CHAPTER 6

DISORDERS OF THE MUSCULOSKELETAL SYSTEM

INTRODUCTION

• The pediatric musculoskeletal system differs from the adult musculoskeletal system due to its unique features.
• These differences include:-

• Anatomical Differences
• Physiological Differences
• Psychological Differences

CONGENITAL AND DEVELOPMENTAL MUSCULOSKELETAL DISORDERS IN CHILDREN

REFER TO BOOK

CONGENITAL HAND AND FINGER ANOMALIES IN CHILDREN

TABLE 1

PAGE NO. 292

Syndactyl

Polydactyl

Ectrodactyle

AMNIOTIC BAND SYNDROME (ABS)

Definition

• Amniotic Band Syndrome (ABS) occurs when fibrous bands from the amniotic sac entangle fetal limbs or other body parts, disrupting normal development.

Clinical Signs and Complaints

• Constriction rings around fingers, toes, or limbs.
• Swelling distal to the constriction site.

Amniotic band syndrome

Management

• Prenatal diagnosis: Detected via ultrasonography.

• Postnatal care: Surgical release of constriction bands to improve circulation and prevent complications.

GENU VARUS (BOWLEG)

• Definition A condition where the knees bow outward, creating a noticeable gap between them when standing with feet together. The term “genu” comes from the Latin word “genu,” which means “knee.”

Clinical Signs and Complaints

• Outward curving of legs below the knees.

Genu verus and genu valgus deformity

Age and Normalcy

• Common in children up to 2-3 years due to fetal positioning.

Management

• Observation
• Pathological Cases

GENU VALGUS (KNOCK-KNEE)

Definition

• A condition where the knees angle inward, touching each other while the ankles remain apart.

Clinical Signs and Complaints

• Knees that knock together when walking.

• Parents may report difficulty in walking or awkward gait.

Age and Normalcy

• Common in children between 3-7 years and typically resolves by 7-8 years.

Management

• Observation
• Pathological Cases

CLUB FOOT

• Congenital talipes equinovarus commonly known as club foot, is one of the most common lower extremity related births defects.

CAVE deformity of club foot (adopted from Dibello D, Di Carlo V, Colin G, Barbi E, Galimberti AMC

Types

Based on the Anatomical Deformity

Types of Talipes based on anatomical deformity

Types of Talipes based on anatomical deformity

Based on Etiology

• Based on etiology clubfoot are of two types idiopathic clubfoot and secondary clubfoot.

Etiology

• Etiology
• Maternal factors

Diagnosis

• Clubfoot is often identifiable during routine intrauterine fetal ultrasound.

Pirani Score

Pirani score

Grades of Pirani scoring (Minimum score 0, maximum score 6)

Management

• Ponseti Treatment Method

• It is a simple, reliable and minimally invasive procedure with a high success rate. This worldwide accepted treatment was developed by Dr. Ignacio Ponseti in 1948.

• Casting Phase
• In this phase, the deformity is manipulated gently and then serial stretch casting is done weekly basis in a long leg plaster casts form.

Clubfoot treatment over 4-6 weeks

Bracing with Dennis-Brown “boot and bar” brace

• Bracing Phase
• The bracing phase is important to maintain correction and prevent relapse of the clubfoot deformity.

• This brace is named Dennis- Brown’s “boots and a bar” brace, as it consists of bilateral boots and a foot abduction bar.

Foot position with “boot and bars”

Surgical Management

• Percutaneous tendo-achilles tenotomy
• It corrects equinus deformity when the cavus, varus, and adductus deformities of the club foot have been corrected by Ponseti treatment but still have a dorsiflexion of less than 10°.
• Midfoot double-column osteotomies
• This technique is efficient and safe for recurrent residual adductionand bean-shaped deformity after surgical correction of clubfoot deformity.

Nursing Care for a Child with Club Foot REFER TO BOOK

PAGE NO. 289 & 299

Complications

• Relapse of deformity (up to 68% of cases) due to non adherence to the brace regime.
• Delayed attainment of gross motor milestones.

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

• Developmental dysplasia of the hip (DDH) is the most common congenital dislocation of the musculoskeletal system.

