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Peds: Chp 28: Musculoskeletal Congenital Disorders

Terms in this set (50)

Clubfoot
● A complex deformity of the ankle and foot

● Can affect one or both feet, occur as an isolated defect, or in association with other disorders such as cerebral palsy and spinal bifida

● Categorized as positional clubfoot (occurs from intrauterine crowding), syndromic (occurs in association with other syndromes), and congenital (idiopathic)
Clubfoot: Risk Factors
presence of other syndromes, hereditary factors
Clubfoot: Expected Findings
● Talipes varus: inversion (bending inward)

● Talipes valgus: eversion (bending outward)

● Talipes calcaneus: dorsiflexion (toes are higher than the heels)

● Talipes equinus: plantar flexion (toes are lower than the heels)

● Talipes equinovarus: toes are facing inward and lower than the heel
Clubfoot: Diagnostic Procedures
Prenatal ultrasound provides data for identification of the deformity.
Clubfoot: Nursing Care
● Encourage parents to hold and cuddle the child.

● Encourage parents to meet the developmental needs of the child.

● Perform neurovascular and skin integrity checks.
Clubfoot: Therapeutic Procedures: Casting
● Series of castings starting shortly after birth and continuing until maximum correction is accomplished.
● Weekly manipulation of the foot to stretch the muscles with subsequent placement of a new cast.
● Following casting, a heelcord tenotomy is usually performed followed by a long leg cast for 3 weeks.
● A Denis Browne bar that connects specialized shoes can be applied to maintain the correction and prevent recurrence.

● NURSING CARE
◯ Assess neurovascular status.
◯ Perform cast care.

● CLIENT EDUCATION
◯ Teach cast care.
◯ Teach the family follow-up care for cast changes.
Clubfoot: Complications: Growth and development delays
● NURSING CARE: Monitor growth and development.

● CLIENT EDUCATION: Teach the family strategies to enhance normal growth and development.
Clubfoot: Complications: Effects of casting
● Skin breakdown

● Neurovascular alterations
Legg‐Calve‐Perthes disease
Aseptic necrosis of the femoral head can be unilateral or bilateral
Legg‐Calve‐Perthes disease: Risk Factors
● Age: Affects children 2 to 12 years but more common between ages 4 to 8 years

● Gender: More common in boys

● Trauma, inflammation to the femoral head
Legg‐Calve‐Perthes disease: Expected Findings
● Intermittent painless limp
● Hip stiffness
● Limited ROM
● Hip, thigh, knee pain
● Shortening of the affected leg
● Muscle wasting
Legg‐Calve‐Perthes disease: Diagnostic Procedure
Radiograph of the hip and pelvis
Legg‐Calve‐Perthes disease: Nursing Actions and CLient Education
NURSING ACTIONS
● Treatment varies with the child's age and the appearance of the femoral head.
● Administer NSAIDs as prescribed.
● Maintain rest and limited weight bearing.
◯ Abduction brace
◯ Casts
◯ Physical therapy
◯ Traction
● Advance to active motion as prescribed.

CLIENT EDUCATION
● Teach about the limited weight bearing treatment prescribed.
● Offer developmental appropriate strategies for learning and activities during the limited weight bearing periods.
Legg‐Calve‐Perthes disease: Surgical Intervention
Osteotomy of the hip or femur
Developmental dysplasia of the hip (DDH)
A variety of disorders resulting in abnormal development of the hip structures that can affect infants or children
Developmental dysplasia of the hip (DDH): Acetabular dysplasia
delay in acetabular development (acetabular roof is shallow and oblique)
Developmental dysplasia of the hip (DDH): Subluxation
incomplete dislocation of the hip
Developmental dysplasia of the hip (DDH): Dislocation
femoral head does not have contact with the acetabulum
Developmental dysplasia of the hip (DDH): Risk Factors
● Birth order (firstborn)
● Female gender
● Family history
● Breech intrauterine position
● Delivery type
● Joint stability
Developmental dysplasia of the hip (DDH): Expected Findings: Infants
● Asymmetry of gluteal and thigh folds
● Limited hip abduction
● Shortening of the femur
● Widened perineum
● Positive Ortolani test (hip is reduced by abduction)
● Positive Barlow test (hip is dislocated by adduction)
Developmental dysplasia of the hip (DDH): Expected Findings: Child
● One leg shorter than the other
● Positive Trendelenburg sign (while bearing weight on the affected side, the pelvis tilts downward)
● Walking on toes on one foot
● Walk with a limp
Developmental dysplasia of the hip (DDH): Diagnostic Procedures
Ultrasound: performed at 2 weeks of age to determine the cartilaginous head of the femur

