Several acquired musculoskeletal disorders may affect children. Nutritional deicits or malabsorption of fats may lead to rickets. Slipped capital femoral epiphysis and Legg-Calvé-Perthes disease affect mainly school-age and adolescent boys. Osteomyelitis, septic arthritis, and toxic synovitis are common infectious musculoskeletal disorders. Spinal curvature may occur as a result of a neuromuscular disorder or idiopathically.
Rickets
Rickets is a condition in which there is softening or weakening of the bones. Childhood rickets may occur as a result of nutritional deiciencies such as inade- quate consumption of calcium or vitamin D or limited exposure to sunlight (required for adequate produc- tion of vitamin D). Rickets caused by vitamin D dei- ciency is a preventable condition but cases continue to be reported in infants, children, and adolescents (Wagner, Greer, & the Section on Breastfeeding and Committee on Nutrition, 2008). Rickets may also occur
FIGURE 45.18 Note wryneck or head tilt in the infant with torticollis.
conirm the diagnosis (anteroposterior and lateral frog-leg views of hips). Bone scan can rule out avascular necrosis, and CT scan helps deine the extent of slippage.
Take Note!
Do not atempt to perform passive range of motion to determine the extent of limitation in the child with SCFE; this may cause worsening of the condition.
Nursing Management
Enforce bed rest and activity restriction. If traction is used for a period before surgery, perform routine trac- tion care and neurovascular assessments. If surgery is performed, provide routine preoperative and postop- erative care. Assess pain and administer analgesics as needed. After in situ pinning, assist the child with crutch walking. Teach the family that weight bearing is usually resumed about a week after the surgery and that the pin will be removed later. Prolonged immobility may isolate the adolescent from usual peer interactions, so encour- age phone calls and visits with friends. Provide books, games, electronic devices, and magazines for distraction during the period of immobility. Provide education and support to the child and family.
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes disease is a self-limiting condition that involves avascular necrosis of the femoral head. It most often affects children between 4 and 8 years of age, but it can occur as early as 18 months and up until skeletal maturity (Hoffmeister, 2008). The disease affects males more often (Grewal & Ahier, 2010). The etiology is unknown, but interruption of the blood supply to the femoral head results in bone death, and the spherical shape of the femoral head may be lost. Swelling of the soft tissues around the hip may occur. As new blood ves- sels develop, the area is supplied with circulation, allow- ing bone resorption and deposition to take place. During this period of revascularization, which takes 18 to 24 months, the bone is soft and more likely to fracture. Over time, the femoral head reforms.
Therapeutic Management
The goal of therapeutic management is to maintain normal femoral head shape and to restore appropriate motion. Treatment of Legg-Calvé-Perthes disease includes anti-inlammatory medication to decrease muscle spasms around the hip joint and to relieve pain. Activity limita- tion may be prescribed, and sometimes bracing, cast- ing, or traction is recommended to contain the femoral head. Serial x-ray follow-up determines progress of the
Nursing Management
Administer calcium and phosphorus supplements at alternate times to promote proper absorption of both of these supplements. Encourage exposure to moderate amounts of sunlight and administer vitamin D supple- ments as prescribed. Teach families that good dietary sources of vitamin D are ish, liver, and processed milk.
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis (SCFE) is a condition in which the femoral head dislocates from the neck and shaft of the femur at the level of the epiphyseal plate. The epiph- ysis slips downward and backward. SCFE occurs most fre- quently in obese males, 11 to 16 years of age, and is more common in African American boys compared to Caucasians (Sankar, Horn, Wells, & Dormans, 2011). The left hip is more often affected (Sankar, Horn, Wells, & Dormans, 2011). The exact cause is unknown, but it is thought that during the teenage growth spurt the femoral growth plate weakens and becomes less resistant to stressors. Hormonal alterations during this period may also play a role.
SCFE is classiied based on its severity and whether the slip is acute or chronic. Chronic SCFE may lead to shortening of the affected leg and thigh atrophy.
Therapeutic Management
Promptly refer the child with SCFE to an orthopedic sur- geon, as early surgical intervention will decrease the risk of long-term deformity. The goals of therapeutic man- agement are to prevent further slippage, minimize defor- mity, and avoid the complications of cartilage necrosis (chondrolysis) and avascular necrosis of the femoral head. Surgical intervention may include in situ pinning, in which a pin or screw is inserted percutaneously into the femoral head to hold it in place. Osteotomy may be used for more severe cases. Osteoarthritis may be a long- term complication of SCFE.
