Chapter 21: Musculoskeletal Disorders in Children

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Welcome back to the Deep Dive.

Today we are taking on a system that literally supports every single move we make.

Quite literally.

Right.

We're pulling apart Chapter 21, which is

Musculoskeletal Disorders from the Davis Advantage for Pediatric Nursing.

And I have to say,

looking at the size of this chapter, it feels a little bit like we're trying to scale a mountain.

It is a beast of a chapter.

There's just no getting around that.

It covers everything from the anatomy of a newborn's foot to teenagers blowing up their knees on the soccer field.

It is massive.

And honestly, it's one of those topics where if you aren't careful, you might fall into the trap of thinking, you know, oh, it's just broken bones, put a cast on it, sign it with a Sharpie and we're done.

Right.

I think that's the common misconception.

Bones are bones.

As we went through this source material, it became very clear, very quickly, that dealing with a child's musculoskeletal system is completely different from dealing with an adult's.

Completely different.

It's not just about structure.

It's about dynamics.

You aren't just managing a static skeleton.

You are managing a construction site that is actively building itself 24 seven.

When you treat a child, you are treating a moving target.

I love that analogy, a moving target.

So our mission today for you, the listener, is to translate this dense textbook material into a survival guide.

We need to bridge the gap between memorizing terms and actually understanding what you're looking at when a kid limps into the ER.

Exactly.

We want to take the panic out of assessment for nursing students facing this material.

So we're going to walk through this sequentially, just like the chapter does.

We'll start with the anatomy, specifically why kids are unique.

Then we move into fractures, which is the absolute bread and butter of pediatric orthopedics.

Then we'll tackle congenital issues, the complex world of hip disorders, infection, spine issues, and finally the systemic disorders like juvenile idiopathic arthritis.

It's a marathon, not a sprint today.

But if there is one core concept I want you to hold onto right from the start, if you take nothing else away from this deep dive,

it is this.

Children are not just little adults.

We hear that a lot in pediatrics.

But how does it apply specifically to bones?

It changes the physics of injury.

Their bones are softer, they heal faster, but they have a unique vulnerability that adults don't have.

The growth plate.

The growth plate.

Or the physis.

That one structure changes the game for everything we're going to talk about today.

An injury there isn't just a break, it's a potential life -altering halt in development.

Okay, so let's unpack that.

Section one is all about anatomy, physiology, and assessment basics.

You mentioned the immature skeleton.

When we look at the source text, it describes the musculoskeletal system as including bones, muscles, joints, tendons, and ligaments.

But it starts way back in fetal development.

It does.

It starts as pure cartilage.

Think of it as a blueprint made of rubber.

It's this flexible framework that gets transformed into bone over time.

The text explains this process involves these little cellular workers called osteoclasts and osteoblasts.

I always get those two mixed up.

What's the trick for keeping them straight?

It's an easy mnemonic.

Osteoblasts with a B build bone.

They are the masons laying down the bricks.

Osteoclasts with a C consume or crash bone.

Crash bone.

I like that.

They are the demolition crew.

You need both of them working together.

The builders lay down the calcium, and the consumers carve it out to shape it properly.

Because this formation happens so rapidly during fetal development, the text points out that congenital abnormalities, things going wrong in the packaging or genetic code, are actually somewhat common.

Now let's talk about the anatomy of a growing bone because the text breaks it down into specific parts.

I feel like these terms come up constantly in the fracture section.

We have the ecophysis, the physis, the metaphysis, the diaphysis, and the periosteum.

Can you walk us through those?

Imagine we are looking at a thigh bone, a femur.

Sure, let's visualize it for everyone.

The very ends of the bone, the part that fits into the joint, usually covered in smooth cartilage, that's the epiphysis.

Okay.

The long middle shaft, so the handle of the barbell is the diaphysis.

Simple enough so far.

Ends and middle.

Now in between the end and the shaft is the magic zone.

You have the metaphysis, which is the wide part where the shaft flares out to meet the end.

But the most critical part for pediatric nursing and the part the text highlights repeatedly is the physis.

The growth plate we were talking about.

Exactly.

It's a thin disc of cartilage located right between the epiphysis and the metaphysis.

It is the factory.

It's responsible for lengthening the bone.

And because it's cartilage, not hard bone, it is the weakest point in the entire structure.

So if a kid takes a hard fall, the ligaments might hold, the hard bone might hold, but that cartilage disc might shear.

Precisely.

In an adult, a twisting force might tear a ligament, like an ACL tear.

