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Course: Pediatric Nursing

Topic: Nursing care of child with Musculoskeletal Disorders Part I

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Module Goals

Learners will be able to:

Describe anatomy and physiology of musculoskeletal system.
Define talipes equinovarus and osteogenesis imperfecta.
Identify causes of talipes equinovarus and osteogenesis imperfecta.
List signs and symptoms of talipes equinovarus and osteogenesis imperfecta.
Describe common diagnostic procedures for these disorders.
Explain management of the above disorders.
Discuss nursing management for the above disorders.

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Skeletal System

Composed of:

Bone: Dense connective tissue that forms most of the skeleton, the support structure of the body.

Cartilage: A semi-rigid form of connective tissue, provides flexibility and smooth surfaces for movement.

Openstax, 2022

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Skeletal System Functions

Supports the body
Facilitates movement
Protects internal organs
Produces blood cells
Stores and releases minerals and fat

Openstax, 2022

Contact info: info@nursesinternational.org

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Skeletal System: Functions (Continued)

Mineral Storage, Energy Storage, and Hematopoiesis:

Bone matrix acts as a reservoir for minerals (especially calcium, and phosphorus).
These minerals are released back into the bloodstream to maintain and support physiological processes.

Calcium ions: essential for muscle contractions and involved in the transmission of nerve impulses.

Openstax, 2022

Contact info: info@nursesinternational.org

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Skeletal System: Functions (Continued)

Serves as a site for fat storage and blood cell production
Types of bone marrow:

Yellow marrow:

Contains adipose tissues, serve as a source of energy

Red marrow

The production of blood cells (hematopoiesis)

Red blood cells, white blood cells, and platelets are all produced in the red marrow

Openstax, 2022

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Critical Thinking Question

What are the functions of bones in the body? (Select all that apply)

Supports the body
Facilitates movement
Protects internal organs
Stores and releases minerals and fat

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Talipes Equinovarus (Club Foot)

NHS, 2020

Health Direct, 2021

Congenital disorder
A baby is born with a foot or feet that turn in and under
One foot or both feet point down and inward with the sole of the foot facing backward
More common in boys than girls
Affects about 1 in 1,000 babies

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Talipes Equinovarus -Club Foot: Causes

No known cause
Genetic link
Runs in families
The bones and ligaments don't develop properly in the womb

NHS, 2020

Health Direct, 2021

Contact info: info@nursesinternational.org

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Talipes Equinovarus: Sign and Symptoms

A twisted and curved foot
May have underdeveloped calf muscles and small feet
The Achilles tendon (the large tendon at the back of the ankle) is too short
Painless
May become painful affect walking if not treated

NHS, 2020

Health Direct, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

Club foot is also known as__________________.

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Talipes Equinovarus -Club Foot: Diagnosis

Usually diagnosed at birth
Ultrasound:

Identified between 18 and 21 weeks of pregnancy before birth

X-ray: to determine severity

NHS, 2020

Health Direct, 2021

Contact info: info@nursesinternational.org

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Talipes Equinovarus -Club Foot: Treatment

Treatment begins within 1 to 2 weeks of a baby being born

Ponseti method:

Gently manipulating and stretching infant’s foot into a better position and then put into a cast
Repeated every week for about 5 to 8 weeks

Surgery:

Under a local anaesthetic to to loosen the Achilles tendon at the back of their ankle

NHS, 2020

Health Direct, 2021

Contact info: info@nursesinternational.org

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Talipes Equinovarus -Club Foot: Nurses Role

History taking
Physical examination
Protect skin integrity

Monitor site of impaired tissue integrity at least once daily (color changes, redness, swelling, warmth, pain, or other signs of infection)
Monitor skin care practices (water temperature, soap)

Promote acceptance of body image (Parents)
Provide health education and support to parents

Belleza, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

Parents brought their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot was made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

“I realize my infant will require follow-up care until fully grown.”
“Treatment needs to be started as soon as possible.”
“I need to come to the clinic every week with my infant for the casting.”
“I only need to bring my infant back to the clinic in 1 month for a new cast.”

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Osteogenesis Imperfecta (OI)

Also called Brittle Bone Disease
An inherited (genetic) bone disorder present at birth
Bones fracture (break) easily, often with no obvious cause or injury

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI): Causes

A change or defect in the genes that carry the instructions for making type I collagen.

Type I collagen is a material in bones that helps make bones strong.

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Critical Thinking Question

The cause of the brittle bone disease is the change or defect in the genes that carry the instructions for making type I collagen.

