NURSING CARE OF CLIENTS WITH

MUSCULOSKELETAL CONDITIONS

- Congenital & developmental disorders: congenital clubfoot,

scoliosis & developmental dysplasia of the hip

Dr Sally Lo
[email protected]
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Learning Outcome
1. Congenital clubfoot
2. Developmental dysplasia of the hip
3. Scoliosis

Students should be able to:

❑Understand the difference in pathophysiology and clinical manifestations;

❑Identify relevant assessment and diagnostic test;
❑Relate respective therapeutic management;
❑Discuss possible nursing management and parental education.
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Club Foot
• Complex deformity of the ankle and foot.
• Involves several bones in hind foot:
❑Tarsals
❑Talus
❑Calcaneus
❑Metatarsals
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Club Foot
• Named according to the anatomy and orientation of the deformity
• For example:
❑Talipes = talus (Latin = ankle bone)
❑Pes (Latin = foot)
❑Cavus/ Adductus/ Varus/ Equinus/ etc.

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Club Foot
• Talipes equinovarus (TEV) is the most common
• Incidence: 1-2/1000 live births, commonly in boys (2:1)

• Etiology is multifactorial:
❑Abnormal positioning and restricted movement in-utero
❑Arrested or abnormal embryonic development
❑Neurological disorders and neural tube defects
❑Environmental factor
❑Genetic factor
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Club Foot - Clinical manifestations

• At birth:
❑Deformity is obvious: calf muscles are
shortened and underdeveloped
❑Soft tissue contractures
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Club Foot – PE & Diagnostic tests

• Physical examination
• X-ray
• USG
• MRI

• Nursing assessment
❑Family history of foot deformities
❑Obstetric history for risk factors
❑Physical assessment for presence of other
❑abnormal and classic foot position and ROM
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Club Foot - Medical management

• Should be start as soon as possible
❑i.e., first week or two of life
❑Takes the advantage of the elasticity of the tissues that forms the
ligaments and tendons in the foot

• Involves 3 stages
1. Correction of deformity
2. Maintenance of the correction
3. Follow up

• Treatment options:
❑French management
❑Ponseti method
❑Surgical treatment
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Club Foot - Ponseti method

• Treatment includes manipulation and stretching of tissues by casting
or taping and splinting

1. Initial step is manipulation

❑Ligaments and tendons are stretched with manipulations
❑The displaced bones are brought into the correct Alignment

2. Serial casts are applied

❑Extends from the toes to the upper thigh
❑Retains the degree of correction and softens the ligaments
❑+/- Percutaneous Achilles tendon lengthening (Tenotomy) before
application of LAST plaster cast

3. Bracing
❑Ligaments and tendons are stretched with manipulations
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Club Foot - Ponseti method

• Series casts

[Bergerault, F., Fournier, J., & Bonnard, C., 2013]

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Club Foot - Ponseti method

• After cast removal, begins a bracing program to prevent relapse
❑A bar with open-toed shoes attached at 2 ends.
❑Full time for 2-3 months, and then at nighttime until aged 3-5 years.

Liu, Y. B., Li, S. J., Zhao, L., Yu, B., & Zhao, D. H. (2018). Timing for Ponseti clubfoot management: does the age
matter? 90 children (131 feet) with a mean follow-up of 5 years. Acta orthopaedica, 89(6), 662-667.
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Club Foot - Nursing management

• Observes the skin and circulation

• Parent education and support:

❑Explains the overall treatment program and the importance of
regular casting.
❑Reinforces and clarifies the orthopedist’s explanations and
instructions
❑Teaches care of the cast or appliance
• The top of the toes should be exposed.
• Assesses neurovascular status around 4 times a day.
• Keeps the cast clean and dry.
• Uses a blow dryer on the cool setting to provide relief of itching.
❑Teaches how to apply corrective shoes and splints
❑Encourages them to facilitate child’s normal development
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Developmental Dysplasia of the hip

(DDH)
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Anatomy of hip
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Developmental Dysplasia of the Hip (DDH)

• Affects the proximal femur and acetabulum

• 2 major groups:
❑Typical: occurs in neurotically intact patients or those without
defined syndromes or genetic conditions
❑Teratologic: involves a neuromuscular defect or have identifiable
causes

• Incidence: 1:1000 live births (girls > boys)

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DDH - Classifications
• Acetabular dysplasia:
❑Mildest form.
❑With subluxation or dislocation.
❑Abnormal morphology and development of the acetabulum.