Types of Hip Dysplasia

• Acetabular dysplasia
• Subluxable
• Dislocatable
• Dislocated

Types of Hip Dysplasia

A- Normal, B- Dysplasia, C- Subluxation, D- Luxation

Risk Factors

• Female gender
• Family history
• Postnatal positioning

Traditional Mongolian swaddling vs hip-healthy swaddling.

Diagnosis

Clinical Examination

• Galeazzi sign, a possible leg length discrepancy, in particular of the thighs.

Galeazzi sign (note the difference in knee height)

• Ortolani’s manoeuvre
• Barlow’s manoeuvre

Barlow’s maneuver and Ortolani’s maneuver

Ultrasound Examination

• Ultrasound examination of hip joint.

X-ray of the Hip

• X-ray of the hip is useful only after the 3rd–4th month of life of the child, when the skeletal structures reach a sufficient degree of mineralization.
• Follow-up the disease to identify its progression/ improvement.

Management

• The goal of DDH management is to achieve and maintain a concentric reduction of the femoral head in the acetabulum.

• 1-6 Months Age

• Pavlik harness (adapted from Jennings HJ, Gooney M, O’Beirne J, Sheahan L.

• Ilfed Orthosis

• If the hips are not reduced by the Pavlik harness by three weeks, then the Ilfred orthosis is used.

• 6 to 18 Months

• Infants who are diagnosed with DDH at this age or who failed with abduction devices, closed reduction is the choice of treatment for them.

Gore-tex lining hip spica cast with tape “petaling” around the opening

18 Months to 8 Years

• Open reduction is preferred for children diagnosed with DDH over 18 months and infants who failed closed reduction.

Nursing Management

• Assessment

• At birth or during the neonatal period inspect the newborn for asymmetrical gluteal fold, unequal length of legs to aid in early diagnosis.
• Observe the child for limited hip movement.

Nursing Interventions

• Positioning and Lifting the Child

• Place pillows, towels, or blankets against the child’s body to keep them in position and to prevent falling.

• Care of Cast

• After cast application it usually dries within 24 hours . Observe the cast for cracks, dents, increasing tightness or looseness, or drainage on the cast.

• Skin Care

• Skin should be checked daily for sore areas if any especially after changing position Flashlights to be used to look inside the cast.

• Toileting and Diapering

• Bedpans and/or urinals are usually used for continent children. When using a bedpan, elevate the child’s head and chest to prevent urine and/or feces from running backward, inside the cast.

Double diapering (A small diaper is tucked into the cast and a large diaper is placed over it).

Complications

• Limping with severe functional limitation while the child start walking.
• Early hip osteoarthritis in adulthood, avascular necrosis of the femoral head.

FRACTURE

• Introduction

• Any disruption in the continuity of bone is called fracture.
• The growing skeleton of children is immature in comparison to the adults.

Causes

• Fall-related injuries (55-60%), due to accidental fall from bed, table, chair, tree, roof, slipping on floor while playing.

• Poor bone mineral density and bone mass.
• Low calcium intake.

Types

• Physeal Fracture

• Salter-Harris Type I fractures
• Salter-Harris Type II fractures
• Salter-Harris Type III fractures
• Salter-Harris Type IV fractures
• Salter-Harris Type V fractures

• Non-Physeal

• Greenstick fractures

• Children have certain elastic properties of the bone, which allows higher compliance to trauma, resulting in the bending of the bone.

• Buckle fractures

• Found at the junction between the diaphysis and the metaphysis.

• Plastic deformation

• Third most common fractures specific to children.

• Subperiosteal fractures

• It occur in the small bones of hands and feet’, in the proximal ulna, and in the tibia.

Difference between complete, spiral and oblique fracture

Management

• Non-surgical Management

• Fracture site immobilization with external plaster fixation.

• Surgical Management

• Open reduction subgroup
• Closed reduction subgroup

Traction

• The core principle of traction is the application of external force to manipulate or reduce fractures and correct the deformity.

Skin Tractions

• It are applied with an adhesive bandage to the skin. Skin traction is applied by using skin adherents, ace wraps, commercial traction tapes, or special foam boots.

Skeletal Traction

• Skeletal traction is traction force applied through the fixation of transosseous pins, wires, screws, and/or tongs that are inserted into the appropriate area of bone.

