Pediatric musculoskeletal nurs 3340 fall 2014

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  • Bones, joints, muscles, and cartilage tissues make up the musculoskeletal system.
  • Bones, joints, muscles, and cartilage-type tissues make up the musculoskeletal system.
    The skeleton is the framework of bones which gives shape and support to the body. It also protects the internal organs like the heart and lungs.
    There are 206 separate bones in the human body.
    Bones are classified by shape and location:
    Long bones, such as the arm and leg bones (humerus, femur).
    Short bones, such as wrist and ankle bones (carpals, tarsals).
    Flat bones (ribs).
    Irregular bones (vertebrae).
    Sesamoid bones (kneecap).
  • Each long bone is composed a a shaft (diaphysis) with an epiphysis on each end.
    The epiphysis is covered with cartilage, which is smooth and slippery, and helps bones move against each other within joints. The muscles attach here and are responsible for joint stability.
    Growth in the length of the long bones occurs at the epiphyses on both ends of the bones. The epiphysis contains the epiphyseal plate, which is responsible for growth until adult height is reached. It is separated from the main portion of the bone by cartilage. New bony tissue is produced from the cartilage during periods of growth. Long bone growth continues until approximately age 20, when skeletal maturation is complete.
    The epiphyseal plate is a highly vascular area of active cell division—these cells are highly sensitive to the influence of human growth hormone, estrogen, and testosterone. The rate of growth varies at different ages according to the influence of these hormones.
    The diaphysis has a hollow core called the medullary cavity which is filled with marrow. Blood cell production (hematopoiesis) takes place in the marrow.
    The periosteum, a double-layered membrane rich in nerve fiber, lymphatic vessels, and blood vessels, covers the bone (on the outside of the bone). This layer contains cells which make new bone to replace the older bone cells, and also provides nourishment for the bone.
    In newborns and young children, the periosteum is very rich, which allows healing to the bone to take place quickly.
  • Bone is a metabolically active tissue that is constantly being renewed or remodeled: "old" bone is resorbed and replaced by "new" bone. Strong, healthy bone is continually maintained through bone remodeling.
    Bone remodeling has two phases: resorption and formation.
    The body has two different cells which constantly work on the bones: the osteoclasts tear down bones and the osteoblasts build up bones. Optimum bone density is a dynamic balance between the bone removal and bone replacement.
    Osteoclasts – responsible for removing old or damaged bone. Osteoclasts replace old bone by releasing acids and enzymes to remove minerals and collagen. They dissolve old bone, releasing calcium into the blood stream.
    Osteoblasts – protein-secreting cells that build bones; remove calcium from the blood stream. Osteoblasts deposit new bone tissue. When osteoblasts make new bone tissue, they first lay down a framework of collagen. Then, tiny crystals of calcium from your blood spread throughout the collagen framework. The hard crystals fill in all the nooks and crannies. Calcium and collagen work together to make bones strong and flexible.
  • Cartilage—cushions
    Cartilage is a soft cushioning substance which covers the ends of the bones (articular surfaces). It acts as a shock absorber and keeps the bones from rubbing against one another. It is made of dense connective tissue that develops at the epiphysis and is capable of withstanding a lot of tension. Cartilage is smooth, slippery and flexible, which helps the joint move more freely and smoothly.
    Ligaments—bind bone to bone
    Ligaments are strong bands of fibrous tissue that join one bone to another across a joint. They connect bone to bone. Ligaments function as the primary stabilizers of the joints in the body. Without them, the joints would become dislocated very easily. Ligaments also function to limit the range of motion that the bones can move between each other. They're elastic to allow the movement of that joint, but are strong enough to stop movement outside the normal range.
    Tendons—attach muscles to bone
    Tendons are strong strips which attach the muscles to bones. Tendons connect muscles to bones in order to provide motion. Once attached, skeletal muscle moves the bones around the joint by contracting and relaxing. When a muscle contracts to move a joint, it is the tendon which pulls on the bone.
  • Tendons – muscles to bone
    Ligaments – bone to bone
    Cartilage – cushions
  • Joints—intersection of bones
    Joints are the places where two bones meet. These allow the skeleton to move. Joints are composed of ligaments and cartilage.
    There are three types of joints: freely movable, slightly movable, and immovable. For example, the bones of the skull are held together by joints which cannot move.
    Most joints are freely movable, and are called synovial joints. A typical synovial joint has a joint capsule that surrounds the joint, supporting and stabilizing it.