• Hip subluxation:
❑Largest percentage.
❑Incomplete dislocation of the hip.

• Dislocation:
❑No contact between the articulating surfaces of the hip
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DDH - Classifications

(Perry, 2014)
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DDH - Risk factors

• Physiologic factors:
❑Female
❑Maternal hormone secretion
❑Intrauterine positioning

• Mechanical factors:
❑Breech presentation
❑Multiple fetuses
❑Any condition that leads to tightened intrauterine space

• Genetic factors:
❑Positive family history for DDH
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DDH - Etiology
• Exact etiology is unknown
• Commonly due to increased laxity of the hip capsule due to a
combination of factors, including:

1. Genetic factors
• 2 heritable features: generalized joint laxity, and shallow
acetabular
2. Hormonal factors
• High levels of maternal estrogen, progesterone, and relaxin may
lead to ligamentous laxity
3. Intrauterine malposition
• Breech presentation with extended legs
• Vertex presentation Intrauterine crowding
4. Postnatal factors
• Swaddles babies
• Carries babies with legs together, hips and knees fully extended
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DDH - Clinical manifestations

Best diagnosed in the first few days of life!!

Neonates:
• Asymptomatic

• Physical findings:
❑Barlow test A. Barlow Test
❑Ortolani test

B. Ortolani Test

Kumari, P., & Rani, M. Developmental Dysplasia of the Hip. Orthopedics and Rheumatology Open Access
Journal (OROAJ), 10(4), 555794. DOI: 10.19080/OROAJ.2018.10.555794
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DDH - Clinical manifestations

Infants
• Physical findings:
• Limited hip abduction
• Apparent shortening of the thigh
• Galeazzi sign:
• Places both hips in 90∘ of
flexion and comparing the
height of the knees

Walking child:
• Physical findings:
• Limp, waddling gait
• Leg-length discrepancy
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DDH - Diagnostic tests

• Physical examination
❑Preferable for newborn

• USG
❑Provides information about the stability of the hip joint Uses to
monitor acetabular development

• X-ray
❑Recommended for infant

• CT scan
❑Assesses the position of the femoral head relative to acetabulum

• MRI
❑Shows soft tissue related to the hip
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DDH - Medical management

• Goal
❑Maintains a concentric reduction of the femoral head within the
acetabulum
❑Aims at early treatment: later the diagnosis, less favorable the
prognosis

Newborns [< 6 months]:

• Commonly treats with a Pavlik harness→ splint the proximal femur
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DDH - Medical management

Newborns [< 6 months]:
• Commonly treats with a Pavlik harness → splint the proximal femur
❑Holds the hip flexed and prevents complete adduction of hip
❑Wears on a full-time basis for 6 weeks
❑After 6 month of age, failure rate > 50% because difficult to
maintain the increasingly active and crawling child
❑If follow up examinations and USG show no concentric reduction of
hip → abandoned the treatment
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DDH - Medical management

6 months - 18 months:
• Goal: obtain and maintain reduction of the hip without damaging the
femoral head
• Traction may be used for 3 weeks preoperatively
• Closed reduction, then monitored and maintained by Spica Cast
❑Failure → open reduction

> 18 months:
• Treats by open reduction
❑Pelvic osteotomy
❑Femoral shortening osteotomy Varus osteotomy
• Child is immobilized in a spica cast for 6-12 weeks after surgery
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DDH – Possible Complications

