MUSCULOSKELETAL CONDITIONS OF
PEDIATRIC CLIENTS
I. Soft Tissue Injury
a. Strain – Tearing, Twisting, sTretching of
a muscle or Tendon.
s/s:
Pain
Localized swelling
Muscle Weakness
b. Sprain – injury to a ligament (sports
injury and ankle injury).
s/s:
Pain
Edema
Joint immobility
c. Contusion – bruise/hematoma; blood
vessel ruptures beneath the skin and
bleeds into the tissue which causes the
discoloration.
s/s:
Purple discoloration of the tissue (fades
to brown, yellow, and green).
Diagnosis: x-ray to rule-out fractures.
Treatment:
RICE (rest, ice, compression, elevation) – 24-36
hrs after injury.
REST – 3P (prevents pain, promotes healing,
prevents further injury).
Nursing Intervention:
1. Assist client with ADLs
2. Teach the parents and the client about
the nature of the injury and how the
treatment will help heal the injury.
3. Contusion: encircle the area and label it
with a date and time. Monitor for the
1st hour if blood has coagulated.
II. Hip Dysplasia
- Abnormal development of the hips
during fetal development.
3 categories:
a. Acetabular Dysplasia (Preluxation) –
femoral head remains in acetabulum.
Acetabulum is shallow and dish-shaped
rather than cup shaped.
b. Subluxation – incomplete dislocation of
the femoral head from the acetabulum.
It is the most common form.
c. Dislocation – femoral head loses
contact with the acetabulum.
Assessment:
Gait Trendelenburg
Ortolani Click (<4 wks old) – hip instsability
Assymetrical gluteal and thigh folds
Limited hip abduction
Shortened femur (unequal knee length) –
Galeazzi’s sign, Allis’s sign
(+) BarLOW Test due to dislocation – the
examiner adducts the hips and applies gentle
pressure down and back with the thumbs. The
examiner can feel the femoral head move out
of the acetabulum.
Ortolani’s Maneuver – examiner abducts the
thigh and applies gentle pressure forward over
the greater trochanter. A “clicking” sensation
indicates a dislocated femoral head moving into
the acetabulum.
Trendelenburg’s Sign – the child stands on one
foot and then the other foot, holding onto a
support and bearing weight on the affected hip;
the pelvis tilts downward on the normal side
instead of upward.
Treatment:
Newborn to 6 months of age:
- Pavlik harness for 3-5 months. Legs are
flexed and knees fall outward.
Six-18 mos:
- Hip Spica cast to immobilize the legs
and knees for 2-4 months after surgical
realignment of the hips.
Older than 18 mos:
- Osteotomy to align the femoral head
with the hips.
Prevention:
1. Proper swaddling technique – hips
flexed and abducted, allowing room for
movement.
2. Choose car seats with wide bases.
3. Avoid positions, devices, seats that
cause hip extension with the knees
straight together.
Nursing Interventions:
a. Patients with Pavlik harness:
- Examine skin integrity under the
harness
- Don’t apply lotions and powder to the
skin.
- Place an undershirt between the skin
and harness.
- Place diaper under the harness straps.
- Massage skin to promote circulation.
- Ask HCP if the harness can be removed
for daily sponge bathing.
b. Patients with hip spica cast:
- Assess for compartment syndrome.
- Explain that the cast is temporary.
- Keep the cast clean and dry.
III. Fracture
- Break in the continuity of the bone as a
result of trauma, twisting, or bone
decalcification.
Types:
Complete – bone separates in two distinct parts
Incomplete – bone doesn’t separate.
Closed (simple) – bone does not break the skin.
Open (compound) – bone breaks the skin.
3 Types of Fractures:
Hairline: incomplete fracture
Greenstsick: incomplete fracture where the
bone is partially broken resulting in the bone
bending like a broken stick.
Comminuted: complete fracture where the
bone is broken into fragments.