In a child, that same exact force will often fracture the growth plate because the child's ligament is actually stronger than their cartilage.

That is a crucial distinction to keep in mind.

Now talk to me about the periosteum.

The text says it's thicker and biologically active.

The periosteum is like the skin of the bone.

In adults, it's this thin papery membrane that you can barely scrape off.

In kids, it is thick, tough, and extremely rich with blood vessels.

The text mentions that this thick periosteum is a huge advantage.

It says it helps stabilize fractures.

Yeah, think of a banana.

If you break a banana inside the peel, the peel keeps the mushy parts aligned.

That's the pediatric periosteum.

It acts like a built -in internal splint.

Because it's so thick and has such a rich blood supply, it lays down new bone incredibly fast.

That explains why the text notes that children heal fractures so much faster than adults do.

Right, a fracture that takes an adult 12 weeks to heal might take a young child three or four weeks.

There's also this concept of resiliency mentioned in the chapter.

It says bones tend to bell rather than break.

This brings us back to the tree branch analogy.

Think of a young green branch on a tree versus an old dry stick.

If you bend the green branch, the pediatric bone, it might bend really far, or maybe break only on one side while the other side holds together.

That's a child's bone.

They are much more porous and pliable.

And then there's remodeling.

This blew my mind a little bit when reading the source.

The text says that misaligned fragments can become solid sooner, but also that the younger the child, the better the bone can correct deformities over time.

It's basically the body's autocorrect feature.

The text gives a specific rule of thumb for this.

If a child has more than two years of expected growth left, the bone has an amazing ability to remodel.

If the bone heals slightly crooked, the osteoclasts and osteoblasts will essentially sand down the high spots and fill in the low spots over a year or two until it's straight again.

But there's a catch.

A very big catch.

This only applies to angulation, meaning bent bones.

It does not apply to rotation.

If the bone is twisted on its axis, the body cannot untwist it.

Rotational deformities must be fixed manually by the doctor.

Okay, moving on to assessment tools.

We're standing at the bedside.

The text highlights inspection, palpation, and range of motion.

What are we looking for practically when assessing a pediatric patient?

Inspection is always your first pass.

Symmetry is huge.

Strip the child down, modestly of course, and really look.

Does one knee look puffier than the other?

Is one leg lying in a weird position?

When you palpate, don't start at the spot that hurts.

Start away from it and work your way in.

You're feeling for heat, which indicates inflammation or infection, and distinct tenderness.

And range of motion.

You have to know what is normal to spot the abnormal.

But here's a tip straight from the text.

Active range of motion, asking the kid to move it themselves, is often much more telling than passive range of motion.

If a kid refuses to use a limb, that's a functional limitation.

And in pediatrics, that is a huge red flag.

Kids don't fake not playing.

If they aren't moving it, it hurts.

Let's get into the labs.

Table 21 -1 in the text is a gold mine for deciphering blood work in musculoskeletal issues.

I feel like students often skip the tables, but we really shouldn't.

Never skip the tables.

That's where the clinical judgment lives.

Let's break down the big ones.

First, the CBC, the complete blood count.

We're looking at the white blood cells mostly.

Right.

If the white blood cell count is high, we're thinking infection.

Maybe septic arthritis, maybe osteomyelitis.

But the text breaks down the differential, the specific types of white blood cells.

It talks about bands and SEGs.

This is a classic nursing school concept, but refresh us on how it applies here.

Think of the bone marrow as an army base.

SEGs, or segmented neutrophils, are the mature soldiers.

They are fully trained and ready to fight.

Bands are the immature neutrophils.

They are the recruits who just got their haircuts.

The baby soldiers.

Exactly.

Normally, the body only sends out the mature SEGs, but if there is a massive bacterial invasion, the body gets desperate.

It screams to send everyone and starts deploying the untrained bands.

If you see a high number of bands on the lab report, it's called a left shift.

It strongly suggests a serious bacterial infection.

That is such a helpful visual.

What about CRP and ESR?

I always see these ordered together in ortho cases.

C -reactive protein, or CRP, and erythrocyte sedimentation rate, the ESR.

These are the smoke detectors of the body.

They indicate information.

They don't tell you where the fire is.

It could be a toe, a hip, or an ear infection, but they tell you there is a fire somewhere.

The text gives us some specific numbers to watch.

It does.

A CRP greater than 0 .9 or an ESR greater than 10.

In the context of a limping child, that points heavily towards septic arthritis or osteomyelitis.

If those numbers are normal, it's much more likely to be something benign like toxic synovitis and rheumatoid factor.