Nursing Assessment
Elicit a health history, determining the onset and extent of pain. In acute SCFE, the pain is usually sudden in onset and results in inability to bear weight. Chronic SCFE may present with an insidious onset of pain and limp. Note risk factors for SCFE, including age 9 to 16 years, African American race, sedentary lifestyle, rapid growth spurt, and being overweight or obese (Grewal & Ahier, 2010;
Sankar, Horn, Wells, & Dormans, 2011). Observe ambula- tion, noting Trendelenburg gait. Assess for pain that is in the hip or that is referred to the groin, medial thigh, or knee. Note decreased range of motion in the affected hip with external rotation. Radiographs will be obtained to
Osteomyelitis is acquired hematogenously. Bacteria from the bloodstream mainly invade the most rapidly growing portion of the bone. The invading bacteria trigger an inlammatory response, formation of pus and edema, and vascular congestion. Small blood vessels thrombose and the infection extends into the metaphyseal mar- row cavity. As the infection progresses the inlammation extends throughout the bone and blood supply is dis- rupted, resulting in death of the bone tissues (Fig. 45.19).
Therapeutic Management
Aspiration is necessary to conirm diagnosis and iden- tify speciic microorganisms. Treatment includes a 4- to 6-week course of antibiotics. Some children may receive 1 to 2 weeks of intravenous antibiotics and then be switched to oral antibiotics for the remainder of the course. Surgical débridement is rarely necessary.
Early treatment may prevent the complications of bone destruction, fracture, and growth arrest. Additional com- plications include recurrent infection, septic arthritis, and systemic infection.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1630. Assessment indings pertinent to osteomyelitis are discussed here.
Explore the health history for risk factors and symp- toms. Risk factors include impetigo, infected varicella lesions, furunculosis, recent trauma, infected burns, and disease. If surgery becomes warranted, which is rarely
done, then osteotomy may be performed. Complications include joint deformity, early degenerative joint disease, persistent pain, loss of hip motion or function, and gait disturbance.
Nursing Assessment
Explore the health history for short stature, delayed bone maturation, related trauma, or a family history of Legg- Calvé-Perthes disease. Note painless limp, which may be intermittent over a period of months. Mild hip pain may result and may be referred to the knee or the thigh. Pain may be aggravated by exercise. Observe the child walk- ing and note Trendelenburg gait. Perform range of motion, noting internal rotation of the hip and limited abduction.
Muscle spasm may result with hip extension and rotation.
Hip radiographs are obtained to evaluate the extent of epiphyseal involvement. MRI or bone scan may also be used to differentiate Legg-Calvé-Perthes disease from other disorders. Ultrasound and arthrograms may also be useful.
Nursing Management
Nursing care of Legg-Calvé-Perthes disease is highly vari- able and depends on the stage of the disease and its severity. Administer anti-inlammatory medications, noting their effect on pain. If activities are restricted, exercise the unaffected body parts. Assist families with use of the brace if prescribed. The brace may be wiped with a damp cloth if it becomes dirty. Some children will be prescribed no treatment other than avoidance of contact or high-impact sports. Swimming and bicycle riding help to maintain range of motion with little risk. If mobility equipment is needed, educate the child and family on its use. If oste- otomy is performed, provide routine postoperative care, including education and support of the child and family.
Osteomyelitis
Osteomyelitis is a bacterial infection of the bone and soft tissue surrounding the bone. The long bone metaphysis is the most common location (Grewal & Ahier, 2010).
Staphylococcus aureus is the most common infecting organism with methicillin-resistant S. aureus (MRSA) infections on the rise (Grewal & Ahier, 2010; Polousky &
Eilert, 2009). Additional causes in infants include group B streptococcus and Escherichia coli; in children, Strep- tococcus pyogenes and Haemophilus influenza (which is now rare due to improvements in immunizations) are also implicated. Children usually present for evalua- tion within a few days to a week of onset of symptoms, though some may present later.
FIGURE 45.19 In osteomyelitis, bacterial invasion leads to infection within the bone.
pressure on blood vessels and cartilage within the joint space. Septic arthritis is considered a medical emergency, as destruction of the joint cartilage may occur within just a few days. Additional complications of septic arthritis include permanent deformity, leg-length discrepancy, and long-term decreased range of motion and disability.
The goals of treatment of septic arthritis are to prevent destruction of the joint cartilage and maintain function, motion, and strength. Septic arthritis is treated rapidly with joint aspiration or arthrotomy, followed by intravenous antibiotic therapy while in the hospital and oral antibiotics at home.
Nursing Assessment
Note history of predisposing factors such as respiratory infection or otitis media, skin or soft tissue infections, or, in the neonate, traumatic puncture wounds and femoral venipunctures. The history is usually signiicant for sud- den onset of fever and moderate to severe pain.
Upon physical examination, the infant or child appears ill. Note extent of fever, reports of pain, refusal to bear weight or straighten the joint, and limited range of motion (the child usually maintains the joint in lexion and will not allow the leg to be straightened). The child will generally hold the joint in a position of comfort and the child or infant will appear without pain as long as the joint is immobile. Any attempt at passive range of motion will reveal pain. Palpate the affected joint for warmth and swelling.
