Chapter 29: Musculoskeletal & Articular Dysfunction in Children

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Welcome back to the Deep Dive.

Today isn't just another episode.

Think of this as your ultimate study companion.

We are tackling,

I mean a beast of a topic today,

Chapter 29 from Wong's Essentials of Pediatric Nursing, 11th edition.

It is.

We're looking at the child with musculoskeletal or articular dysfunction.

It is a massive chapter.

I think for many nursing students, this is one of those sections where you open the book, you see the page count, and you just immediately feel your blood pressure spike.

But it's also one of the most critical, I mean if you are a nursing student prepping for the NCLEX, or a professional about to start a rotation in ortho, or even just the ER, this is the survival guide you've been looking for.

Exactly.

We aren't just reading the text, we are really trying to decode the clinical frameworks.

Yeah, we're talking about everything from the kid with a simple cast on their arm to really complex congenital defects, and we know who you are, the learner.

You might be prepping for a big exam, or maybe you're about to start a clinical rotation.

You need those aha moments without all the overwhelm.

And the mission here is, well, it's safety and effectiveness.

That's really the core of pediatric nursing, isn't it?

It is.

Children are naturally active beings.

I mean, mobility is absolutely essential for their growth, for their development, even for how they communicate.

Absolutely.

So when something disrupts that, whether it's a trauma, a congenital issue, or an illness,

it affects the whole child, not just the bone.

So here's our roadmap for today.

We're going to start with the why we care, the effects of immobilization.

The foundation.

Then we'll move into the acute stuff, you know, fractures, casts.

From there, we'll look at sports injuries.

And finally, we will break down those complex congenital and acquired defects like club foot and scoliosis.

And we're going to teach this step by step.

By the end of this deep dive, you won't just know what a fracture is.

You'll understand the physiological cascade of immobility.

You'll know how to spot the six Ps before they become a disaster.

And you'll know how to support a family through what can be really long -term care.

OK, let's jump right in.

Section one, the immobilized child.

This really feels like the foundation of the whole chapter.

It is.

So what actually happens when a kid stops moving?

It's the concept of disuse.

And this is so crucial for you, the listener, to grasp.

It is not just about weak muscles.

Immobilization affects every single body system, every single one, every one.

When a child stops moving because of an illness or an injury, the body's homeostatic mechanisms, which really thrive on feedback and use, they just sort of falter.

So let's unpack the muscular system first.

We hear the word atrophy a lot.

Is that the main concern?

It's the most obvious one, for sure.

Atrophy is the loss of muscle mass.

Right.

But deeper than that, you have contractures.

OK, this is where the collagen in the connective tissues actually alters.

It becomes dense and it doesn't glide anymore.

So you don't just lose strength.

You lose your range of motion.

The joints essentially stiffen up.

Wow.

And what about the bones themselves?

I always think of bones as these, you know, static structures, but they aren't, are they?

Not at all.

They are so dynamic.

Bones need the stress of weight bearing to maintain their density.

It's a use it or lose it system.

So when you immobilize a child, you get bone demineralization.

The lack of stress causes calcium to literally leave the bones.

This leads to osteopenia, which is basically a thinning of the bone, which brings us to a huge red flag.

Pathological fractures.

Exactly.

The bones become incredibly brittle.

But there's a second problem with all that calcium leaving the bones.

Where does it go?

It goes into the blood.

So you end up with hypercalcemia and that has its own whole set of problems.

OK, let's use that to pivot to the systemic effects, specifically using table twenty nine point one from the text as our guide.

I feel like this table is just a goldmine for nursing interventions.

It absolutely is.

Let's start with metabolism.

OK, so when you stop moving, your metabolic rate drops.

That makes sense.

But here is the tricky part.

You enter a state of what we call negative nitrogen balance.

OK, decode that for us.

Essentially, the body starts breaking down protein for energy faster than it can build it up.

Protein breakdown releases nitrogen.

Right.

So when you're losing more nitrogen than you're taking in, you're in a negative balance.

This is what leads to that really profound muscle wasting.

So the nursing intervention here has to be diet.

It's diet.

You need a high protein, high fiber diet to counteract that breakdown.

But what about the fact that these kids often lose their appetite?

That's the anorexia of immobility.

It's a real thing.

So you want to offer small, frequent feedings with their favorite foods.

You can't force a huge meal on a kid who feels sluggish, but you have to maintain that protein intake to stop the wasting.

Makes sense.

OK, moving to the cardiovascular system.

I remember learning about Virchow's triad in school.

Yes, the triad of venous stasis,

hypercoagulability and vessel damage.