  • There are three types of muscle: smooth muscle (found primarily in the internal organs), cardiac (heart), and skeletal (striated) muscle.
    Muscle produces movement by contraction.
    Skeletal muscle is attached to bone.
    Skeletal muscle cells are arranged in long bands or strips, called striations. These have a striped appearance under the microscope.
    Skeletal muscle is voluntary, meaning it can be contracted at will. Skeletal muscles are responsible for body movement.
  • Function (Physiology) of the Musculoskeletal System:
    Protection (of vital organs)
    Support weight
    Control motion
    Store minerals
    Supply red blood cells
    Bones provide a rigid framework for the body, muscles provide for active movement, and tendons and ligaments hold the bones and muscles together.
  • In the fetus, bony tissue begins to develop as closely-packed connective tissue.
    The infant’s bones are only 65% ossified at 8 months of age and are neither as firm nor as brittle as those of the older child; soft.
    Fractures in children less than 1 year of age are unusual because a large amount of force is necessary; abuse or underlying pathophysiology is often the cause of fractures in infants.
  • Child’s bones more plastic than an adult’s—more force is required to fracture a bone. The long bones are porous and less dense than those of adults. For this reason, children’s bones tend to bend or buckle, rather than break.
    Child’s bones generally heal much faster than an adult’s.
    Soft tissues are found under the skin. Soft tissues are more resilient, or flexible, in children. Until the child reaches puberty, ligaments and tendons are stronger than bones.
    Dislocations or sprains are less common than in adults. A sprain is a tearing of ligaments (join bone to bone), usually when a joint is twisted or traumatized.
  • In initial assessment of a child’s musculoskeletal system, the nurse should obtain a complete health history of problems pertaining to this system, focusing on:
    Family history (some MSK diseases run in families)
    Nutrition (some MSK diseases are associated with nutrition, such as rickets)
    Any trauma?
    Delayed walking or other developmental abnormalities
    Pain (PQRST**; If the pain is sharp with movement and decreases with rest—it is usually an injury; if the pain it wakes the child up at night crying and the pain does not stop with decreased movement—then it is probably a disease)
    Structural abnormalities (clubfoot, hip dysplasia, scoliosis)
    Any physical limitations or lifestyle alterations imposed by the problem
    Mobility aids used
    Physical assessment of the musculoskeletal system should include examination for:
    Structural abnormalities, including leg length discrepancy and spinal deformities
    Posture and gait
    Range of motion in all joints
    Muscle symmetry, mass, tone, strength
    Color, temperature, sensation, motion, pain, pulses, capillary filling, and edema in each extremity
    **P-provoking, precipitating, Q-quality (sharp, dull, burning, boring), R-region or radiation, S-severity, T-time
  • Diagnostic Tests:
    X-ray (Radiography)—number one diagnostic test of MSK disorders. Not very expensive. For abnormalities or to determine bone age. Make sure there are no buttons or jewelry.
    CT (computed tomography)—a three-dimensional cross section of body parts is shown. Narrow-beam x-rays are used to scan an area in successive layers. A computer processes the readings and converts them to a picture shown on the screen, which is stored on disks.
    MRI (magnetic resonance imaging)—huge magnet and radio waves create an energy field that can be translated into a visual image. Study is not done in patients with metal implants, pacemakers, or prosthesis.
    Bone scan (radionuclide scintigraphy)—Radioactive material given IV. In 2-4 hours, the entire body is scanned, front, and back. Young children need sedation. Encourage fluids 2-4 hours before the test to ensure the child is well-hydrated and to quickly eliminate radioactive material not absorbed by the bones.
    Arthrography—recording of a joint. Dye is injected is injected into the joint (usually the knee, sometimes the shoulder or other joint). Performed under local anesthesia. Check for allergies to iodine. Joint should rest for about 12 hours.
    Arthroscopy—invasive procedure. Fiberoptic endoscope is inserted into the joint, to examine interior of the joint. Normally, arthrography is performed before arthroscopy. Requires local or general anesthesia; prophylactic antibiotics may be ordered. Use ice bags postoperatively to reduce swelling. With both arthrography and arthroscopy, you worry about infection.
    Creatine kinase (CK) assay—specific test for cardiac and muscle damage. Levels are elevated in trauma, myocardial infarction, muscular damage such as muscular dystrophy.
    Rheumatoid factor (RA) assay—RA is a macroglobulin antibody that may be responsible for the destructive changes associated with RA. A positive assay for RA supports the possible diagnosis or JA; often present with RA.