That checks for autoimmune issues, like juvenile idiopathic arthritis,

JIA.

But the text has a massive caveat here.

Not all kids with JIA will test positive for it.

In fact, many don't.

So a negative test doesn't rule it out, but a positive one helps confirm it.

Got it.

Let's touch on imaging from table 21 to 2.

X -rays are the standard, right?

Yes, for fractures.

They are cheap, they're fast, and they're available everywhere.

But remember, they're basically two D shadows.

And critically, they do not see soft tissue, inflammation, or early infection well at all.

So when do we jump to a CT or an MRI?

CT gives you a 3D view.

It's great for complex fractures, like in the pelvis.

But it's a high radiation dose for a growing body.

MRI is the absolute gold standard for soft tissue and bone marrow.

If you suspect an infection inside the bone, like osteomyelitis or a torn ligament, you need an MRI.

But there's a major downside to an MRI for, say, a four -year -old.

A huge one.

The machine is loud, it's scary, and you have to be perfectly still for 45 minutes.

That almost always means sedating the child.

And sedation carries its own respiratory risks, so we don't order MRIs lightly in pediatrics.

And ultrasound?

The unsung hero.

No radiation, no sedation.

It's actually the primary tool for hip dysplasia in infants.

Why is that?

Because newborn hips are mostly cartilage.

X -rays just go right through them.

You can't see anything.

Ultrasound bounces off cartilage perfectly, giving us a great picture of the joint.

Okay, let's move into the action -packed part of the chapter, section two, fractures.

The most common injury.

Incidence varies, but boys fracture more than girls.

And it peaks in adolescents when kids get risk -taking and adventurous.

The text introduces us to the acronym FO -O -F -O -O -S -H.

I love this acronym.

Fall on outstretched hand.

It's basically physics in action.

It really is.

You trip.

Your brain says protect the face.

You throw your hands out.

The hand hits the pavement, and that kinetic energy shits straight up the arm.

It hits the wrist first, causing a distal radius fracture, then travels to the elbow for a superchondrofracture, or all the way to the collarbone, causing a clavicle fracture.

The text breaks down the classification of fractures in Figure 21 -2.

We have the usual suspects, but also some pediatric specials.

Let's distinguish those for everyone.

What is plastic deformation?

Plastic deformation is where the bone bends like a bow, but doesn't actually snap.

The microscopic structure changes and the bone just stays bent.

It actually needs to be bent back by the doctor.

And the buccal fracture.

Also called a torus fracture.

This is a compression injury.

Imagine an empty soda can.

If you step on it gently, the sides crinkle out.

That's a buccal fracture.

The bone cortex bulges out.

These are very stable and heal incredibly fast.

And the famous green stick fracture.

Back to the tree branch analogy.

The bone breaks on the tension side, the outside of the bend, but stays completely intact on the compression side, the inside of the bend.

It's an incomplete fracture.

Now we have to spend some time on the Salter -Harris classification.

The text says this is absolutely crucial for growth plate injuries.

This is non -negotiable knowledge for anyone working with kids.

It is the system used to grade fractures that involve the physis, the growth plate.

It goes from type 1 to type 5.

And there's a mnemonic for this.

SALTR.

Walk us through SALTR.

S is for straight across.

The fracture goes straight through the growth plate.

These usually heal well.

A is for above.

The fracture goes through the growth plate and up into the metaphysis.

This is the most common type we'll see.

Okay.

S and A.

L is for lower.

The fracture goes through the growth plate and down into the epiphysis.

Now we're getting into joint involvement, which is trickier.

T is for through.

It goes through everything.

Metaphysis, physis, and epiphysis.

These are messy.

And R is for ram or ruined.

This is a crush injury where the growth plate is completely squashed.

And the prognosis gets worse as you go down the list.

Exactly.

Type 1 and 2 usually do fine.

Type 5 is a disaster.

The growth cells are crushed and may stop making bone permanently.

That leads to severe limb length discrepancies, meaning one leg ends up shorter than the other.

So as nurses, when we hear Salter -Harris, we need to be thinking about future growth monitoring.

Absolutely.

You have to tell the parents that this isn't just about healing now.

It's about watching that limb length for years.

It requires serious long -term follow -up.

Let's get to the nursing care.

The text gives us the safe and effective tips.

What do we do when a kid comes in with a suspected fracture?

First, emergency management.

We use the price acronym, protect the injury, rest it, ice it 20 minutes on, 20 off to reduce swelling, compression, usually an ace wrap, but watch for tightness,

and elevation, keep it above the level of the heart.