In an immobilized child, the blood just pools in the extremities because that muscle pump isn't working, which puts them at risk for deep vein thrombosis or DVT.

Exactly.

A DVT, even in kids, even in kids, really, even in kids and especially in adolescents.

So your nursing actions are going to be things like anti embolism stockings, intermittent compression devices and, of course, hydration to keep the blood from getting too thick.

And you have to watch for orthostatic intolerance to.

Oh, absolutely.

When they finally stand up, all that blood rushes down and they can pass out.

You have to move them slowly and carefully.

Respiratory is another big huge.

When a child is lying down, they have really poor abdominal tone.

This leads to shallow breathing.

They don't expand their chest fully and the secretions just pool.

They pool in the lungs.

This leads to hypostatic pneumonia and atelectasis, which is the collapse of part of the lung.

It's a perfect storm.

So as a nurse, this is where I'm getting the bubbles out.

Yes, exactly.

Incentive spirometry for the older kids, absolutely.

But for the little ones, blowing bubbles or pinwheels is fantastic therapy.

It turns a boring medical necessity into a fun game.

I love that.

You also want to use the semifowler position whenever you can.

Just getting their head up a bit helps gravity pull the diaphragm down.

OK, so we mentioned the calcium leaving the bones earlier.

How does that connect to the kidneys?

That's the renal system impact.

First, you have urinary stasis because gravity isn't helping the urine drain from the kidney pelvis down into the bladder.

And then you add the calcium.

And then you combine that stasis with high calcium levels in the urine.

And you have the perfect recipe for renal calculi kidney stones.

Ouch.

So hydration is key there, too, then.

Hydration is critical.

And cranberry juice can sometimes help acidify the urine, which might prevent some types of stone formation.

And finally, the skin.

We all know about pressure ulcers.

We do.

But in pediatrics, the text points out we use a specific tool, the Braden QD scale.

It helps us assess risk in kids.

Right.

And beyond the assessment, you need to be turning these patients every two to four hours and using pressure reduction mattresses.

It's fundamental.

Before we leave this section, we have to talk about the mind, the psychological effects, because for a kid, movement isn't just exercise, it's exercise.

It's how they learn about the world.

It is how they exert control.

It's how they master their environment.

Think about a toddler.

Their main developmental task is autonomy.

They need to explore.

So if you tie them down to a bed, you are directly blocking their development.

They might regress, start wetting the bed again or wanting a bottle.

It's a response to that loss of control.

And what about the older kids?

Well, school age kids are driven by industry and competition.

Adolescents are driven by independence and their peer group.

Immobilization threatens their very identity.

So what's the nursing intervention?

You have to give them back some control, let them participate in their care, let them choose their clothes or their menu.

And if you can transport them out of the room, a change of scenery is so powerful.

I love the idea from the text of using play as an intervention,

using dolls to explain procedures or just to let them act out their frustration.

Absolutely.

It allows them to express feelings they might not have the vocabulary for.

It's incredibly therapeutic.

OK, moving on to section two,

traumatic injury.

This is the acute stuff.

We are talking soft tissue injuries and fractures.

Right.

Let's start with soft tissue.

So contusions, dislocations, sprains and strains.

There's a really specific injury mentioned for kids under five.

Nursemaid's elbow.

I feel like I see this on every exam.

It's a classic pediatric injury.

It's a subluxation.

So a partial dislocation of the radial head.

It almost always happens when a parent swings a child by the arms or, you know, pulls them suddenly by the wrist.

And the annular ligament slips.

The annular ligament slips over the radial head.

The kid suddenly stops using their arm and holds it close to their body.

And the fix seems surprisingly simple.

It is.

The provider performs a reduction by supinating and flexing the forearm.

You often feel a little click and the child stops crying almost immediately.

It's like magic.

But a hip dislocation is a completely different story, right?

A completely different story.

A hip dislocation in a child under five is a true medical emergency.

Why?

The blood supply to the femoral head is so tenuous.

If it's cut off for too long, the bone dies.

That's a vascular necrosis.

You need reduction within 60 minutes.

Wow.

OK.

For general sprains and strains, we have our classic acronyms rice and ICs.

Breast, ice, compression, elevation.

And ICS is just adding support to that.

The key with ice that the book points out is max 30 minutes.

And not directly on the skin.

Never directly on the skin.

And here's a good tip from the text.

A wet elastic wrap actually transfers the cold better than a dry one.

Good to know.

Let's talk fractures.

Why are kids bones so different?

Two main things.

First, they're more porous so they can actually bend without breaking.

And second, the periosteum, that outer covering of the bone, is much thicker and has a much better blood supply.