Assessment:
Crepitation
Loss of Function
Obvious deformity
Muscle spasm
Pain or tenderness on the area
Edema
Ecchymosis
Diagnosis:
X-ray: confirms the fracture.
Treatment:
1. Immobilize the bone (align and revent
injury).
2. Closed Reduction – realigns the surface
area of the bone by manipulating the
bones or by applying traction to
encourage healing.
3. Open Reduction – done if closed
reduction is not possible. It is a surgery
done to repair torn muscle and
ligaments. Pins, screws, plates, or rods
are used.
4. Provide adequate fluid in increase
hydration and prevent renal calculi.
Tractions:
1. Skin traction – adhesive material,
straps, or foam boot are used to pull
the surface of the skin. Types:
a. Buck extension: knee immobilization
b. Byrant traction: hip dysplasia and
fractured femur ( <3y.o., weigh
<17.5kg)
c. Russel traction: fractures of the femur
and lower legs.
2. Skeletal Traction – pins, wires, and
tongs are surgically placed in the bone
applying direct traction to the bone.
Types:
a. Skeletal cervical traction (crutchfield
tongs): cervical spine injuries.
b. Halo traction: head and neck
immobilization.
c. 90/90 femoral traction: femur and tibia.
d. Dunlop (sidearm) traction: humerus
fractures where the arm is suspended.
 e. External fixators: pins or wires are
transfixed percutaneously to the
extremity.
f. Balanced Skeletal traction: fractures of
the femur, tibia, or fibula. Provide pin
care.
Nursing Interventions for Traction:
1. Maintain correct amount of weight.
2. Ensure that weights hang freely.
3. Check all ropes for fraying and all knots
for tightness.
4. Monitor neurovascular status of the
involved extremity.
5. Protect the skin from breakdown.
6. Monitor complications (constipation,
skin breakdown, lung congestion, renal
complications, disuse syndrome of
unaffected extremities).
7. Provide therapeutic and diversional
play.
Cast – made of plaster or fiberglass to provide
immobilization of bone and joints after a
fractureor injury.
Nursing Intervention for casts:
1. Observe cast for pressure areas.
2. Ensure that no rough casting material
remains in contact with the skin.
3. Monitor circulatory impairment (pain,
edema, rubor, pallor, numbness,
tingling, coolness, decreased sensation
and mobility, or pulselessness).
4. Notify HCP for circulatory impairment.
Bivalving if this happens. Emergency
fasciotomy if cast removal does not
improve neurocirculatory compromise.
5. Instruct parents and child not to stick
objects down the cast.
6. Keep cast clean and dry.
7. Isometric exercises to prevent muscle
atrophy
IV. Osteogenesis Imperfecta
- genetic, bones fracturing easily.
4 classifications:
Type I (most common): bones fracture easily
before puberty.
Type II (most severe): severe bone deformity
and numerous fractures resulting in respiratory
problems at or shortly after birth  death.
Type III: Fractures present at birth and may hae
healed.
Type IV: Fractures greater than type I and occur
before puberty.
Signs and Symptoms:
Blue Sclerae
Hyperextensible ligaments
Easy bruising
Epistaxis
Fractures
Short stature in all except type I
Nursing Interventions:
1. Physical therapy to strengthen muscles.
2. Handle patients gently.
3. Teach parents how to care for the child.
V. Torticollis
-sternocleidomastoid muscle is damaged from
intrauterine malposition of the fetus in or from
birth trauma  unusual contraction of the
sternocleidomastoid muscle causing the head to
bend toward the affected muscle.
Treatment:
- Low-impact neck stretching exercise.
- Heat application to encourage healing.
- Massage to relieve tension
Nursing Intervention:
1. Handle patients gently to prevent fractures
and bruising.
2. Teach the parents how to care for the
patient.
VI. Scoliosis
- Lateral curvature of the spine.
- Types:
1. Dextroscoliosis – curvature on the right
side.
2. Levoscoliosis – curvature on the left
side.