Elevation sounds simple, but it's vital.

It's just the law of gravity.

If the hand is dangling down, fluid pools there.

If it's up, fluid drains.

Less swelling means less pain and less risk of severe complications.

Speaking of complications, we are monitoring neurovascular status, the five P's.

The five P's are your Bible in orthopedics.

You will do these checks a thousand times in your career.

Number one, pain.

Are they hurting more than expected?

Is the pain relief not working?

Number two, pulse.

Can you feel the radial or pedal pulse distal to the injury?

Number three, pallor.

What color is the hand or foot?

Is it pink and warm or pale, blue, and cold?

Capillary refill should be under three seconds.

Okay, that's three.

What are the last two?

Number four, paresthesia.

This is sensation.

Ask the kid if it feels like pins and needles or if it feels asleep.

And number five, paralysis.

Can they actually wiggle their fingers or toes?

Which of these is the earliest sign of trouble?

Pain.

Specifically, pain out of proportion to the injury or pain on passive movement.

If you gently pull the child's finger and they absolutely scream, that is compartment syndrome until proven otherwise.

And late signs?

Pulselessness is a very late sign.

If you wait until the pulse is gone, the tissue damage is likely already permanent.

Let's talk cast care.

We send these kids home with plaster or fiberglass.

What are the big parent education points?

The don'ts.

The biggest battle, by far.

Do not stick things inside the cast.

It itches so much, though.

I remember having a cast.

It drives you crazy.

It really does.

But using a coat hanger or a pencil is a disaster.

You scratch the skin you can't see.

Bacteria loves warm, dark, moist places.

That little scratch turns into an infected ulcer quickly.

Next thing you know, you smell something rotting or the cast feels like it has a hot spot on the outside.

So what do we tell them to do for the itch?

Ice packs on the outside of the cast help a lot.

Sometimes tapping on the cast provides a vibration that distracts the nerves.

Or using a hairdryer on the cool setting, strictly cool to blow air down in there, but never, ever stick anything inside.

Also, the two feet on the ground rule, no climbing or jumping while in a cast.

Moving on to section three, specific fracture management.

The text highlights a few that have specific nursing implications.

Let's start with the clavicle.

The collarbone.

This is often a birth injury in big babies or a foosh in older kids.

You might see a visible lump or notice the kid holding their arm against their chest and refusing to move it.

The text notes a specific safety check here called tenting.

Right.

If the bone is completely broken and displaced, the sharp end can push up against the skin from the inside, looking like a tent pole.

If the skin is blanched or looks like it's about to puncture, that's an urgency.

The surgeon needs to relieve that pressure before the bone pokes through and turns a closed fracture into an open one, which is a massive infection risk.

Now here's a big red flag in the chapter, maybe the biggest one.

The supacondylar fracture of the elbow.

This is a critical alert.

Everyone should highlight this in neon yellow.

This is a fracture of the humerus right above the elbow joint where the bone flares out.

It is the thinnest, weakest part of the humerus.

Why is it so dangerous?

It's just an arm break, isn't it?

It's all about the location.

The brachial artery and the median nerve run right over that exact spot.

If the bone breaks and shifts, it acts like a guillotine.

It can sever or compress the artery.

So the immediate risk is vascular compromise.

Yes.

If a kid comes in with a swollen, painful elbow, you check that radial pulse immediately.

If the pulse is weak or absent or the hand is cold, that fracture must be reduced, meaning put back into proper alignment immediately to restore blood flow.

You do not wait.

The text mentions Volkman's contracture.

That sounds ominous.

That is the nightmare scenario.

If the blood supply is cut off, which is ischemia, for too long, the muscles in the forearm actually die.

Dead muscle gets replaced by scar tissue.

The scar tissue shrinks and it pulls the wrist and fingers into a permanent claw -like flexion.

The hand becomes completely useless.

That is terrifying.

So supacondylar fracture equals obsessive pulse checks.

Obsessive.

Every 15 minutes, if you have to, to check hand nerve function constantly.

Okay, moving to the lower extremity.

The toddler's fracture.

This is a classic diagnostic puzzle.

You have a toddler, two or three years old.

They were playing, maybe tripped over a toy.

Now they refuse to walk.

Or they will crawl but absolutely won't stand.

But you do the x -ray and it looks normal.

Right.

It's a non -displaced spiral fracture of the tibia.

Because the periosteum is so thick in toddlers, it holds the bone tight.

So you don't even see a crack on the x -ray initially.

It's called an occult fracture.