    C-reactive protein (CRP) assay—indicates nonspecific inflammation somewhere in the body.
    Erythrocyte sedimentation rate (ESR)—inflammation and necrotic problems will elevate.
  • Metatarsus Adductus is a congenital deformity of the forefoot. It is characterized by a sharp, inward angle of the front half of the foot and a convexity (curvature) of the lateral border of the foot. It is the most common congenital deformity. It has been linked to genetic factors (runs in families). It is also been linked with intrauterine positioning. It may occur as a result of the infant's position inside the uterus where the feet are bent inward at the instep.
    Metatarsus Adductus can be manipulated easily into proper alignment. This distinguishes it from clubfoot which cannot be manipulated into proper alignment.
  • Most cases resolve spontaneously by the time the infant is 3 months of age and the majority of the remainder can be corrected with simple exercises.
    Conservative Treatment
    Passive stretching exercises – Simple exercises. The foot is held securely by the heel and the forefoot is moved outward from the body with the other hand (passively abducted). This is used with mild-to-moderate deformity. The position is held for 5 seconds and repeated 5 times at each diaper change.
    Serial Casting
    Serial casting - use of a series of casts. Each is used to stretch the forefoot to a more neutral position.
    Surgery is performed on severe deformity that has failed conservative treatment.
  • Congenital Talipes Equinovarus, sometimes called Club Foot, is a congenital abnormality affecting the foot, ankle, and lower leg.
    Apparent at birth.
    Clubfoot is distinguished from metatarsus adductus, which is a nonrigid deviation of the midfoot. The foot can be straightened out.
    If you try to straighten out the child’s foot with true clubfoot, you will not be able to. It cannot be manipulated into proper alignment.
    This is because clubfoot is a true structural defect. The bones in the foot (metatarsal bones) are turned inward. The foot is small with a shortened Achilles’ tendon. Muscles in the lower leg are atrophied, but leg lengths are generally equal.
    Varus: abnormal position of a limb that involves bending inward towards the midline of the body.
    Three areas: midfoot is directed downward (equinus); hindfoot turns inward (varus); forefoot curls toward the heel (adduction).
  • The exact cause of clubfoot is unknown, but clubfoot shows a genetic predisposition and a multifactorial etiology. In other words, both genetic and environmental forces play a role in the development of this malformation.
    Restricted movement in the womb may contribute to the development of clubfoot. During fetal development, the foot passes through a number of stages in which it is flexed and turned outward. If this developmental process is interrupted, the foot may remain frozen in one of these primitive positions.
    A positive family history increases the chance of the deformity.
    Clubfoot is apparent at birth.
    Can be unilateral or bilateral deviation. In other words, can be one or both feet.
    Occurs in 1 in 1000 births, males are more commonly affected.
    There is a wide range of severity of this condition. Can be at any angle.
  • Early treatment is critical, since rapid growth and softer bones in infancy make it easy to remodel the foot.The bones of the foot are primarily cartilage at birth, but begin to ossify shortly after.
    The sooner treatment begins, the greater the chances that the child will eventually walk normally. Treatment is often initiated within hours of the delivery. At this early stage, correction is much easier because the joints, tendons, ligaments, and bones are very flexible and easy to reposition.
    A newborn baby's clubfoot is initially treated with casts. The foot is stretched into a more normal position and a light-weight cast is applied to retain the corrected position. The cast is removed every week or two, so that the foot is continually stretched into a better position and maintained with a new cast. This serial casting is continued for 8 to 12 weeks, and is successful in at least 50% of clubfoot cases.
    If the deformity has been corrected, the child may begin wearing a splint or corrective shoes to maintain the correction.
    Long-term follow-up is necessary until the child reaches skeletal maturity because recurrence is common.
    Surgery is considered if the cast does not correct the clubfoot.
  • If manipulation does not correct the clubfoot, surgery is required. Most children have surgery between 3 and 12 months of age.
    The surgery involves realignment of the bones of the foot and releasing tight ligaments or lengthening tendons to allow bones to adopt a normal position position. The foot is held in the proper position by one or more stainless steel pins. A cast is then applied with the knee flexed to prevent damage to the skin and to discourage weight bearing. Casting continues for 6 to 12 weeks.
    Even with aggressive treatment, the foot is seldom completely normal. The foot is usually a half size smaller than the other, the calf muscles are small, and certain tendons may be too short. These rarely change a child's overall functional ability, and the child should be able to enjoy a normal life.