And that means they heal faster.

They heal way faster.

But it also leads to these really unique types of breaks.

OK, box 29 .1 in the text lists these types.

Walk us through the ones that are unique to kids.

OK, so first you have plastic deformation.

This is where the bone bends up to 45 degrees, but doesn't actually snap.

It's permanently bent, but not broken through.

Then you have the buckle or torus fracture.

It looks like a little bump or a bulge on the bone because the porous bone just sort of compressed on itself.

And the green stick.

I remember this one.

Think of a fresh green branch from a tree.

If you try to break it, it splinters on one side, but stays connected on the other.

That's a green stick fracture.

The tension side breaks.

The compressed side just bends.

Now, the growth plate, the physis, the book emphasizes this is the weakest point of a long bone, right?

It is.

And it's absolutely critical because damage here can stunt or deform the bone's growth.

And this is where we use the Salter -Harris classification system.

I feel like Salter -Harris is a guaranteed test question.

It usually is.

It goes from type I to type V.

Type I is a simple flip or separation of the growth plate.

Type V is a crushing injury to the growth plate itself.

And type V is the worst.

It has the worst prognosis for growth disturbance.

It's a really big deal.

Let's get to what might be the most important nursing assessment in this entire chapter.

The six P's of compartment syndrome.

This is your number one safety priority.

Compartment syndrome happens when pressure builds up within the fascia, that little compartment, and it cuts off blood flow.

It can kill a muscle and nerve within hours.

So walk us through the six P's.

What's number one?

Number one and the most reliable early sign is pain.

But it's a very specific kind of pain.

It's pain that is out of proportion to the injury and is not relieved by pain meds.

So if you give morphine and the kid is still screaming or if passive movement of their fingers or toes causes excruciating pain, you have to be worried.

That's a huge red flag.

OK, what are the others?

Pulselessness, that's actually a late sign.

If you lose the pulse, the damage is probably already done.

Wow.

Then power pale skin, poor capillary refill more than three seconds.

Peristhesia, that tingling or burning pins and needles feeling paralysis.

They can't move their digits.

And finally, pressure.

The skin feels tight and shiny.

So if I see these, I'm calling the provider immediately.

Immediately.

And you do not elevate the limb above the heart if you suspect this, because that can actually impede the arterial flow even more.

Good tip.

But yes, this is a surgical emergency requiring a fasciotomy to relieve that pressure.

Let's talk about casts.

Dealing with a calf on a toddler is.

Well, it's an adventure.

It starts with the application.

The saw is really scary.

It's loud.

So you need to explain to the child that it's just a tickly feeling and it won't cut their skin.

Using a doll helps, I bet.

A doll is a perfect way to show them and explain that synthetic material will feel warm as it hardens.

And when the cast is wet.

If it's plaster, it takes a long time to dry, anywhere from 10 to 72 hours.

And you must handle it with your palms, not your fingertips.

Why is that so important?

Your fingertips can cause little indentations.

Those indentations create pressure points inside the cast, leading to ulcers that you can't see until it's too late.

Talk to me about spica casts.

These are the huge ones that cover the waist and one or both legs.

Right.

Often used for femur fractures or hip dysplasia.

They are a massive undertaking.

The hygiene challenge is real.

So what do we do?

Nurses use a technique called pedaling.

You take strips of waterproof tape and you wrap the edges of the cast around the perineal opening like petals on a flower.

This helps keep urine and stool from soaking into the plaster.

And diapers.

You essentially double diaper.

You tuck a small one under the cast edges and then put a larger one over the top to hold everything in place.

Is there a safety warning for spica casts?

Yes, a big one.

Never use the abduction bar.

That's the bar between the legs to lift or turn the child.

It's not a handle.

It is not a handle.

It can break the cast or hurt the child.

And car seats require special modification.

You can't just jam them into a standard seat.

What about traction?

We don't see it as much anymore, but we still need to know it for exams.

Right.

Traction is used to fatigue the muscle spasm and help realign the bone.

You have skin traction like buck traction, which just pulls on a foam boot.

And skeletal traction.

That's where pins are inserted directly through the bone.

It's much more invasive.

And the number one nursing rule for skeletal traction.

Never, ever release the weights unless you have a specific order.

They must hang freely at all times.

And pin care is vital to prevent osteomyelitis.

What's the best practice for pin care?

The book mentions the current best practice is usually a two mil GML chlorhexidine solution.

You have to keep those sites meticulously clean.

OK, let's move on to section three, sports participation.

We are seeing a real shift in pediatrics, aren't we?

We really are.

Kids are specializing in sports earlier.