 3. Rotoscoliosis: rotation of the vertebrae. VII. Osteomyelitis
- Infection of the bone or bone marrow
Treatment: commonly cause by Staphylococcus
Spinal Fusion by thorascopic surgery. aureus, r/t skin infection, otitis media,
Use of Braces or URTI.

Signs and symptoms: Signs and Symptoms:

1. Asymmetry of the ribs and flanks with Warmth
Adam’s test. Abrupt Fever
2. Hip height, rib positioning, leg length, and Rapid pulse
shoulder height are asymmetrical. Swelling over the affected area
Lethargy
Nursing Interventions: Irritability
1. Monitor curvature progression. Pain
2. Prepare the child for the use of braces.
3. Prepare the child and parents for Diagnostics:
surgery. Increased WBC
C&S to identify microorganism and antibiotic.
Braces:
1. Worn 16-23 hours a day. Treatment:
2. Observe for signs of skin breakdown. Prolonged IV antibiotic therapy (nafcillin or
3. Keep the skin clean and dry, and avoid clindamycin)
lotions and powders. Physical therapy
4. Wear soft clothing under the brace.
5. Instruct exercises that strengthens the Nursing Interventions:
spinal and abdominal muscles. 1. Monitor hematologic, renal, and hepatic lab
6. Encourage verbalization of body image tests for signs of toxicity due to prolonged IV
issues. antibiotic use therapy.
2. Monitor ototoxic side effects.
Post-Op Interventions: 3. Support the affected area when positioning.
1. Avoid twisting movements and 4. Avoid weightbearing on the infected area.
maintain proper alignment. 5. Bed rest.
2. Log Roll. 6. Assess for ischemia: 5P (Pain, Pallor,
3. Assess extremities for neurovascular Paresthesia, Pulselessness, Paralysis).
status.
4. Encourage DBE. VIII. Juvenile Rheumatoid Arthritis
5. Assess pain and administer analgesics. - Autoimmune disease that causes
6. Monitor for incontinence. chronic inflammation of connective
7. Monitor for signs of infection. tissue and joints resulting in swelling,
8. Monitor for superior mesenteric artery pain, and limited motion that occurs
syndrome (caused by mechanical <16 y.o.
changes in the position of the child’s
abdominal contents during surgery) and Assessment:
notify HCP. Symptoms: emesis, 1. Stiffness, swelling, and limited joint
abdominal distention. motion.
9. Activity restriction. 2. Joints are warm to touch, tender, and
10. Assist with ambulation. painful.
 3. Joint stiffness in the morning and after
inactivity.
4. Uveitis (inflammation of structures in
the uveal tract), can cause blindness.
Diagnosis:
1. X-ray: shows soft tissue swelling and
joint space widening from increased
synovial fluid in the joint.
2. Elevated ESR
3. Leukocytosis/ increased WBC
Medications:
1. NSAIDS – WOF GI irritation and bruising
2. Methotrexate – monitor CBC and liver
function.
3. Corticosteroids – immunosuppressive;
taper dosage.
- Prolonged use can cause Cushing’s
syndrome, osteoporosis, infection,
glucose intolerance, hypokalemia,
cataracts, growth suppression.
4. Tumor Necrosis Factor Receptor
Inhibitors
- Etanercept (Enbrel)
- Infilximab (Remicade)
- WOF: allergic reaction at injection site,
infection, demyelinating disease,
pancytopenia.
5. Slower Acting Antirheumatic Drugs
- Used in combination with NSAIDS
- Sulfasalazine (Azulfidine),
hydroxychloroquine (Plaquenil), gold
sodium thiomalate (Myochrysine),
penicillamine.
Nursing Interventions:
1. Provide room for social and emotional
development.
2. Instruct parents and child in medication
administration.
3. Assist in ROM exercises.
4. Encourage normal ADLs.
5. Use hot or cold packs, splinting, and
positioning the joint in a neutral
position during painful episodes.
6. Encourage physical and occupational
therapy.
7. Report visual disturbances.
IX. Ewing Sarcoma
- Cancer of the bone that stems from
primitive nerve cells.