Laboratory indings may include:
• White blood cell count normal or elevated with el- evated neutrophil counts
• Elevated erythrocyte sedimentation rate and C-reactive protein levels
• Fluid from joint aspiration demonstrates elevated white blood cell count; culture determines responsible organism.
• Joint radiograph may show subtle soft tissue changes or increase in the joint space.
• Positive blood culture for the causative organism (15%
of cases)
Nursing Management
Refer to Nursing Care Plan 45.1 for interventions related to musculoskeletal disorders. Assess aspiration wound for signs of infection. Monitor vital signs for resolution of fever. Pain management with ibuprofen or acetamino- phen will be suficient for some children; others may initially require codeine or morphine. Assess the affected joint for a decrease in swelling, increasing range of motion, and decreasing or absent pain. The child may be discharged after 72 hours of intravenous antibiotics fol- lowing joint aspiration if he or she is improving and can tolerate oral antibiotics. At discharge, if the child cannot prolonged intravenous line use. Obtain history of current
or recent antibiotic therapy and response. Note history of irritability, lethargy, possible fever, and onset of pain or change in activity level. The child usually refuses to walk and demonstrates decreased range of motion in the affected extremity. Inspect the affected extremity for swelling. Palpate for local warmth and tenderness. Note point tenderness over affected bone.
Laboratory and diagnostic testing may reveal:
• Elevated white blood cell count, erythrocyte sedimen- tation rate, and C-reactive protein level
• Positive blood cultures
• Deep soft tissue swelling on radiography
• Changes on ultrasound or CT scan
Nursing Management
Nursing management of the child with osteomyelitis focuses on assessment, pain management, and mainte- nance of intravenous access for administration of anti- biotics. Individualize care based on the child’s and fam- ily’s response to the illness; see Nursing Care Plan 45.1.
Maintain bed rest initially to prevent injury and promote comfort. Administer antipyretics as ordered if the child is febrile in the initial stage of the illness. Encourage the use of unaffected extremities by providing developmen- tally appropriate toys and games. Instruct the child and family on safe and proper use of crutches or walker if prescribed. Some children will be discharged home on intravenous antibiotics, while others will inish an oral antibiotic course. Teach parents proper administration of medications and maintenance of a peripherally inserted central catheter or central line at home if the child is in- ishing the antibiotic course intravenously.
Septic Arthritis
Acute septic arthritis is a condition in which bacteria invade the joint space, most often the hip or knee. It can occur at any age but usually occurs in children younger than 3 years old (Dugdale, Vyas, & Zieve, 2009). Usually bacteria gain access to the joint through the bloodstream but can be due to direct puncture from injections, veni- puncture, wound infection, surgery, or injury.
S. aureus is the most common causative organism with community-acquired MRSA on the rise (Schwentker, 2009). Various streptococci species, Pseudomonas aeru- ginosa, pneumococci, Neisseria meningitidis (with or without an associated meningitis), Escherichia coli, Kleb- siella species, and Enterobacter species are also respon- sible organisms. Haemophilus influenza used to be a common cause, but is now rare due to improvements in immunizations (Schwentker, 2009). Sepsis of the hip joint may cause avascular necrosis of the femoral head due to
Nursing Management
Nursing care focuses on educating the family including instructions on administering nonsteroidal anti-inlam- matory medications, analgesics, and bed rest. Parents are very concerned when their child refuses to walk; there- fore, provide signiicant support and reassure the child and family of the self-limiting nature of the disease.
Scoliosis
Scoliosis is a lateral curvature of the spine that exceeds 10 degrees. It may be congenital, associated with other disorders, or idiopathic. Table 45.3 explains the types of scoliosis. Idiopathic scoliosis, with the majority of cases occurring during adolescence, is the most common sco- liosis (Spiegel & Dormans, 2011). Hence, this discussion will focus on adolescent idiopathic scoliosis. The etiol- ogy of idiopathic scoliosis is not known, but genetic fac- tors, growth abnormalities, and bone, muscle, disc, or central nervous system disorders may contribute to its development. Early screening and detection of scoliosis result in improved outcomes.
Pathophysiology
In the rapidly growing adolescent, the involved verte- brae rotate around a vertical axis, resulting in lateral cur- vature. The vertebrae rotate to the convex side of the curve, with the spinous processes rotating toward the concave side. Wedge-shaped vertebral bodies and discs develop because growth is suppressed on the concave side of the curve (Grewal & Ahier, 2010). As the curve progresses, the shape of the thoracic cage changes and respiratory and cardiovascular compromise may occur (the main complications of severe scoliosis).