X-ray: can diagnose DDH in infants older than 4 months of age
Developmental dysplasia of the hip (DDH): Nursing Care
● Treatment starts as soon as DDH is diagnosed and depends on the child's age and the extent of the dysplasia.

● Encourage parents to hold and cuddle the infant/child.

● Encourage parents to meet the developmental needs of the infant/child.
Developmental dysplasia of the hip (DDH): Newborn to 6 months
Pavlik harness

● Maintain harness placement for to 12 weeks.
● Check straps every 1 to 2 weeks for adjustment.
● Perform neurovascular and skin integrity checks.
● Removing the harness is dependent on the client.

● CLIENT TEACHING
◯ Teach the family not to adjust the straps.
◯ Teach the family how to place the harness if removal is prescribed.
◯ Teach the family skin care (use an undershirt, wear knee socks, assess skin, gently massage skin under straps, avoid lotions and powders, place diaper under the straps).
Developmental dysplasia of the hip (DDH): When adduction contracture is present

Bryant traction
● Skin traction
● Hips flexed at a 90° angle with the buttock raised off of the bed

● NURSING ACTIONS
◯ Neurovascular checks
◯ Maintain traction (ropes, boots, pulleys, and weights)
◯ Ensure the client maintains alignment
◯ Skin care
Developmental dysplasia of the hip (DDH): When adduction contracture is present

Hip spica cast
● Needs to be changed to accommodate growth

● NURSING ACTIONS
◯ Assess and maintain the hip spica cast.
◯ Perform frequent neurovascular checks.
◯ Perform range of motion with the unaffected extremities.
◯ Perform frequent assessment of skin integrity,
especially in the diaper area.
◯ Assess for pain control using an age-appropriate pain tool. Intervene as indicated.
◯ Evaluate hydration status frequently.
◯ Assess elimination status daily.

● CLIENT EDUCATION
◯ Reinforce teaching regarding positioning, turning, neurovascular assessments, and care of the cast.
◯ Position casts on pillows.
◯ Keep the casts elevated until dry.
◯ Encourage frequent position changes to allow for drying.
◯ Handle the casts with the palm of the hand until dry.
◯ Note color and temperature of toes on casted extremity.
◯ Give sponge baths to avoid wetting the cast.
◯ Use a waterproof barrier around the genital opening of spica cast to prevent soiling with urine or feces.
◯ Educate regarding care after discharge with emphasis on using appropriate equipment (stroller, wagon, car seat) for maintaining mobility.
Developmental dysplasia of the hip (DDH): 6 months to 2 years
Surgical closed reduction with placement of hip spica cast

NURSING ACTIONS
◯ Prepare family and client for surgery
◯ Perform neurovascular checks
◯ Manage postoperative pain
◯ Skin care
◯ Cast care

CLIENT EDUCATION: Teach about spica cast and home care management
Developmental dysplasia of the hip (DDH): Older children
● Surgical reduction with presurgical traction

● Femoral osteotomy, reconstruction, and tenotomy are often needed
Developmental dysplasia of the hip (DDH): Postoperative complications
Atelectasis, ileus, infection
Developmental dysplasia of the hip (DDH): Complications: Effects of immobilization
Decreased muscle strength, bone demineralization, altered bowel motility
Developmental dysplasia of the hip (DDH): Complications: Effects of casting
Skin breakdown, neurovascular alterations
Developmental dysplasia of the hip (DDH): Complications: Infection
● Infection can be caused by bacteria, such as Staphylococcus aureus.