So how do we treat a fracture we can't even see?

Clinical picture.

If they refuse to bear weight, we trust the child.

We put them in a walking boot or a cast for safety.

Then we repeat the x -ray in three weeks.

By then, the body has started to heal and you will see a callus, which is new bone formation, right where the crack was.

That confirms the diagnosis retroactively.

Now femur fractures.

The text notes that in toddlers, we must rule out abuse.

We have to be highly vigilant here.

A femur is the strongest bone in the body.

Breaking it takes a huge amount of energy, like a car accident or a fall from a second story window.

If a nine -month -old who isn't even walking yet comes in with a spiral femur fracture and the stories that he rolled off the sofa, the physics just don't match the story.

Spiral means twisting, right?

Yes.

A spiral fracture comes from torque, like someone forcefully grabbing the leg and twisting it.

That is a massive red flag for non -accidental trauma.

We have a legal and moral duty to investigate that further.

For femur fractures, the text discusses traction and spichocasts.

Let's talk about traction first.

We don't see this as much as we used to, but it's still in the book.

Traction is using weights and pulleys to pull the muscles tired.

If the femur breaks, the big thigh muscle spasm and pull the bone ends past each other, which is called overriding.

That's agonizing for the patient.

Traction pulls the leg straight to align the bones before they can do surgery.

Specifically, the 90 -90 traction is mentioned often.

And the spichocast.

This is, well, an experience for the family.

It's a complete lifestyle change.

A spichocast goes from the nipple line all the way down the legs.

The child is immobilized in a frog leg position.

Nursing care here is incredibly intense.

You are essentially managing a statue.

You have to turn them every two to four hours to prevent pressure sores, but you can't use the crossbar, the stabilizer bar between the legs, as a handle.

If you pull that, you can break the cast or the cast can dig into the kid's skin.

You have to log roll the child carefully.

And cast syndrome, what is that?

This is serious.

It's also called superior mesenteric artery syndrome.

Basically, if the cast is too tight against the belly or if the child gets bloated, the duodenum gets compressed.

The gut stops moving, which is an ileus.

The child gets nauseous, vomits, and the belly gets dangerously distended.

So what do we do?

We can cut a belly window in the cast to relieve the pressure.

But prevention is key.

Avoiding constipation is huge.

Decreased mobility slows the gut.

So we need liquids and high fiber diets.

Let's talk about the messy part.

Toileting in a spika cast.

It is the art of peddling and waterproofing.

You take waterproof tape and wrap the edges of the cast around the groin area that's peddling.

So urine slides off instead of soaking into the plaster.

Then you use a smaller diaper tucked deeply inside the cast edges and a larger diaper on the outside to hold it all together.

Exactly.

If urine soaks into that cast padding, it sits against the skin for weeks.

The skin will macerate, basically turn to mush, and you'll get a massive infection.

You have to keep it perfectly dry.

There's a medication sidebar here that caught my eye.

It mentions lorazepam, or Ativan, for muscle spasms and traction.

Right.

We usually think of Ativan for anxiety or seizures.

But in orthopedics, it's a muscle relaxant.

When that femur breaks, the muscle spasms are violent.

Pain meds like opioids help the pain, but Ativan actually stops the spasm.

But then there's a drug alert about proton pump inhibitors, PPIs, and depoprovera.

This is fascinating research.

We prescribe PPIs for reflux all the time, but studies show they impair calcium absorption.

If a child is on these long term, their fracture risk goes up by 11%.

And depoprovera.

That's the birth control shot.

It works by suppressing estrogen.

But estrogen helps build bone.

So adolescents on depo have significantly lower bone density.

We need to be counseling these families that if you are on this shot, you need to be taking calcium and vitamin D supplements religiously.

That's a great catch.

Okay, let's shift gears to section four.

Congenital lower extremity abnormalities.

Starting with club foot.

Talipes equinovaris.

It's complex.

The foot is fixed, pointing down, which is equinus, and twisted inward, which is varus.

It looks painful, but it actually isn't painful for the infant.

The key differentiator here is rigidity.

Yes.

A lot of babies have feet that look turned in because they were squished in the womb.

But if you can gently tickle the foot and straighten it out, that's just positional.

Club foot is rigid.

You cannot straighten it manually.

The bones are actually misshapen.

The treatment is the Ponsetti method.

This has revolutionized care.

It really has.

In the olden days, we did massive invasive surgeries.

Now we use serial casting.

We start almost immediately day one or two of life.

The doctor manipulates the foot to stretch the ligaments a tiny bit and puts on a cast.