Table 4: Types of skin traction

Side arm 90-90

Dunlop traction

Pelvis sling

Bryant’s traction

Buck’s traction

Split Russell’s

Types of skeletal traction

Dunlop’s side-arm 00-90

Knee 90-90

Thomas ring with Pearson attachment (balanced suspension)

Nursing Management

• Care of a child with a plaster cast has been discussed earlier in the section under DDH and club feet.
• Care of child with traction
• Maintenance of skin integrity

Traction Care

• Assess the pain level of the child in each shift and document it.
• Ensure that the traction weight bag is hanging freely, NOT resting on the bed or the floor.

Daily Activities

• The child can sit up in bed thus engaging them in creative activities such as crafts, board games, drawing, reading story books and watching TV.

Complications of Fracture

• Fat embolism.
• Multisystem injury.
• Concomitant neurological injuries, fracture site was the skull, shock.

Osteogenesis Imperfecta

• Osteogenesis Imperfecta (OI) is a group of rare genetic disorders which affect the skeletal system. It is also known as brittle bone disease.

Etiology

• Based on phenotypic characteristics and mode of inheritance (autosomal dominant/autosomal recessive) OI is of eleven different types.

Clinical Manifestations

• Milder manifestations include generalized laxity of joints, easy bruising, hernias, and excess sweating.
• Decreased bone density, increased bone fragility.
• Blue Sclera.

Management

• Management of OI depends on the age, severity, and functional status of the child.

Pharmacological Management

​

• Bisphosphonates increase bone density and reduce fractures in OI.
• Pamidronate is the most commonly used drug.
• They inhibit osteoclast activity, reducing bone resorption.

OSTEOMYELITIS

• It is most commonly caused by Staphylococcus aureus and can occur as a hematogenous infection or after a direct inoculation of bacteria, for instance, due to surgery or open fractures.

Classification

• Acute (duration of symptoms<2 weeks)
• Subacute (duration of symptoms 2 weeks to 3 months)
• Chronic (a long-standing infection that evolves over months to years).

Etiology

• The pathogen most often associated with acute hematogenous osteomyelitis is Staphylococcus aureus followed by group A Streptococcus (GAS).

Pathophysiology

(A) During an episode of bacteremia, bacteria are deposited in the metaphysis from the metaphyseal vessels.

(B) A focus of infection develops in the metaphysis, which leads to cellulitis in the bone marrow. (C) Exudate under pressure is forced laterally through the Haversian systems and Volkmann canals and into the cortex of the bone, where it can lift or rupture through the periosteum.

Pathophysiology of osteomyelitis (Adapted from Mehul Gupta, Pathogenesis of osteomyelitis, published May 21, 2021 on www.thecalgaryguide.com)

REFER TO BOOK

PAGE NO. 310

Clinical Manifestations

• The symptoms of acute osteomyelitis are often insidious.
• Fever, tachycardia, localized pain, swelling, and rarely erythema around a long bone, limited range of motion, and limping or refusal to bear weight .

Diagnosis

• Nonspecific inflammatory markers
• Blood culture and bone/joint fluid cultures
• Imaging Techniques

Management

Complications

• Deep vein thrombosis at a site adjacent to the infected bone.
• Pathologic fractures.
• Disruption of longitudinal bone growth, and angular deformity.

OSTEOSARCOMA

Definition

• Sarcomas are malignant tumors that arise in tissues such as bones, cartilage, and muscle.

Incidence

• OS predominantly affects children, teenagers, and young adults aged 10-30 years, with a higher incidence in males.

Etiology

• Rapid bone proliferation during the pubertal growth spurt is associated with OS.

Origin

• OS typically originates in the metaphyseal region of long bones, commonly in the femur (42%), tibia (19%), and humerus (10%).

Subtypes

• Osteoblastic, Chondroblastic, Fibroblastic
• Parosteal, Central Low-Grade, Periosteal

Clinical Manifestations

• Children may present with pain and swelling in the affected region, often seeking medical attention after trauma or vigorous exercise.
• Symptoms persist for 3-4 months or longer before diagnosis.

Diagnosis

• History and physical examination
• CT scan of chest

Management

• Radiotherapy
• Chemotherapy

Surgical Management

• Complete tumor removal with a shift towards limb salvage surgery.

Complications

• Metastasis
• Treatment side effects

Prognosis

• If untreated, OS leads to systemic disease progression and death within months. Children with periosteal OS have an 83% survival rate at 10 years.

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