● NURSING ACTIONS
◯ Monitor vital signs. Observe changes in temperature that could be associated with complications of infection.
◯ Keep the cast dry and intact.
◯ Monitor for changes in neurovascular status (numbness; tingling; decreased mobility, sensation, or capillary refill).
◯ Reposition the child frequently.
◯ Maintain a high-fiber diet and promote adequate hydration.
◯ Monitor bowel and bladder elimination. Report any changes, especially the decrease or absence of bowel sounds or distention.
◯ Report any foul odor from cast or urine.
◯ Observe changes in behavior, especially increasing irritability in infants.

● CLIENT EDUCATION
◯ Discuss possible complications of specific treatment or procedure with the child and/or family.
◯ Reinforce the need to notify the provider with any concerns or indications of complications.
◯ Educate the child and family about follow-up.
Osteogenesis imperfecta
An inherited condition that results in bone fractures and deformity along with restricted growth.
Osteogenesis imperfecta: Risk Factors
Parent who has osteogenesis imperfecta (OI)
Osteogenesis imperfecta: Expected Findings
Classic manifestations
● Multiple bone fractures
● Blue sclera
● Early hearing loss
● Small, discolored teeth
Osteogenesis imperfecta: Diagnostic Procedure: Bone Biopsy
● NURSING ACTIONS
◯ Prepare the client for the procedure.
◯ Assist with positioning the client.
Osteogenesis imperfecta: Medications: Pamidronate
● Increase bone density

● NURSING ACTIONS
◯ Administer IV.
◯ Monitor for adverse effects (hypokalemia, hypomagnesemia, hypocalcemia, hypophosphatemia, thrombocytopenia, neutropenia, dysrhythmias, kidney failure, general malaise).

● CLIENT EDUCATION
◯ Teach adverse effects and when to call the provider.
◯ Instruct the family and client that antibiotics will be needed prior to some dental work
◯ Teach the family and client low-impact exercises.
◯ Teach the family about medication regime as prescribed.
◯ Consult with physical therapy.
◯ Assist with braces and splints as prescribed.
◯ Assist client with meeting developmental milestones.
◯ Educate the parents on the client's limitations.
◯ Encourage support groups.
Osteogenesis imperfecta: Surgical Intervention
● For severe cases
● Correct bone deformities, placement of rods.
Osteogenesis imperfecta: Complications
Disuse osteoporosis
● Limit time in casts.
● Encourage activity.

Hearing loss

Permanent deformities
Scoliosis
Complex deformity of the spine that also affects the ribs.

● Characterized by a lateral curvature of the spine and spinal rotation that causes rib asymmetry.

● Idiopathic or structural scoliosis is the most common form of scoliosis and can be seen in isolation or associated with other conditions.
Scoliosis: Risk Fatcors
● Genetic tendency
● Gender: more common in girls
● Age: highest incidence between 8 to 15 years of age
Scoliosis: Expected Findings
● Asymmetry in scapula, ribs, flanks, shoulders, and hips

● Improperly fitting clothing (one leg shorter than the other)
Scoliosis: Diagnostic Procedures
● Screen during preadolescence for boys and girls.
◯ Observe the child, who should be wearing only underwear, from the back.
◯ Have the child bend over at the waist with arms hanging down and observe for asymmetry of ribs and flank.
◯ Measure truncal rotation with a scoliometer.

● Perform radiography.
◯ Use the Cobb technique to determine the degree of curvature.
◯ Use the Risser scale to determine the skeletal maturity
Scoliosis: Therapeutic Procedures: Bracing
Customized braces slow the progression of the curve.

