally Absence of vertebrae Partially formed vertebrae Lack of separation of the vertebrae
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Neuromuscular Scoliosis
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Cerebral palsy Spina bifida Muscular dystrophy Paralytic conditions Spinal cord tumors Neurofibromatosis - a genetic condition that affects the peripheral nerves that causes changes to occur in the skin, called café-au-lait spots.
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Idiopathic Scoliosis
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Infantile - occurs from birth to 3 years of age. The curve of the vertebrae is to the left and it is more commonly seen in boys. Typically, the curve resolves as the child grows. Juvenile - occurs in children from 3 to 9 years of age. Adolescent - occurs in children from 10 to 18 years of age. This is the most common type of scoliosis and is more commonly seen in girls.
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Scoliosis Pathophysiology
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Vertebral column begins to curve laterally Spin and ribs rotate toward the convex portion of the curve On the concave side, the muscles and ligaments are contracted and thickened & on the convex side they become thin & atrophied A compensatory curve results as the child attempts to maintain erect posture Thoracic cavity also changes and becomes asymmetrical = respiratory problems
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What are the symptoms of scoliosis?
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difference in shoulder height the head is not centered with the rest of the body difference in hip height or position difference in shoulder blade height or position when standing straight, difference in the way the arms hang beside the body when bending forward, the sides of the back appear different in height
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Scoliosis Nursing Assessment
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From the Front: Is the head midline? Are the shoulders at the same height? Is there the same amount of space between arms, and body on each side?
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Scoliosis Nursing Assessment
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From the Back: Is the head midline? Are the shoulders at the same height? Is the spine straight? Is there the same amount of space between arms and body on each side?
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Scoliosis Nursing Assessment
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With the Adolescent Holding Hands Together and Bent Over Slightly Are the scapular humps even? With the Adolescent Holding Hands Together and Bent Over Toward Floor Are the flank humps even? Is the spine straight? Is there marked roundness when viewed form the side?
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Scoliosis Treatment
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Exercises to improve posture and muscle tone. Exercises to maintain or possibly increase flexibility of the spine. Bracing (Boston or Milwaukee) worn 18 to 23 hours per day Electrical stimulation Surgery (spinal fusion)
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Priority Nurse Diagnoses for Scoliosis
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Disturbed body image related to bracing Risk for injury related to brace Pain related to surgical experience Ineffective breathing pattern related to postop discomfort Impaired physical mobility related to brace wear Risk for noncompliance with treatment
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What is Legg-Calvé-Perthes disease?
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Legg-Calvé-Perthes disease is a temporary condition in children in which the ball-shaped head of the thigh bone, referred to as the femoral head (epiphysis), loses its blood supply. As a result, the femoral head collapses. The body will absorb the dead bone cells and replace them with new bone cells. The new bone cells will eventually reshape the femoral head of the thigh bone.
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What are the symptoms of Legg- Calvé-Perthes disease?
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The child typically complains of pain in his/her hip that is aggravated by activity. Sometimes, they will also experience pain in their thigh or knee area. The child usually walks with a limp and reports that rest will alleviate the pain.
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LCPD Medical Assessment
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X-rays Bone scans Magnetic resonance imaging (MRI) Arthrograms - a diagnostic imaging test to study the non-bony structures of joints.
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Treatment LCPD
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Rest Activity restrictions Medications Bed rest and traction Casting or bracing (to hold the femoral head in the hip socket, permit limited joint movement, and allow the femur to remold itself into a round shape again - may take 2-4 years) Surgery (to hold the femoral head in the hip socket) - returns child to normal activities in 3-4 months Physical therapy (to keep the hip muscles strong and to promote hip movement) Crutches or wheelchair (in some cases)
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LCPD Priority Nursing Diagnoses
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Impaired physical mobility related to brace or cast Deficient knowledge - disease process & complications Pain related to disease process Activity deficit related to brace or cast Undiagnosed LCPD can lead to osteoarthritis & hip dysfunction in later life
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What is Osgood-Schlatter disease?
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Osgood-Schlatter (OS) disease is one of the most common causes of knee pain in the adolescent. Consisting of pain and edema of the tibial tubercle (and hence this is an extraarticular disease), OS disease is generally a benign, self-limited knee condition associated with traction apophysitis ( in adolescent boys and girls).
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What causes Osgood-Schlatter disease?
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Osgood-Schlatter disease is characterized by inflammation of the patellar tendon and surrounding soft tissues. It is caused by the constant pulling of the patellar tendon on the area below the knee where the tendon attaches.
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What are the symptoms of Osgood-Schlatter disease?
