musculoskeletal/ neurological functions

• Developmental dysplasia of the hip (DDH)

  Also known as hip displacement, can be associated with breech position, recommended infant's hips in slight flexion and abduction when swaddled
• Types of DDH

  • Acetabular dysplasia
  • Subluxation
  • Dislocation
• Acetabular dysplasia

  Mildest form, hypoplasia of the acetabular roof ball is in the socket
• Subluxation

  Largest occurrence, incomplete dislocation, head is in contact with acetabulum but stretched capsule and round ligament allow the femur head to be partially dislocated
• Dislocation

  Femoral is not in contact with the acetabulum
• Diagnosis in the newborn period is the best for treatment success, ultrasound in young infants, x-ray in older infant or child
• Signs and symptoms of DDH

  • Asymmetry gluteal and thigh folds
  • Limited hip abduction
  • Apparent shortening of femur
  • Ortolani's test (audible click when the hip is abducted one hip at a time)
• Treatment of DDH

  • 0-6 months= Pavlik harness, abducts and prevents adduction for 3-5 months
  • 3-6 months hip spica
  • 6-18 months= closed or open reduction and casting
  • Older children= surgical correction followed by casting
• Nursing care of DDH

  • Initial screening of the newborn
  • Teaching regarding abduction device
  • Harness= removing it is based on provider instructions, straps not adjusted at any time, skin care/bathing, placing clothing, under strap areas
  • Hip spica cast= post op monitoring NV checks, respiratory assessment, follow up for cast
• Care of child in a cast

  • NV checks/distal pulses/sensation/movement
  • Monitor temp for infection
  • Handle cast carefully no pressure points
  • Protect cast integrity around diaper area
  • Protect skin petal the edges (soft spots over the cast)
  • Prevent child from inserting objects into the cast
• Congenital club foot

  Unilateral or bilateral more of the cases, forefoot adduction midfoot supination, bone deformity and malposition with soft tissue contracture
• Diagnosis Congenital Club Foot= visual assessment, may be detected ultrasound prenatally
• Treatment of congenital club foot

  • Exercise manipulation
  • Serial casting newborn period 8-12 weeks
  • Percutaneous heel cord tenotomy at the end of serial casting then long leg cast for 3 weeks
  • Denis brown split for foot position
  • If alignment not achieved by 3 months consider surgical correction at 6-12 months
• Legg calve perthes disease

  Idiopathic avascular necrosis of the femoral head (ischemic necrosis), children age 2-12 average age 6
• Signs and symptoms of Legg calve perthes disease

  • Limping particularly in the morning or night
  • Hip/thigh/knee pain
  • Stiffness is constant or intermittent
  • Limited ROM
• Diagnosis Legg calve perthes disease= MRI/x-ray
• Treatment of Legg calve perthes disease

  • Goal is to keep the head of the femur in the acetabulum to decrease hip irritability, restore/maintain ROM of hip, maintain well-rounded femoral head
  • Rest, non weight bearing, ROM exercises, abduction casts/brace, leather harness, surgical reconstruction
  • Conservative approach may require 2-4 years
• Nursing care for Legg calve perthes disease

  • Developmental concerns
  • Active children who must remain inactive
  • Concepts of immobility
  • Post op cast care/wound care/drain care/ NV assessment/ pain management
  • Mostly do one leg first then the other
• Slipped femoral capital epiphysis (SFCE or coxa vera)

  Spontaneous displacement of the proximal epiphyses in an inferior and posterior direction (femoral cap starting to dislocate from bone), usually occurs during growth spurt, can be associated with endocrine issues and radiation, most frequently seen in boys and obese children, bilateral in most cases
• Signs and symptoms of SFCE

  • Gradual disability of the hip
  • Hip/groin/thigh/knee pain continuously or intermittently
  • Limping
  • Loss of abduction and internal rotation
• Diagnosis SFCE= x-ray
• Treatment of SFCE

  • Non weight bearing, traction preoperative
  • Surgical intervention can have pin or screw placement and osteotomy for shape and correction
  • Post op non weight bearing with crutches until acceptable and painless ROM is achieved
• Idiopathic scoliosis

  Lateral curvature of the spine causing spinal rotation and rib asymmetry, may occur with growth spurts or in those with neuromuscular disorders, recommended screening girls 10-12 and boys 13-14
• Signs and symptoms of idiopathic scoliosis