They're training harder.

We are seeing less play and more training.

And this leads to overuse syndromes.

How is that different from an acute trauma like a sprain?

An acute trauma is a single event, like a twisted ankle.

Overuse is repetitive microtrauma.

The tissue is breaking down faster than it can repair itself.

Stress fractures are the classic example here.

And what should we look for with a stress fracture?

A sharp persistent pain or a deep dull ache right over the bone.

It's really common in track runners and gymnasts.

And the tricky part is diagnosis, right?

Right.

X -rays are often negative for the first few weeks.

You don't actually see the fracture until the callus starts to form as it heals.

So if a kid has shin pain, that just won't go away.

But the x -ray is clean.

You have to treat it like a stress fracture until proven otherwise.

And the treatment isn't necessarily total bed rest.

It's alternative exercise.

What does that mean?

If they're a runner, you put them in the pool.

Deep water running maintains their cardiovascular fitness without the impact.

It's so important because it keeps the athlete engaged mentally, too.

That makes a lot of sense.

OK, section four, congenital defects.

These are the things often found at birth or in early screenings.

Let's start with DDH developmental dysplasia of the hip.

DDH is a spectrum.

It can range from just a shallow socket, the acetabulum, to a partial subluxation, to a full dislocation.

And what are the risk factors?

The big ones are breech birth, being female, having a family history of it, and also tight swaddling that keeps the legs in adduction.

OK, how do we assess for it?

I always get the names of the maneuvers mixed up.

Ortolani and Barlow.

OK, here's how to remember it.

Barlow goes back.

You would duck to the hip and push back gently.

If it dislocates, that's a positive Barlow.

And Ortolani.

Ortolani involves opening or abducting the hip.

If you feel a clunk as the femoral head slips back into the socket, that's a positive Ortolani.

The book is clear.

It's a clunk, not a click.

Yes, that's a critical distinction.

Hip clicks are common and often benign ligaments just snapping.

A clunk is the actual bone moving in and out of the socket.

Another sign is the Goliadzi sign.

Right.

If you lay the infant on their back and flex their knees, one knee will appear lower than the other.

That's because the femur is effectively shortened by the dislocation.

You should also look for asymmetric gluteal folds.

The treatment for a newborn is the Pavlik harness.

What are the nursing priorities here?

The Pavlik is a dynamic split.

It keeps the hips flexed and abducted, kind of like a little frog.

The number one priority is that it must be worn continuously, usually 22 to 24 hours a day.

And the straps.

And here is the big one for nurses and for parents.

Do not adjust the straps.

Only the provider does that.

Messing with the straps can do more harm than good.

What about skin care under that thing?

You put the diaper under the straps and you check the skin frequently, especially in the creases.

You can massage the healthy skin to stimulate circulation.

But you want to avoid lotions and powders because they just cake up and cause irritation.

OK, next is club foot or talipes equinovaris.

This is a complex deformity.

The foot is pointed down and twisted inward.

It's rigid.

You can't just wiggle it straight.

And the treatment is the Ponsetti method.

Yes, that is the gold standard.

It involves serial casting that starts very shortly after birth.

The provider manipulates the foot a little more each week and puts on a new cast.

And that usually ends with a minor surgery.

Usually a heel cord tenotomy.

They just clip the Achilles tendon to release that final bit of tightness.

Then they wear special sandals with a bar between them, mostly at night to maintain the correction and prevent recurrence.

Just to clarify for our listeners, this is very different from metatarsus adductus.

Yeah, very different.

Metatarsus adductus is what people call pigeon toed.

The heel and the ankle are in a normal position.

It's just the front of the foot that turns in.

That often corrects itself or with some simple stretching exercises.

Club foot involves the entire foot and ankle and is much more serious.

Got it.

Let's talk about a really tough one.

Osteogenesis imperfecta, OI, also known as brittle bone disease.

This is a genetic defect in collagen production.

The bones are incredibly fragile.

A classic sign, which you'll see on exams, is blue slerae.

The rights of the eyes look bluish.

They might also have discolored teeth.

The nursing care for this sounds terrifying.

It requires extreme gentleness.

And there is one rule you must burn into your brain.

Never hold these babies by the ankles when diapering.

Because you could fracture their legs just doing that.

Exactly.

You know how you usually lift a baby's legs to wipe them?

You cannot do that.

You have to lift them by placing a hand under their buttocks.

Even a manual blood pressure cuff, if inflated too high, can cause a fracture.

And tragically, these families are often investigated for child abuse because the child presents with multiple fractures in various stages of healing.

So you have to rule out non -accidental trauma.

You have to.