    The child will require orthopedic care throughout childhood, special braces and corrective shoes. Caring for a child with clubfoot requires a great deal of patience. The parents will require much support and guidance, and frequent follow-up. A referral to home health for a visiting nurse may be necessary.
  • “B” is correct.
  • “A” is correct.
  • “B” is correct.
  • “A” is correct.
  • “D” is correct
  • Genu varum (bowlegs): knees are widely separated and lower legs turned inward.
    Genu valgum (knock-knees): knees are close together and lower legs directed outward.
    To evaluate the child with knock-knees, have the child stand on a firm surface. Measure the distance between the ankles when the child stands with the knees together. The normal distance is not more than 2” (5 cm) between the ankles.
  • Bowlegs and knock-knees are usually a normal part of a child’s growth and development.
    Until 2 to 3 years of age, the knees are normally bowed.
    After 2-3 years abnormal and needs further evaluation.
    The most common cause of bowed legs are Blount disease (disruption of tibial growth plate) and rickets.
    By 4 to 5 years, some knock-knee is common.
    However, the persistence of knock-knees beyond the age of 4 to 5 years necessitates further evaluation.
    Treatment:
    Most often resolve on their own.
    Braces: for mild deformities. Braces for bowlegs are worn at night and those for knock-knees are worn both day and night.
    If the deformity continues to worsen, surgery is necessary. An osteotomy (cutting of the bone) is performed and the angle surgically corrected. The child is then placed in a cast for 6-10 weeks or until completely healed.
  • “A” is correct.
  • “B” is correct.
  • An immobilizing device, typically used for closed fractures; used to hold bones in alignment.
    Make sure area is clean before casting.
    They put on a stockinette, then wrap the extremity.
    Equipment needed for cast application includes:
    Tubular gauze (stockinette)
    Casting material (rolls or strips)
    Water
    Two types of casting material used:
    Old plaster of paris
    Fiberglass
  • Read “Nursing Care of the Child in a Cast,” p. 1320-1321.
    When you cast an extremity, usually above and below injury.
    If you lift the extremity, support it by the holding the joint above and the joint below.
    While the cast is wet, handle it gently with the hands cupped, palm sides up. Don’t use the fingertips, as fingertips can indent the plaster and create pressure areas.
    It takes about two days for a plaster cast to dry.
    Fiberglass—hardens quicker, and it is much better material; tolerates water better.
    Keep the cast uncovered to help it dry.
    After the cast has dried, do not let it become wet.
    When the child bathes, cover the cast with a plastic bag to keep it dry.
  • Read “Nursing Care of the Child in a Cast,” p. 1320-1321.
    When you cast an extremity, usually above and below injury.
    If you lift the extremity, support it by the holding the joint above and the joint below.
    While the cast is wet, handle it gently with the hands cupped, palm sides up. Don’t use the fingertips, as fingertips can indent the plaster and create pressure areas.
    It takes about two days for a plaster cast to dry.
    Fiberglass—hardens quicker, and it is much better material; tolerates water better.
    Keep the cast uncovered to help it dry.
    After the cast has dried, do not let it become wet.
    When the child bathes, cover the cast with a plastic bag to keep it dry.
  • Circulation, movement, and sensation (CMS) checks: Assess the distal pulses, and check the fingers and toes for color, warmth, capillary refill, and edema. Assess sensation as well as movement.
    During the first 24 hours, CMS checks should be performed every 15-30 minutes for the first 2 hours, then every 1-2 hours thereafter. For the next 2 days, the casted extremity should be assessed at least every 4 hours.
    Check the edges of the cast. You don’t want to leave a cast with raw edges. Check the skin around the cast edges for irritation, rubbing, or blistering.
    If necessary, pull the inner stockinette over the edge of the cast and tape. The rough edges of the cast may also be smoothed out by “petaling.” If they are rough or irritating the skin, “petal” the edges by overlapping moleskin or adhesive tape around the edges.
    Prop up the child’s leg or arm on a pillow above heart level for the first few days to prevent swelling. Swelling generally peaks within 24 to 48 hours.
    Teach parents to check circulation, movement, and sensation (child’s fingers or toes of the casted arm or leg). They should feel warm, have a normal skin color, and the child should be able to move them. Pulses should be equal and strong in both extremities. The way to check for sensation is to tell the child to close his eyes and ask which toe your are touching.
    During cold weather, keep the child’s fingers or toes warm with socks.