• Failed reduction
• Avascular necrosis of the femoral epiphysis
• Re-dislocation
• Residual subluxation
• Other postoperative complications
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DDH - Nursing management

• Assessment
❑Any deviation from normal

• Cast Care
❑Teaches correct use of the appliance
• e.g., whether remove during bathing, not to adjust the harness
without medical supervision
❑Encourages parents to hold the infant with harness and continue
care and nurturing activities

• Pavlik harness care

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DDH - Nursing management

• Pavlik harness care:
❑ Avoids anything that hold the legs together,
❑ Puts an undershirt under the chest straps, and put knee socks under the
foot and leg pieces
❑ Checks frequently for red areas under the straps and the clothing
❑ Avoids lotions and powders
❑ Always place the diaper under the straps
❑ Check the marking for correct positions.
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Scoliosis
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Scoliosis
• Most common spinal deformity
• Involves lateral curvature, spinal rotation and thoracic hypokyphosis

• Complications:
❑> 80∘: restrictive pulmonary disease
❑>100-120∘: reduced life expectancy

• Types:
❑Idiopathic (most common)
❑Congenital
❑Neuromuscular
❑Genetic syndromes
❑Compensatory
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Scoliosis - Idiopathic scoliosis

• Etiology is unknown, maybe multifactorial
• Risk Factors for Disease Progression
❑Sex;
❑Magnitude of curve on presentation;
❑Growth potential

• Classified according to age of onset:

1. Infantile
2. Childhood/juvenile
3. Adolescent

Others: early onset (0-5 years) and late onset (after age of 5 years)
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Scoliosis - Clinical manifestations

• Asymmetry of shoulder and hip
height, scapular or flank shape:
❑Elevation of the shoulder
❑Lateral shift of the trunk
❑Leg-length discrepancy
❑Asymmetry of waistline
❑Asymmetry of elbow-to-flank
distance

• Adams test:
• Asymmetry of the ribs and
flank (Smith, Sciubba, & Samdani, 2008)

• Vertebral rotation and posterior

displacement of the ribs
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Scoliosis - Diagnostic tests

• Physical examination:
❑Scoliometer : measure truncal rotation
❑Tanner maturity rating:
• An objective classification system to
assess sexual maturity ratings

• Neurologic assessment:
❑Pain
❑Sacral dimple or hairy patches
❑Cutaneous vascular change
❑Absent or abnormal reflexes
❑Bowel or bladder incontinence
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Scoliosis - Diagnostic tests

• X-ray:
❑Cobb technique:
determines the degree of
curvature
❑Risser scale: evaluates
skeletal maturity on x-rays

• MRI:
❑Uses when an underlying
cause is suspected or in
abnormal findings
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Scoliosis - Medical management

• Bases on magnitude, location and type of curve, age, skeletal
maturity, and underlying disease
• Most curves do not require surgery or bracing

• Treatment options:
❑Observation
❑Bracing
❑Surgical intervention
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Scoliosis - Medical management

1. Observation
• Regular clinical and radiographic
evaluation

2. Bracing:
• For mild to moderate curvatures (30∘ -
45∘)
• Goal: to prevent progression of deformity
thus ↓ need for surgery
• Not curative and works together with
exercises
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Scoliosis - Medical management

3. Surgical intervention
• Indications:
o For severe curves (45∘≤ in skeletally immature and 50∘ to 55∘
≤ in skeletally mature)
o Those not response to conservative treatment

• Goal:
o Correct the curvatures on sagittal and coronal planes
o With maximum mobility of the remaining spinal segments

A. Halo-gravity traction
B. Spinal Surgery
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Scoliosis - Surgical interventions

A. Halo-gravity traction:
❑In severe scoliosis (>80∘)

B. Spinal Surgery
❑Goal: Halts progression and Improves cosmesis.

• Technique:
1. Instrumentation: Applying mechanical implants
2. Fusion: Joining 2 vertebrae by bone graft