  • Parent history of clothes fit unevenly/pant leg lengths/skirt hems
  • Back view is asymmetrical scapula/shoulder height/flank shape/hip height
  • Bending forward so torso is parallel with the floor can view asymmetrical ribs and flank from behind
  • Pronounced curvature will compromise pulmonary and cardiovascular function
• Diagnosis idiopathic scoliosis = x-ray, determine skeletal maturity with risser scale

  -cobb technique is used to determine the degree of curvature (<10% considered postural variation, 10-25% mild usually no treatment if non progressive, bracing and exercise for moderate 25-45% helps slow progression)
• Operative treatment of idiopathic scoliosis

  • Anterior approach (recovery shorter less pain but will need a chest tube)
  • Posterior approach (recovery is longer and more painful)
  • Instrumentation, goal straightening with well-balanced torso (balanced shoulders and hip) and maximum mobility
• Nursing care for idiopathic scoliosis

  • Pre op with screenings/development/skin issues of bracing/teaching/type and cross/VS/skin assessment/anxiety of parent and patient
  • Post op is neurological and neurovascular assessment/activity like log rolling to prevent twisting/pain management/anterior management of chest tube/fluid volume issues
• Idiopathic scoliosis

  Parent history of clothes fit unevenly/pant leg lengths/skirt hems, back view is asymmetrical scapula/shoulder height/flank shape/hip height, bending forward so torso is parallel with the floor can view asymmetrical ribs and flank from behind, pronounced curvature will compromise pulmonary and cardiovascular function
• Muscular dystrophy

  Genetic origin, gradual and progressive degeneration of muscle fibers, progressive weakness/wasting of skeletal muscles/increasing disability, several varieties most prevalent in early childhood is Duchene's which is x linked recessive transmission
• Duchene's muscular dystrophy (DMD)

  In the first two years developmental milestones may seem on target, may be subtle delays particularly with walking, onset is 3-5 years with progressive muscle weakness, may have mild mental delays, no cure
• Operative approaches

  • Anterior (recovery shorter less pain but will need a chest tube)
  • Posterior (recovery is longer and more painful)
• Operative goals

  Straightening with well-balanced torso (balanced shoulders and hip) and maximum mobility
• Nursing care - pre-op


  Screenings/development/skin issues of bracing/teaching/type and cross/VS/skin assessment/anxiety of parent and patient
• Treatment of DMD

  • No cure, corticosteroids use prolonged ambulation
  • Promote optimal function for as long as possible
  • Prevent contractures with muscle strengthening/ROM/bracing/incentive spirometers
  • Decisions about level of care as progressive muscle weakening
• Nursing care - post-op

  Neurological and neurovascular assessment/activity like log rolling to prevent twisting/pain management/anterior management of chest tube/fluid volume issues
• Nursing care for DMD

  • Focus of ROM
  • Genetic counseling
  • Family support
  • Mainstreaming kids with classroom education and school nurse
  • Support devices like braces/wheelchairs/positive pressure ventilation
  • Could have tracheostomy and is controversial
  • Teen years admission for cardiac and pulmonary events/anticipatory grieving/life support/end of life decisions
  • Death usually due to cardiopulmonary failure
• Duchene's muscular dystrophy (DMD)

  In the first two years developmental milestones may seem on target, may be subtle delays particularly with walking, onset is 3-5 years with progressive muscle weakness, may have mild mental delays, no cure
• Duchene's muscular dystrophy (DMD) signs and symptoms

  • First noticeable deficit is trouble with walking/climbing stairs/riding a bike, difficulty arising from
  • Gower signs a sitting position and walking up the legs
  • pseudohypertrophy of the calf muscles which is fat infiltrate, demonstrates a progression of increasing muscle weakness,
  • loss of ambulation by 9-11 years, wheelchair bound in teens, progressive cardiac and pulmonary muscle involvement in teen years, death is from cardiac or pulmonary failure
• Duchene's muscular dystrophy (DMD) diagnosis

  Clinical manifestations, blood polymerase chain reaction for dystrophin gene mutation, muscle biopsy is gold standard
• Cerebral Palsy


  Disorder of posture and movement from brain injury prenatally or postnatally, possible causes birth asphyxia/prenatal brain abnormalities/maternal and perinatal infections, postnatally infections such as meningitis/intracerebral hemorrhage/MVAS/child abuse/falls