And then?

Seven days later, cut it off, stretched a little more, put on a new cast.

It's usually about six to 12 weeks of weekly casting.

It slowly morphs the foot back into alignment.

But it doesn't end when the cast comes off.

No.

And this is the compliance valley of death for parents.

Once the foot is straight, the child has to wear a brace shoes connected by a metal bar called a Dennis Brown bar to hold it there.

For how long?

23 hours a day for the first three months, then at night, and during naps for three to four years.

Years.

That's a huge ask for parents.

It is.

Imagine trying to get a toddler to sleep with their feet strapped together on a bar.

But if they don't do it, the recurrence rate is incredibly high.

The foot will twist back.

We have to coach parents that strict compliance prevents recurrence.

The brace is part of the cure.

Let's talk about the other twists.

Metatarsus adductus versus tibial torsion versus femoral torsion.

Metatarsus adductus is when just the forefoot turns in, making a kidney bean shape.

That often resolves spontaneously or with gentle stretching.

Internal tibial torsion is when the shin bone itself is twisted, often from intracrauterine positioning.

That usually resolves on its own by age four.

Internal femoral torsion is what you see when kids sit in the W position with kissing knees.

And bullies versus knock knees.

Parents freak out about this constantly.

They do.

They'll say, my kid walks like a cowboy.

But the text describes a very predictable normal progression.

Walk us through the timeline.

Newborn to age two, genuvarum or bull legs is normal.

They are bulky from diapers and just learning to balance.

Age two to four, the legs straighten out.

Age four to seven, they swing the other way into genuvalgum or knock knees.

The knees touch, but the ankles are apart.

And then by age seven to adolescence, they straighten out to the normal adult alignment.

So if a three -year -old is a bit knock -kneed, we do nothing.

We reassure the parents.

We observe.

But when is it a problem?

The text mentions Blount's disease.

Blount's disease, or tibiavara, is pathological bowing.

It's not normal.

It is an abrupt, severe bowing, often just in one leg, or it gets markedly worse after age two instead of better.

What causes it?

It's largely mechanical.

It's seen in early walkers and often in obese children.

The weight places too much pressure on the inner part of the knee growth plate, and it stops growing.

The outer part keeps growing, so the leg bows inward.

This needs treatment with bracing or surgery, or the growth plate is permanently damaged.

It will not fix itself.

Okay, section five, hip dysplasia, developmental dysplasia of the hip, DDH.

This is a major screening topic.

It is.

The hip is a ball and socket joint.

In DDH, the socket, the acetabulum is too shallow.

It's like a saucer instead of a cup.

The ball or femoral head slides around or pops out completely.

Who is at risk?

The text has a specific profile.

The four Fs roughly apply here.

Females, they make up 80 % of cases.

Firstborns, because the uterus is tighter, family history.

And feet first, meaning breech presentation.

Breach is a huge risk factor.

If a baby is breech, their hips are flexed up against their ribs.

That stretches the ligaments and makes the hip very unstable.

We assess this with the Ortolani and Barlow maneuvers.

These are specific tests for infants.

Barlow, you bring the knees together and push back.

You are trying to see if the hip dislocates out.

Think Barlow, back, bad.

Ortolani, you frog leg the hips out, abducting them.

You are trying to put a dislocated hip back in.

And what are you feeling for during these?

A clunk, not a click.

Hip and legs are just tendon snapping, totally normal.

A clunk is the feeling of the femoral head physically jumping over the ridge of the socket.

It is a distinct palpable thud.

You also look for asymmetrical gluteal folds on the back of the thighs.

What if we miss it in the newborn period?

What does it look like in an older child?

They might have a limp.

Or the Galliazzi sign.

That's where you lay them down, bend the knees with feet flat on the table, and look at knee height.

If the hip is dislocated, the femur sits higher, so that knee will look uneven or lower than the healthy side when you look from the feet.

Treatment usually involves the pavilla carnis.

Right, it looks like a little pair of overalls with straps.

It keeps the hips abducted in that frog leg position.

This pushes the ball deep into the socket.

The idea is that the pressure carves out a deeper socket.

The socket is cartilage.

The pressure of the ball molds it into a nice deep cup over a few months.

Nursing care for the Pavlik is very specific.

First rule, do not take it off.

It is worn 23 to 24 hours a day.

Second rule, skin care.

Check the skin folds, like the neck and the knee creases, for irritation.

And third rule, do not adjust the straps without the doctor.

The doctor sets the angle.

If you tighten them too much, you can cut off blood supply to the hips.

