Chapter 40

The Child with a Musculoskeletal

Disorder

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 Growth and Development of the
Musculoskeletal System
• Provides the structure and framework to support, protect,
and permit movement of the body
• Skeletal system is made up of four types of bone
• Bone formation begins with calcification
• Bone growth takes place between birth and puberty, most
growth completed by age 20
• When epiphyseal plate cartilage no longer present: Bone
growth complete
• During childhood, bones are more sponge-like
– Bend, break more easily than adults
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 Growth and Development of the
Musculoskeletal System (cont.)
• Bones of the skull
• Spine or vertebral column
– Birth: Continuous, rounded convex curve
– Adulthood: Four distinct curves
• During growth: Muscles become stronger; increased
muscle tone, strength, coordination

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 Fractures
• Break in the bone usually with vascular and soft tissue
damage, characterized by pain, swelling, tenderness
• Child fractures differ from adult
– Less complicated
– Heal more quickly
– Occur from different causes (usually)
• Most commonly fractured
– Clavicle; femur; tibia
– Humerus; wrist; fingers

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 Fractures (cont.)

• Fracture classifications
– Complete: Separated fragments of bone
– Incomplete: Bones partially joined
• Greenstick fracture: Common in children
– Compound/open: Fractured bone penetrates skin
– Simple/closed: Single break in bone without skin
penetration
– Spiral fractures: Wrenching force fracture, frequently
associated with child abuse
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 Fractures (cont.)
• Treatment and nursing care
– Assess
• Five Ps: Pain; pulse; paresthesia; paralysis; pallor
• Odor; drainage; “hot spots”; cast fit; fever
– Casts
• Child/family teaching: Postapplication events; cast
care
– Traction: Carefully monitor for signs of neurovascular
complications
• Types of traction
– External fixation devices: Pin site care
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 Osteomyelitis

• Infection of the bone caused by Staphylococcus aureus

• Clinical manifestations: Abrupt occurrence
– Fever; malaise; pain; localized tenderness; limited
joint motion
• Diagnosis: Laboratory results; later on: radiographs
• Treatment
– Immediate IV antibiotic therapy
– Continued for at least six weeks

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 Osteomyelitis (cont.)

• Nursing care
– Reducing pain: Positioning; minimizing limb
movement
– Administering medications
• Antibiotics; analgesics
• Monitoring IV medication administration
– Monitor oral nutrition and fluids

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 Muscular Dystrophy
• Hereditary, progressive, degenerative muscle disease
• Most common form: Duchenne (pseudohypertrophic)
muscular dystrophy
• Clinical manifestations: First signs noted: infancy or
childhood
– Difficulty standing and walking; trunk muscle
weakness develops (later)
• Gowers sign
– Mild mental retardation
– Progressive muscle weakness
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 Muscular Dystrophy (cont.)
• Diagnosis
• Treatment: No effective treatment
– Research is rapidly closing in on genetic identification
• Nursing care
– Encourage activity as possible: Delay muscle atrophy,
contractures
– Promote physiotherapy, diet, parental encouragement
– Breathing exercises
– Keep child’s life as normal as possible
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 Legg–Calvé–Perthes Disease

• Aseptic necrosis of the head of the femur

• Occurs four to five times more often in boys than girls;
10 times more often in whites than other ethnic groups
• Clinical manifestations
– Pain in hip/groin; limp with muscle spasms; limited
motion
• Diagnosis: Radiograph (later)
• Stages of disease: Three

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 Legg–Calvé–Perthes Disease (cont.)
• Treatment
– Containing the femoral head within acetabulum
during revascularization process: facilitate new
femoral head formation into smoothly functioning
joint
– Reconstructive surgery
• Nursing care
– Assisting child/caregiver management of corrective
device
– Emphasizing importance of compliance: promote
healing, avoid long-term disability
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 Question
In what disease does the nursing care focus on helping the
child and caregivers understand the importance of
compliance to promote healing and avoid long-term
disability?

a. Osteosarcoma
b. Legg–Calvé–Perthes disease
c. Osteomyelitis
d. Muscular dystrophy

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 Answer
b. Legg–Calvé–Perthes disease

Rationale: Nursing care focuses on helping the child and

caregivers to manage the corrective device, and the
importance of compliance to promote healing and to
avoid long-term disability.

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 Osteosarcoma
• Malignant, long-bone tumor; boys more frequently than
girls
• Pediatric exposure to radiation or retinoblastoma increase
likelihood
• Clinical manifestations
– Pain, swelling at tumor site
– Pathologic fractures of the bone and lung metastasis
can occur
• Diagnosis
– Biopsy; radiograph; CT; MRI
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 Osteosarcoma (cont.)

• Treatment
– Surgical removal of the bone or the limb
(amputation), followed by chemotherapy
• Nursing care
– Honest answers and support are helpful
– Support groups with other children
– Prognosis: Early diagnosis, treatment can result in
survival

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 Ewing Sarcoma
• Malignant tumor found in bone marrow of the long bones
of older school-aged or adolescent boys
• Clinical manifestations: Pain at tumor site
• Diagnosis
– Progressive pain becomes severe enough to keep child
awake at night
– Metastasis to lungs, other bones: May have taken
place by time of diagnosis
– Biopsy; bone scan; bone marrow aspiration

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 Ewing Sarcoma (cont.)

• Treatment
– Tumor is removed; radiation; chemotherapy
– Amputation possible
• Nursing care
– Support and encouragement
– Prognosis: 50% achieve five-year survival rate, if no
metastasis at diagnosis

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 Juvenile Rheumatoid Arthritis
• Most common connective tissue disease of childhood
• Clinical manifestations
– Joint inflammation: If untreated, results in
irreversible joint changes
– Inflammation types: Systemic; polyarticular;
oligoarthritis
• Treatment: Maintain mobility; preserve joint function
– Drug therapy; physical therapy
• Nursing care: Family teaching regarding medications
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 Scoliosis
• Lateral curvature of the spine in two forms: Structural;
functional (more common)
– Functional causes: Poor posture; traumatic muscle
spasm; unequal leg length
– Idiopathic causes: Treatment requiring appears 10
times more frequently in girls than boys
• Diagnosis: Screenings in fifth to eighth grade
• Treatment
– Electrical stimulation; braces; surgical treatment

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 Scoliosis (cont.)
• Nursing process
– Assessment
– Nursing diagnosis
– Outcome identification and planning
– Implementation
• Promoting: Mobility, positive body image, therapy
compliance
• Preventing: Injury, skin irritation
– Evaluation: Goals and expected outcomes
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 Question
In what disease is electrical stimulation used in treatment?

a. Juvenile rheumatoid arthritis

b. Muscular dystrophy
c. Scoliosis
d. Osteomyelitis

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 Answer

c. Scoliosis

Rationale: Treatment occurs at night while the child is

asleep. The leads are placed to stimulate muscles on the
convex side of the curvature to contract as impulses are
transmitted, causing the spine to straighten.

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