• Options:
❑Instrumentation without spinal fusion or with limited fusion
❑Posterior instrumentation with both anterior and posterior fusion
❑Anterior fusion with instrumentation
❑Posterior fusion with instrumentation *most common
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Scoliosis - Surgical interventions

• Example: Posterior spinal fusion
❑Includes 2 rods anchored to the spine by hooks, wires +/- screws
❑The screw-rod constructs: helps correcting scoliosis and restoring
lordotic balance
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Scoliosis - Nursing management

• Explains the therapy program and the nature of the device:
❑e.g. anticipated results, how the appliance corrects the defect,
constraints and freedom imposed by device

• Preoperative teaching:
❑How to manage PCA, log-roll

• Postoperative care:
❑Wound assessment, circulation, vital signs, neurologic status of
extremities
❑Pain management
❑Skin integrity
❑Family involvement in patient care
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Summary
• Congenital clubfoot (TEV) is the commonest congenital anomaly with
an incidence of one to two per 1000 live births.
❑Ponseti method

• Developmental dysplasia of the hip (DDH) is a condition where the

hip joint has not formed normally and may be easy to dislocate.
❑Pavlik harness

• Congenital scoliosis refers to spinal deformity caused by abnormally

formed vertebrae.
❑Bracing, Spinal Fusion Surgery
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References
• Bergerault, F., Fournier, J., & Bonnard, C. (2013). Idiopathic congenital clubfoot: Initial treatment.
Orthopaedics & Traumatology: Surgery & Research, 99(1), S150-S159.
• Horne, J. P., Flannery, R., & Usman, S. (2014). Adolescent idiopathic scoliosis: diagnosis and
management. American family physician, 89(3), 193-198.
• Hinkle, J., & Cheever, K. (2018). Brunner & Suddarth's Textbook of Medical-surgical Nursing.
• Frymoyer, J. W., Wiesel, S. W., An, H. S., Boden, S. D., Lauerman, W. C., Lenke, L. G., McLain, R. F.
(2004). The Adult & Pediatric Spine (3rd ed.). Philadelphia : Lippincott Williams & Wilkins
• Gould, B.E. & Dyer, R. M. (2011). Pathophysiology for the health professionals. (4th ed.). St. Louis:
Saunders.
• LeMone, P., & Burke, K. (2019). LeMone and Burke’s medical-surgical nursing: Critical thinking for person-
centered care (4th ed.). Pearson Education Austral.
• Lewis, S. L., Dirksen, S.R., Heitkemper, M.M., Bucher, L. & Camera, I.M. (2011). Medical -surgical nursing:
assessment and management of clinical problems (8th ed.). St. Louis: Mosby Elsevier.
• Lewis, S. L., Dirken, S.P., Heitkemper, M.M., Bucher, L & Camera, I.M (2011).Study Guide for Medical-
Surgical nursing: Assessment and Management of Clinical Problems (8th ed.). .St. Louis, : Mosby Elsevier.
• Nettina, S. (2019). Lippincott Manual of Nursing Practice (11th ed.). . Philadelphia : Wolters Kluwer
• Perry, Hockenberry, Lowdermilk, Wilson, Wong, Hockenberry, Marilyn J., . . . Wong, Donna L. (2014).
Maternal child nursing care (Fifth ed.). St. Louis, Missouri: Elsevier.
• Robinson, M. J., & Roberton, D. M. (2003). Practical paediatrics. (5th ed.). New York: Churchill Livingstone.
• Sabella, C., & Cunningham III, R. J. (2010). The Cleveland Clinic intensive review of pediatrics (3rd ed.).
Philadelphia, PA : Wolters Kluwer Health/Lippincott William & Wilkins.
• Smith, J. R., Sciubba, D. M., & Samdani, A. F. (2008). Scoliosis: A straightforward approach to diagnosis
and management. Journal of the American Academy of Physician Assistants, 21(11), 40-45
• Staheli, L. (2016). Fundamentals of pediatric orthopedics (Fifth edtion ed.). Philadelphia: Wolters Kluwer.
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END