Late diagnosis might require Bryant's traction or surgery and a spica cast.

Section 6 acquired hip disorders.

These are the hip problems that hit older kids.

First up, leg calvopirthes disease, LCPD.

Let's just call it pyrthes.

This is weird science.

It is a vascular necrosis of the femoral head.

Meaning the bone literally dies.

Yes.

For some reason, and we don't fully know why, the blood supply to the ball of the hip just stops.

The bone cells die.

The ball softens and can collapse.

Then over a year or two, blood vessels grow back and the bone rebuilds itself.

Who is the typical patient for this?

Usually boys 4 to 8 years old.

And the symptom?

A painless limp.

Or maybe mild hip or knee pain.

But the key is that the symptoms wax and wane.

The parents might say, he limps after playing soccer, but he's fine the next morning.

The goal of treatment is containment.

Right.

We can't stop the bone from dying that train has left the station.

But we need to make sure that when it regrows, it regrows in a round shape.

So we use braces or surgery to keep the ball deep inside the socket.

The socket acts like a mold.

If we keep it contained, it heals round.

If we let it slide out, it heals flat.

And the kid gets severe arthritis at age 20.

Now contrast that with slipped capital femoral epiphysis, SCFE.

SCFE pronounced skiffy is totally different.

This isn't necrosis.

This is mechanical failure.

The text describes it like ice cream falling off a cone.

The femoral head, the ice cream, stays in the socket.

But the neck of the femur, the cone, slips upward and outward.

Who gets this one?

Totally different demographic.

This is adolescence during a rapid growth spurt.

The classic patient is an overweight boy or sometimes a very tall lanky child.

The growth plate is weak from rapid growth, and the extra weight or stress shears it off.

Symptoms.

Hip pain, obviously.

But here is the trap.

Referred pain.

A huge number of SCFE cases present with knee pain.

The obturator nerve shares pathways.

So the kid points to his knee, but the problem is actually the hip.

And the leg position.

The leg is externally rotated.

When they walk, the foot turns way out.

The text puts a big warning label on SCFE.

It is an orthopedic emergency.

As soon as you suspect SCFE like an obese teen with knee pain and a limp, that child becomes non -weight -bearing immediately.

Put them in a wheelchair.

If they keep walking, the slip gets worse, and they can completely sever the blood supply to the hip.

The fix is always surgery.

Always.

They put a screw through the neck into the head to pin it in place.

And then there is transient monoarticular synovitis or toxic synovitis.

This is the one that scares everyone but turns out okay.

It's basically the common cold of the hip.

It's a common cause of a limp.

It's inflammation of the hip lining, often following a viral infection.

It's benign and resolves with rest.

But we must differentiate it from septic arthritis.

Which brings us perfectly to section seven, infection of bone and joint,

septic arthritis, and osteomyelitis.

These are emergency conditions.

Time is cartilage.

Septic arthritis is infection in the joint fluid.

Osteomyelitis is infection in the bone itself, usually caused by staph aureus.

How do we tell the difference between a benign toxic synovitis and a deadly septic hip?

The clinical picture is much more intense.

One, high fever.

Two, severe pain.

The child will scream if you try to move the limb.

They hold it completely still, refusing to move it.

And three, they are ill -appearing.

They look systematically sick.

And the labs we talked about earlier.

WBC high with a left shift.

Elevated ESR and CRP.

There are clinical prediction rules that use these stats to calculate the probability of infection.

And the definitive diagnosis.

Stick a needle in it.

Joint aspiration.

If you pull out purulent fluid, pus, it's septic arthritis.

And the treatment is aggressive.

Incredibly aggressive.

Surgical drainage and IND if needed to get the pus out.

Then IV antibiotics via a PICC line for weeks.

Why the rush for surgery?

Because the bacteria and the white blood cells release enzymes that actively digest cartilage.

They can eat away the joint surface in a matter of days.

Once that cartilage is gone, it's gone forever.

It leads to permanent disability.

Moving on to section 8.

Scoliosis.

The lateral curvature of the spine.

We define it as a lateral curve greater than 10 degrees.

There are a few types.

Congenital, meaning you're born with it.

Juvenile, which is early onset and risky for lung development.

And adolescent idiopathic, which is the most common.

Girls are at higher risk than boys for severe curves.

Screening is something school nurses do a lot.

The Adams forward bend test.

Simple test.

Have the child put hands together like they are diving and bend forward at the waist.

You stand behind them.

You aren't actually looking at the spine itself.

You are looking for asymmetry of the back.