But it's also critical to get a careful family history and look for those other signs like the blue sclerae.

OK, let's move to our last section, section five, acquired defects.

Yeah, these are things that develop in the growing child.

Let's start with Lake Calvo Perthas disease.

Right.

LCP is a vascular necrosis of the femoral head.

Basically, for some unknown reason, the blood supply to the ball of the hip joint just stops.

The bone dies and starts to flatten.

Who gets this?

It's typically boys, usually between the ages of four and eight.

They often present with a limp that might be intermittent.

They might complain of hip soreness or stiffness.

And it's often worse in the morning or at the end of a long day of playing.

Is it very painful?

It can be, but often it's described initially as a painless limp or just a vague soreness.

The goal of treatment is containment.

You want to keep the ball of the femur inside the socket while it regenerates so that it heals round, not flat.

This usually involves rest, non -weight bearing and sometimes abduction braces.

OK, now contrast that with SCFE slipped capital femoral epiphysis.

SCFE is a true orthopedic emergency.

This usually happens in older kids, adolescents, often during a big growth spurt, and it's frequently seen in children who are obese.

And what is the mechanism here?

OK, imagine the femoral head is a scoop of ice cream on a cone.

In SCFE, the ice cream slips off the cone.

The epiphysis, the growth plate area slips backward and down from the neck of the femur and the symptoms.

They'll have pain in the hip or groin.

But here is the big curveball.

The thing you have to remember, referred pain.

They might come into the ER complaining of knee pain.

So a teenager complains of knee pain.

A good nurse always, always checks the hip.

You have them lie down and you check their hips range of motion.

And what does the leg look like?

The affected leg is usually externally rotated.

And unlike LCP, this needs surgery immediately.

You do not let this kid walk.

They go straight to a wheelchair.

They need pinning to prevent the head from slipping further and cutting off that blood supply.

That's a huge takeaway.

Finally, let's talk spinal defects, specifically scoliosis.

And even more specifically, adolescent idiopathic scoliosis.

This is a lateral curvature of the spine that also involves rotation.

It's most common in girls during that pre pubertal growth spurt.

How do we screen for it?

With the Adams forward bend test, you have the child bend forward at the waist with their arms hanging down.

And you aren't looking at the spine directly.

You're looking for a rib hump on one side or asymmetry in the stapula and shoulder blades.

If the curve is moderate, the book says 25 to 45 degrees.

The treatment is bracing.

Right.

Usually a Boston or a Wilmington brace.

These are hard plastic shells.

And this is where the nursing care gets really psychological.

Oh, absolutely.

Imagine being a 13 year old girl already insecure about your changing body.

And now you have to wear a hard plastic shell for 18 to 23 hours a day.

Compliance must be the biggest battle.

It is the biggest battle.

As a nurse, you need to acknowledge how difficult it is, help with clothing choices to hide it and really emphasize that the brace is what can prevent them from needing major surgery.

It's not a cure.

It just slows or stops the progression.

But if they do need surgery, a spinal fusion, what does the post -op care look like?

It's a huge surgery.

The pre -op teaching is so important.

You have to teach them about the PCA pump for pain.

And you have to teach them and their family about log rolling.

You have to turn the patient as a single unit, shoulders and hips moving at the exact same time to prevent any twisting of that newly fused spine.

You'll need pillows between their legs.

And it usually takes two or three people to do it safely.

And what are the big risks post -op?

Paralysis is the nightmare scenario.

So neurovascular checks of the legs are vital and frequent.

You also need to watch for a rare complication called superior mesenteric artery syndrome.

It's a duodenal compression that causes a lot of vomiting.

And obviously,

just incredible attention to pain management.

We have covered a massive amount of ground today.

We really have.

I mean, from the cellular effects of immobility all the way to the clunk of a hip exam and the complexity of spinal fusion surgery.

It really is a journey through the entire pediatric skeletal system.

And if we summarize, I think the core philosophy is that your understanding of a nasoline physiology guides every single nursing action, whether it's the six P .S.

for fractures or the handling rules for O .I.

Safety is always the number one priority.

The nurse treats the bone, but cares for the child.

That's it.

Exactly.

So here's a final thought for you to mull over.

We talked a lot today about the physical molding of bones, you know, casting a club foot, bracing a scoliotic spine.

But think about the psychological molding.

How does wearing a visible medical device during the most socially sensitive years of adolescence shape a person's identity and their body image for the rest of their life?

That is a fascinating angle.

So important to consider something to think about.

Thank you so much for listening to this deep dive.

A warm thank you from the last minute lecture team.

Go out there and be safe, effective nurses.