True
False

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Osteogenesis Imperfecta (OI)

Four are common

Type I

The mildest and most common
Quality collagen but not enough
Bones fracture with mild to moderate trauma
Mild or no bone deformity
Possible changes in the strength and color of teeth
Possible hearing loss

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI):Types

Type II

Most severe form, may be life-threatening
Improperly formed collagen
Underdeveloped lungs
Numerous broken bones before birth while in the womb
Severe bone deformities
Very small stature
Frequently death at birth or shortly after, because of the inability to breathe

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI):Types

Type III

Most severe type among those who survive
Improperly formed collagen
Greatest number of physical disabilities
Bone fracture with very little trauma:

(Broken bones often present at birth, and x-rays reveal healed broken bones that occurred before birth)

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI):Types

Type IV

Most variable form
Symptoms range from mild to severe
Bone fracture sometimes before birth
Mild to moderate bone deformity
Improperly formed collagen

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Critical Thinking Question

Which one of the following is the most severe and life threatening form of Osteogenesis Imperfecta (OI)?

Type I
Type II
Type III
Type IV

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Osteogenesis Imperfecta (OI): Symptoms

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Bone deformities and loose joints
Small suture
Skin bruises easily
Blue, purple, or gray sclera
Triangle shape face
A barrel shape rib cage
Kyphosis, Scoliosis
Hearing loss

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Osteogenesis Imperfecta (OI): Symptoms

Compression of the vertebrae in the spine
Brittle, misshapen, or discolored teeth
Breathing problems
Coxa Vara:

A deformed hip joint in which the neck of the femur is bent downward

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Critical Thinking Question

A nurse is assessing a child for Osteogenesis Imperfecta.

What are the sign and symptoms a nurse might see in the child? (Select all that apply)

Bone deformity
Blue sclera
Yellow sclera
Bruises on the skin

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Osteogenesis Imperfecta (OI): Diagnosis

Family and medical history
Physical exam
X-rays
Bone density tests
Genetic blood test:

Detects the changed in the inherited gene

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI): Treatment

No cure
Treatment goal:

Depends on the type of OI
To prevent or control symptoms, increase bone mass and muscle strength, and maximize a individual’s ability to be independent

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI): Treatment

Physical or Occupational Therapy:

Build muscle strength, improve joint movement
Safely perform activities of daily living
Recover from broken bones

Medication:

To relieve pain
Bisphosphonates to strengthen the bones

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Johns Hopkins, 2022

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI): Treatment

Bone Care:

Cast, splint, or brace
Surgery to repair bone deformities

Mobility Aids:

Walkers, Canes and crutches
Braces or prosthetics
Wheelchairs

Oral and Dental Care
Hearing: Hearing aids, Cochlear implant, stapedectomy

NIH Osteoporosis and Related Bone Diseases National Resources Center, 2019

Kivi, 2020

Contact info: info@nursesinternational.org

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Osteogenesis Imperfecta (OI): Nurses Role

Environment modification for child safety
Help child find safe and enjoyable activities and hobbies
Careful handling to prevent injuries
Gently support a child while turning, positioning, moving
Even changing a diaper may cause a fracture:

Never held by ankles when changing diapers, gently lift the buttocks

Assess the child for sign of abuse
Education
Support parents/caregivers

Anzilotti, 2022

Hockenberry and Wilson, 2007

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

There is cure for the Osteogenesis Imperfecta.

True
False

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Red Flags

Underdeveloped lungs
Numerous broken bones before birth while in the womb
Severe bone deformities

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

Contact info: info@nursesinternational.org

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Cultural Considerations (con.):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References:

Anzilotti, A.W. (2022). Osteogenesis Imperfecta (Brittle Bone Disease). https://kidshealth.org/en/parents/osteogenesis-imperfecta.html

Belleza, M. (2021). Congenital Talipes Equinovarus (Clubfoot). https://nurseslabs.com/congenital-talipes-equinovarus-clubfoot/

Health Direct. (2021). Club Foot. https://www.healthdirect.gov.au/clubfoot

Hockenberry, M. J. & Wilson, D. (2007). WONG’S Nursing Care of Infants and Children. 8th edi. Mosby

Johns Hopkins Medicine. (2022). Osteogenesis Imperfecta. https://www.hopkinsmedicine.org/health/conditions-and-diseases/osteogenesis-imperfecta#:~:text=Osteogenesis%20imperfecta%20(OI)%20is%20an,range%20from%20mild%20to%20severe

Contact info: info@nursesinternational.org

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References:

Kivi, R. (2020). Brittle Bone Disease (Osteogenesis Imperfecta) [Review of article ‘Brittle Bone Disease (Osteogenesis Imperfecta)’ by, M. Milliam] Healthline. https://www.healthline.com/health/osteogenesis-imperfecta

NIH Osteoporosis and Related Bone Diseases National Resources Center. (2019). Osteogenesis Imperfecta Overview. https://www.bones.nih.gov/health-info/bone/osteogenesis-imperfecta/overview

NHS. (2021 March 24). Club Foot. https://www.nhs.uk/conditions/club-foot/#:~:text=Club%20foot%20 (also%20called%20talipes,of%20the%20foot%20facing%20backwards.

Openstax.(2022). The Functions of the Skeletal System. Anatomy and Physiology. https://openstax.org/books/anatomy-and-physiology-2e/pages/6-1-the-functions-of-the-skeletal-system

Contact info: info@nursesinternational.org

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