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Point tenderness below the knee Swelling around the knee (usually localized just below the knee cap at the area of tenderness) Limping (may worsen following activities)
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Treatment for Osgood-Schlatter disease:
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R.I.C.E. - rest, ice, compression, and elevation (ice 20 minutes every 2-4 hours) Medications (for discomfort) Elastic wrap or a neoprene knee sleeve around the knee Activity restrictions Physical therapy (to help stretch and strengthen the thigh and leg muscles) Disease usually resolves with time
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What is slipped capital femoral epiphysis?
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Slipped capital femoral epiphysis (SCFE) is a condition of the hip joint that affects children. In SCFE, the femoral head slips off the neck of the femur.
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What causes slipped capital femoral epiphysis?
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Etiology is unknown Common in obese or rapidly growing children May be a genetic predisposition May result from trauma
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What are the symptoms of SCFE?
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Hip pain aggravated by activity. Pain in groin, thigh, or knee. Feels like "leg is giving away." May walk with leg turned.
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Treatment of slipped capital femoral epiphysis:
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Surgery (involving the use of a steel pin to hold the femoral head onto the femur to prevent it from slipping further) Physical therapy (following surgery, to help strengthen the hip and leg muscles)
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Club Foot Talipes
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Congenital - 1 in every 1,000 births Boys 2 times as often as girls 1 in 3 cases affect both feet The foot is usually short and broad in appearance The heel points downward while the front half of the foot (forefoot) turns inward Heel cord (Achilles tendon) is tight. The heel can appear narrow Muscles in the calf are smaller compared to a normal lower leg.
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Talipes Description
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Varus - Inward rotation Would walk on ankles, bottoms of feet face each other Valgus - Outward rotation Would walk on inner ankles Calcaneous - Upward rotation (Dorsiflexion) Would walk on heels Equinas - (Plantar flexion) Would walk on toes
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What causes talipes (clubfoot)?
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Exact cause unknown Abnormal intrauterine position Neuromuscular or vascular problems Twice as common in males as females Strong familial tendency One in 10
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Treatment for clubfoot
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Correct in newborn period because small bones in foot ossify shortly after birth The aim of the treatment regime should be: Correct the deformity early. Correct the deformity fully Hold the correction until growth stops.
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Casting and Bracing
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This may begin from the 1st day of life to several weeks after birth. The foot is pushed and twisted into an over corrected position by the Orthopedist. The cast is then applied in order to hold the foot into that position. This may be uncomfortable for the child. Casts are usually changed every two weeks. Splints or braces may be used after a few years of casting the feet.
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Surgery for Clubfoot
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If casting doesn't correct then surgery (ideally before child's 1st B-day) Perctuneous tenotomy. The Achilles tendon is cut to allow the foot to drop. Posterior release. Medial release. Sub tarsal release. Complete tendon transfer. Casting follows surgery for at least 3 months
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Talipes Nursing Care
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Neurovascular checks - cap refill less than 2 seconds Observe for swelling around cast edges Elevate ankle and foot on pillows Monitor drainage on cast Pain management Appropriate distraction Change diapers frequently
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Developmental Dysplasia of the Hip
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Head of the femur is seated improperly in the acetabulum.
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Hip Dysplasia Etiology
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Congenital Cause unknown Family history Increases 10 fold Usually 1st born female Prenatal conditions Sociocultural
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DDH Assessment
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Asymmetry of the gluteal and thigh skin folds. Restricted abduction of the hips after 6-10 weeks of age.. Asymmetric abduction of the affected hip. Shortening of affected limb. Allis sign Ortolani or Barlow sign
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DDH Assessment Older Child
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Affected leg shorter than the other History of delay in walking Limp and toe walking Trendelenberg's sign Waddling gait with bilateral dislocation Lordosis with bilateral dislocation
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Further Treatment for DDH
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Traction and casting Surgery and casting What is a short leg hip spica cast? A short leg hip spica cast is applied from the chest to the thighs or knees. This type of cast is used to hold the hip in place after surgery to allow healing.
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DDH Cast care instructions
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Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges can be padded to protect the skin from scratches. Do not scratch the skin under the cast by inserting objects inside the cast. Assessment of capillary refill less than 2 seconds Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast. Do not put powders or lotion inside the cast. Cover the cast during feedings to prevent spills from entering the cast. Prevent small toys or objects from being put inside the cast. Elevate the cast above the level of the heart to decrease swelling. Do not use the abduction bar on the cast to lift or carry the baby
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Muscular Dystrophy
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Muscular dystrophy (MD) is a broad term that describes a genetic (inherited) disorder of the muscles. Muscular dystrophy causes the muscles in the body to become very weak. The muscles break down and are replaced with fatty deposits over time
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What are the symptoms of muscular dystrophy?