Therapeutic Management
Treatment of scoliosis is aimed at preventing progression of the curve and decreasing the impact on pulmonary ambulate, physical therapy may be consulted for short-
term use of crutches or a wheelchair. Teach families how to assess for signs and symptoms of wound infection, how to administer oral antibiotics and pain medication, and how to assist their child with crutch walking.
Transient Synovitis of the Hip
Transient synovitis of the hip (also termed toxic synovitis) is the most common cause of hip pain and limping in children in the United States (Polousky & Eilert, 2009). It occurs in children as young as 9 months of age through adolescence, most commonly affecting children between 3 and 8 years old (Sankar, Horn, Wells, & Dormans, 2011).
Boys are affected twice as often as girls (Polousky & Eilert, 2009). The exact cause is unclear, but it is thought to be associated with recent or active infection, trauma, or aller- gic hypersensitivity (Sankar, Horn, Wells, & Dormans, 2011;
Whitelaw & Schikler, 2012). It is a self-limiting disease and most cases resolve within a week, but it may last as long as 4 weeks. Usually septic arthritis and osteomyelitis must be excluded before diagnosis can be conirmed.
Therapeutic management involves nonsteroidal anti-inlammatory medications, analgesics, and bed rest to relieve weight bearing on the affected hip joint.
Nursing Assessment
Explore the health history for risk factors such as ante- cedent trauma, concurrent or recent upper respiratory tract infection, pharyngitis, or otitis media. Note sudden acute onset of moderate to severe pain of one hip. Some- times pain is referred to the anterior thigh or knee. Pain is usually the worst upon arising in the morning, and the child refuses to walk; pain then decreases throughout the day. Temperature will be normal or low grade (less than 38°C). Observe for a limp or for refusal to bear weight.
Observe position of the affected hip: it will be held in a lexed and externally rotated position. Note restricted range of motion for abduction and internal rotation.
TABLE 45.3 TYPES OF SCOLIOSIS
Type Associated Factors
Idiopathic Unknown cause
Infantile: occurs in the irst 3 years of life
Juvenile: diagnosed between age 4 and 10 years, or prior to adolescence Adolescent: age 11 to 17 years
Neuromuscular Associated with neurologic or muscular disease such as cerebral palsy, myelomeningocele, spinal cord tumors, spinal muscular atrophy, muscular dystrophies
Congenital Results from anomalous vertebral development
may be anterior, posterior, or both. Traditional rod place- ment (Harrington rod) involved a single rod fused to the vertebrae, resulting in curve correction but also a lat- backed appearance. Newer rod instrumentations allow for scoliosis curve correction with maintenance of nor- mal back curvature. The rods are shorter, and several are wired or grafted to the appropriate vertebrae to achieve correction. Figure 45.21 shows one example of surgical rod instrumentation.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1630. Assessment indings pertinent to scoliosis are discussed below.
Health History
Determine why the child is presenting for evaluation of scoliosis. Commonly the child or adolescent will not report back pain; only mild discomfort is associ- ated with idiopathic scoliosis until the curve becomes severe. Often the family recognizes asymmetry in the hips or shoulders or the child is screened for scoliosis at school and determined to be at risk. Explore the child’s current and past medical history for risk factors such as:
• Family history of scoliosis
• Recent growth spurt
• Physical changes related to puberty
Determine the age of development of secondary sex characteristics and the age of menarche, as these signs of pubertal development indicate the expected velocity and length of remaining growth.
and cardiac function. Treatment is based on the age of the child, expected future growth, and severity of the curve. Observation with serial examinations and spine radiographs is used to monitor curve progression. For curves of 25 to 40 degrees, bracing may be suficient to decrease progression of the curve (Grewal & Ahier, 2010). Box 45.1 describes types of scoliosis braces and Figure 45.20 shows examples of braces. The choice of brace will depend on the location and severity of the curve. Some curves will progress despite appropriate bracing and compliance.
Surgical correction is often required for curves greater than 45 degrees; it is achieved with rod placement and bone grafting (Grewal & Ahier, 2010; Whitelaw &
Schikler, 2012). Partial spinal fusion accompanies many of the corrective surgeries. Multiple surgical approaches and techniques with various instrumentation methods exist for fusion and rod placement. The surgical approach
BOX 45.1
TYPES OF BRACES USED TO TREAT SCOLIOSIS
• Underarm (thoracolumbosacral orthosis [TLSO], Boston, Wilmington): for low thoracic and thoracolumbar curves; less conspicuous, no visible neckpiece
• Milwaukee: for thoracic or major double curves;
traditional, standard, has a visible neckpiece with chin rest
• Nighttime bending (Charleston): creates a curve so severe that walking is not possible, so can be worn only at night
A B C
FIGURE 45.20 (A) Boston brace. (B) Milwaukee brace. (C) Nighttime bending brace.