You look at the ribs.

Wide ribs.

Because scoliosis isn't just a side to side curve.

It's a rotation.

The spine twists and it pushes the ribs backward on one side.

You will see a rib hump.

One side of the back is higher than the other.

You also look for uneven shoulders or hips.

Treatment depends on the degree of the curve.

Mild, which is 15 to 25 degrees we just observe.

Moderate, 25 to 45 degrees requires bracing.

Specifically, the TLSO brace.

Severe, greater than 45 degrees, needs spinal fusion surgery.

Let's talk about the brace.

The text is very clear about the goal of bracing.

The goal is not to fix the curve.

The brace will not make the spine straight.

The goal is simply to stop it from getting worse while the child finishes growing.

That's a hard sell for a young teenager.

It is.

Wear this hard plastic shell under your clothes for hours a day.

Compliance is the biggest barrier.

Body image is everything at that age.

We have to be really supportive.

If they need surgery, the spinal fusion.

Post -op nursing care is extensive.

Log rolling to turn them so you don't twist the fresh hardware?

Pain management is huge.

Neurovascular checks of the legs to ensure the spinal cord wasn't compromised.

And watch for an ileus because the gut shuts down from the trauma.

Section 9, chronic and systemic disorders.

Let's talk about juvenile idiopathic arthritis, JIA.

This is an autoimmune disease.

The body attacks its own joints, causing inflammation, swollen joints, and notably morning stiffness.

And in systemic JIA, you might see a rash and fever.

There's a surprising complication mentioned in the text that involves the eyes.

Uveus.

Inflammation of the eye.

It is silent.

The eye isn't red or painful, but it can cause blindness.

Every kid with JIA needs routine eye exams.

Meds for JIA.

We step it up.

NSA's like naproxen for inflammation.

Then demods like methotrexate.

Then biologics like etanercept or humira for severe cases.

There is a scary acronym associated with JIA, MAS.

Macrophage activation syndrome.

It's a cytokine storm.

The immune system goes nuclear.

It is life -threatening.

If a JIA kid suddenly gets a high fever and systemic symptoms, think MAS.

Next is osteogenesis imperfecta, OI, also known as brittle bone disease.

This is a genetic defect in collagen.

Without good collagen, bones are extremely brittle.

These kids fracture just from rolling over or being diapered.

The text mentions a classic sign.

Blue sclera.

The whites of the eyes look blue because the collagen is so thin you can see the veins underneath.

Nursing care for OI focuses heavily on handling.

You have to be incredibly careful.

Never pull the legs up by the ankles to change a diaper.

A manual blood pressure cuff might cause a fracture.

We put fragile signs on the bed.

And unfortunately, the text notes these kids are sometimes mistaken for abuse cases.

It's tragic.

They present with multiple fractures in different stages of healing.

That looks exactly like abuse.

But the blue sclera and genetic testing help differentiate.

Finally, section 10.

Sports injuries.

We see sprains and strains.

Ankle inversion is very common.

Overuse injuries like little leaguer's elbow.

Prevention is key stretching.

Proper equipment.

Not playing through pain.

But there's a specific toddler injury here.

Nursemaid's elbow.

Subluxation of the radial head.

This happens when you pull a toddler by the arm.

The annular ligament slips over the head of the radius and gets trapped.

The kid presents refusing to use the arm, but that doesn't look swollen.

Right.

The fix is a reduction maneuver.

The doctor relocating it.

It's quick and the kid is usually using the arm normally minutes later.

We have covered a massive amount of ground.

Let's head to the outro and summarize.

If we look at the big picture, the child's skeleton is a dynamic, resilient, but vulnerable framework, especially at the growth plate.

Let's recap the red flags one more time for everyone listening.

One, supercondyly fracture.

Always check the pulse.

Two, SCFE.

An obese teen with hip or knee pain is an emergency.

Three, septic arthritis.

A fever plus refusal to walk.

And I want to leave you with that case study teaser from the text.

You have a 12 -year -old obese boy complaining of knee pain.

Don't just check the knee.

Check the hip for SCFE.

That is the big takeaway.

Always look beyond the obvious.

And as a final provocative thought for you to explore on your own, consider how the bone mass built during these pediatric years acts as a bank account.

Poor nutrition or excessive soda intake now doesn't just risk a fracture today.

It determines osteoporosis risk 50 years later.

A fascinating point to ponder.

This has been a true deep dive into pediatric musculoskeletal disorders.

Thank you for listening.

Thank you.

Keep learning.

This is the Last Minute Lecture Team signing off.