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Clumsy movement Difficulty climbing stairs Frequently trips and falls Unable to jump or hop normally Tip toe walking Leg pain Facial weakness Inability to close eyes or whistle Shoulder and arm weakness
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How is muscular dystrophy diagnosed?
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Blood enzymes - level of creatine kinase Muscle biopsy - the primary test used to confirm diagnosis. A small sample of muscle tissue is taken and examined under a microscope. To see if it resembles muscle in MD or that of another muscle disorder. Electromyogram (EMG) - test to check if the muscle weakness is a result of destruction of muscle tissue rather than nerve damage. Nerve conduction velocity (NCV) - Involves sending electrical impulses down the nerves of the arms and legs. Measures is nerves are functioning normally
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Treatment for muscular dystrophy: Supportive
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Physical therapy Positioning aids - used to help the child sit, lie, or stand Braces and splints - used to prevent deformity, promote support, or provide protection Medications Nutritional counseling Psychological counseling Surgical
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Priority Nursing Diagnoses for MD
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Long term outlook MD is a progressive condition that needs lifelong management to prevent deformity and complications. Walking and sitting becomes more difficult. Usually by the age of 12, the child needs a wheelchair because the leg muscles are too weak to work. Heart or lung problems often occur by the late teenage years or into the early 20s.
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Priority Nursing Diagnoses for MD
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Risk for injury related to disease process Anticipatory grieving related to chronic & terminal illness Impaired physical mobility related to wasted muscles Risk for constipation related to poor muscle tone Impaired gas exchanged related to accumulation of secretions, lack of mobility Disturbed self-esteem related to debilitating disease process
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DECIDE FOR YOURSELF ... IS THIS AN ABUSED CHILD?
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Unlikely or unsatisfactory explanation of how the fracture occurred. X-rays reveal old fractures in various stages of healing Evidence of bruising Varied types of fractures Bones that appear normal on X-rays
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Osteogenesis Imperfecta
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OI is a genetic disease. The inheritance pattern is usually autosomal dominant. Affects collagen formation and results in pathologic fractures. There are normal calcium and phosphorus levels but abnormal precollagen type I, which prevents formation of collagen, the major component of connective tissue. There are 10 subtypes of Collagen
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OI Diagnosis
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Osteoporosis with abnormal fragility of skeleton Blue sclera Dentinogenesis imperfecta Premature Otosclerosis The presence of 2 of the above abnormalities confirms diagnosis
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Type 1 (Mild) OI
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Fragile bones Triangular-shaped face Blue sclera (whites of the eye) Hearing loss - often beginning in their 20s with complete deafness by 30 Scoliosis (curvature of the spine) Thin, smooth skin Loose joints Low muscle tone Brittle teeth 40 fractures by puberty
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Type II (Lethal) OI
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Most severe form affecting 10% of children with OI. Bones of people with Type II OI are extremely fragile and often have severe deformities. Type II OI frequently causes death at or shortly after birth.
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Type III (Progressive deforming) OI
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20% of children who have OI have Type III OI usually resulting from spontaneous mutation. Short stature (some people only grow three feet tall) Sclera have a blue, purple, or gray tint Soft bones that not only break easily but also bend Loose joints Poor muscle development Barrel-shaped ribcage Triangular face Scoliosis Poor tooth development, often causing teeth to be brittle and discolored Possible hearing loss Possible respiratory problems 100 fractures before puberty = decreased life expectancy
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Type IV (Moderately severe) OI
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Below average height Scoliosis Mild to moderate bone deformity Triangular face Barrel-shaped ribcage Possible hearing loss Possible brittle teeth Loose, easily overstretched joints Compatible with normal life expectancy Resurgence of fractures after menopause
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OI Treatment & Management
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Fractures must be repaired quickly in the usual ways to avoid deformities Good nutrition and directed exercise Surgical procedures, including the placement of metal rods through bones The use of biphosphonates may be prescribed to increase bone mass Other medical interventions: including bone marrow transplant, the use of growth hormone, and gene therapy-are also under investigation. Physical therapy-especially swimming
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OI Pain management
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Coping with and managing pain are essential if a person with OI is to lead a happy and productive lifestyle. The pain associated with fractures, joint deformities, and muscle contractures can be treated in a number of ways: Heat/Ice TENS OTCs Prescription Meds Nerve Block
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OI Nursing Interventions
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Support limbs, do not stretch. Position with care; use blankets to aid in mobility and provide support. Instruct parents in bathing, dressing, diapering. Support parents; encourage expression of feelings of anger or guilt.