- r/t chromosomal abnormalities.
Signs and symptoms:
- Swelling at the site
- Weight loss
- Awakening at night with pain at the site
of the tumor
- Limp, if legs are affected
- DOB, if ribs are affected
DX:
Serology: (+) for ewing sarcoma cells
Bone marrow biopsy
CT scan: tumor present
Treatment:
- Surgical removal of the tumor without
amputation
- chemotherapy
Nursing Interventions:
1. Enable child to make choices about
daily care (sense of control).
2. Teach parents about the disorder.
3. Encourage child to continue normal
ADLs.
X. Legg-Calve-Perthes Disease
- a necrosis of the femoral head caused
by a decreased in blood supply.
- occurs between 2-12 y.o.
- self-limiting.
Stages:
Avascular: blood supply to the femoral head is
interrupted within 1 year.
Revascularization: creeping substitution occurs
where the connective tissue and vascular tissue
enter the necrotic bone causing live
noncalcified bone to replace the necrotic tissue.
Healing: bone ossification over 3 years.
Signs and Symptoms:
 - painless limp
- pain in the knee during activity
- pain in the groin and anterior thigh.
Nursing Interventions:
1. Administer analgesics to reduce pain.
2. Physical therapy to regain ROM.
3. Teach patient how to use crutches.
4. Explain the nature of the disease.
XI. Talipes (Clubfoot)
- A congenital deformity that occurs in
utero due to adverse effects of
medications, infection, trauma, or
genetic trait resulting in contracture of
soft tissue and abnormal development
of a joint and muscle.
Assessment:
1. Talipes varus – inversion or bending
inward.
2. Talipes valgus – eversion or bending
outward.
3. Talipes equines – plantar flexion in
which the toes are lower than the heel.
4. Talipes calcaneus – dorsiflexion in
which the toes are higher than the heel.
Interventions:
1. Monitor for pain, and neurovascular
status of the toes.
2. Manipulation and casting are
performed weekly for 8-12 weeks
because of the rapid growth of early
infancy; a spint is applied if casting and
manipulation are successful.
3. Surgical intervention if normal
alignment is not achieved by 6-12
weeks of age.
XII. Marfan Syndrome
- Disorder of connective tissue that
affects the skeletal system,
cardiovascular system, eyes, and skin.
- Defect in fibrillin-1 gene, a building
block for elastic tissue in the body.
- Could be genetic
Assessment:
a. Tall and thin body structure: long arms
and legs, slender fingers, curvature of
the spine
b. Visual problems
c. Cardiac Problems
Nursing Interventions:
1. Have a regular visual examination
2. Assess the curvature of the spine
(especially during adolescence)
3. Cardiac medications to slow the heart
rate. And to decrease stress on the
aorta.
4. No contact sports to avoid heart injury,
5. Antibiotics should be taken before
dental procedures to prevent
endocarditis.
6. Surgical replacement of the aortic root
and valve may be necessary.
XIII. Paget’s Disease
XIV. Duchenne Muscular Dystrophy
- Most common muscular dystrophy of
children
- X-linked recessive (female carriers,
males are affected)
- Cause: lack of protein dystrophin
(responsible for muscle stabilization).
Disease onset: 2-5 y.o.
Progression:
 Pelvis and extremities are affected first.
 Calf muscles hypertrophy
(pseudohypertrophy) – initially in
response to proximal muscle weakness
and are later replaced by fat and
connective tissue.
 Gower’s sign: involves use of one’s
hand to rise from a squat or from a
chair to compensate for proximal
muscle weakness.
 NO CURE!!!
 Most children are wheelchair bound,
and die by age 20-30 y.o. from
respiratory failure.
Nursing intervention:
1. Provide safety (avoid clutter and
prevent falls).
2. Diet: increase OFI, fruits and
vegetables, and whole grains to prevent
constipation brought about by
immobility.
3. Gentle recreation exercises and
swimming.