NURSING ACTIONS
● Assist with fitting the client with a brace.
● Assess skin.
● Promote the client's positive self-image.

CLIENT EDUCATION: Teach the client how to apply the brace.
Scoliosis: Surgical Intervention: Spinal fusion with rod placement

Preopertaive Nursing Actions
Used for curvatures greater than 45°

PREOPERATIVE NURSING ACTIONS
● Inform and assist the adolescent to obtain autologous (self-donated) blood donations.
● Obtain routine laboratory studies, including a type and cross match for blood as prescribed.
● Orient the adolescent and family to the ICU.
● Inform the adolescent and family about what can be expected during the postoperative period, such as monitoring equipment, NG tube, chest tubes, indwelling urinary catheters, and self-administering analgesic pumps.
Scoliosis: Surgical Intervention: Spinal fusion with rod placement

Postopertaive Nursing Actions
● Monitor the adolescent initially in the intensive care unit.
● Perform standard postoperative care to prevent complications.
● Monitor pain using an age-appropriate pain tool.
● Administer analgesia using a patient-controlled analgesic (PCA) pump as prescribed.
● Perform frequent neurovascular checks.
● Turn the adolescent frequently by log rolling to prevent damage to the spinal fusion.
● Assess skin for pressure areas, especially if a brace has been prescribed.
● Provide skin care by keeping skin clean and dry.
● Monitor surgical and drain sites for indications of infection. Provide wound care as prescribed.
● Assess bowel sounds and monitor, observing for paralytic ileus.
● Monitor for decreases in Hgb and Hct. Observe for indications of bleeding.
● Administer blood transfusion as prescribed. The adolescent can have self-donated blood available for transfusion.
● Encourage mobility as soon as tolerated.
● Assess for infection.
● Perform range of motion on unaffected extremities.
● Provide age-appropriate activities and opportunities to visit with friends and family during the hospital stay.
Scoliosis: Client Education: Preopertaive and Postopertaive
PREOPERATIVE
● Reinforce teaching (use of incentive spirometer, turning, coughing, deep breathing) to prevent complications.
● Perform extensive preoperative teaching to educate the adolescent and family and to promote cooperation and participation in recovery.
● Demonstrate the use of a PCA pump if age-appropriate.
● Demonstrate log rolling that will be used after surgery.
● Demonstrate the respiratory therapy techniques that will be used postoperatively to reduce complications of anesthesia.
● Discuss medical terms that are unfamiliar to the adolescent and/or family.

POSTOPERATIVE
● Emphasize the importance of physical therapy and proper positioning of the spine.
● Encourage independence following surgery for the adolescent who has a brace.
● Encourage the adolescent to contact friends when able.
● Emphasize the necessity of follow-up care.
Scoliosis: Care After Discharge
● Reinforce the expected course of treatment and recovery.

● Suggest that the family arrange the environment to facilitate the adolescent's ability to be as independent as possible (keep favorite items within reach).

● Emphasize the necessity of follow-up care.
Scoliosis: Complications
Breathing difficulties (with severe curvatures)

Spine or nerve damage

Lowered self-esteem: Assist the client with age-appropriate actions to promote positive self-esteem.
Scoliosis: Complications: Infection following surgery
● Infection can be caused by bacteria, such as Staphylococcus aureus.

● NURSING ACTIONS
◯ Monitor vital signs. Observe changes in temperature that could be associated with complications of infection.
◯ Monitor for changes in neurovascular status (numbness; tingling; decreased mobility, sensation, or capillary refill).
◯ Reposition the child frequently.
◯ Maintain a high-fiber diet and promote adequate hydration.

● CLIENT EDUCATION
◯ Discuss possible complications of specific treatment or procedure with the child and family.
◯ Reinforce the need to notify the provider with any concerns or indications of complications.
◯ Educate the child and family about follow-up.
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