  • Keep the cast dry.
    Cleanse the skin just under the cast edges with rubbing alcohol.
    Protect the skin under the cast from moisture or irritants—this means NO powder, lotion, oils, or perfume. These products can also cake under the cast.
    Do not allow the child to put anything inside the cast to scratch an itch such as a pencil, ruler or small toys. This can cut the skin under the cast, and an infection can develop.
  • The cast feels warm, hot, or has a bad odor
    The child’s fingers or toes feel numb, tingly, cold or burning.
    The child’s fingers or toes swell or turn blue, purple or pale in color.
    The child cannot move her fingers or toes.
    There is drainage or blood on the cast.
    Any sudden, unexplained fever.
  • The child feels a pinching, stabbing or burning pain under the cast.
    Unusual fussiness or irritability in an infant or child.
    The child feels a pinching, stabbing or burning pain under the cast.
    Any pain that is not relieved by any comfort measures (repositioning or pain medication).
    The child’s fingers or toes slip up into the cast
    Any objects such as coins, rocks, or small toys get under the cast.
    The cast crumbles, cracks or breaks.
    The cast becomes wet or soggy and soft.
    Cast removal—there is a saw to remove the cast, but it is frightening to the child. Let the child know that it only vibrates (don’t mention that it cuts).
  • The hip joint is a ball and socket joint, the ball is the femoral head and the socket or cup is the acetabulum. 
    Developmental dysplasia of the hip (DDH) refers to imperfect hip development affecting the femoral head, acetabulum (hip socket), or both. The femoral head is coming out of the hip socket or does not fit properly.
    The hip usually comes out of joint just before, during or after birth. It is more likely to happen if the baby was carried in the breech position. Very large babies or babies born with a difficult delivery with a slightly twisted neck, are also at risk.
    The condition can run in the family. Most commonly diagnosed in the newborn, or later in infancy. May be found in older children, especially those with neuromuscular disorders such as spina bifida or cerebral palsy.
    This is the most common congenital defect. Females more frequently affected than males.
    Usually affects only one hip and not two. Can be mild, moderate, or severe.
  • During routine assessments, bathing, and diaper changes, the nurse may inspect the baby’s hips for any deviations from normal. The legs of the newborn should appear to be equal in length and with symmetrical skin folds.
    The following are the most common symptoms of DDH:
    The folds in the skin of the thigh or buttocks may appear uneven.
    The leg may appear shorter on the side of the dislocated hip (look at knee height or leg length).
    The leg on the side of the dislocated hip has limited abduction (won’t come outward—don’t force it).
    The leg on the side of the dislocated hip may turn outward (externally rotated).
    The space between the legs may look wider than normal.
    Place the infant supine on the examining table and flex the infant’s hips and knees so the heels are as close to the buttocks as possible. Place the feet flat on the examining table. The knees are usually the same height. A difference in knee height is an indicator of hip dislocation.
    Positive Ortolani and Barlow maneuvers
  • If the nurse observes the legs to be unequal or the skin folds to be asymmetrical, further evaluation for hip dislocation or instability is indicated and Ortolani's or Barlow’s maneuvers should be conducted.
    (Left) Ortolani maneuver. (Right) Barlow maneuver.
    These tests are usually done on children less than 8 weeks old. The earlier DDH is diagnosed, the more easily it is corrected.
    Ortolani maneuver.
    Rotate the hip joint (the baby’s thighs are grasped and gently abducted). Put downward pressure on the hip and then inward rotation.
    If the hip is dislocated or unstable, this maneuver forces the hip back into socket (returns the femoral head to the acetabulum) with a noticeable "clunk."
    Barlow Maneuver.
    The baby’s thigh is grasped and placed together (adducted) with gentle pressure. The thighs are pushed posteriorly. Dislocation is palpable if the hip goes out of socket (femoral head slips out of the acetabulum).
    If the hip goes out of the socket, the test is termed "positive."
  • DDH is more easily corrected if found in a newborn because no damage to the hip joint has been done yet. There is rich periosteum in newborns that allows to healing to take place quickly.
    The Pavlik harness is the most common treatment in the neonatal period. It is used on babies up to 3 months of age to hold the hip in place, while allowing the legs to move a little. The idea is to hold the legs apart (abducted) with the hip joint in the socket. This brace keeps the baby's knees spread apart, bent up toward the chest, hips rotated outward.
    The harness is put on by the physician and worn 23º/day, for 3-4 months, and should be removed only for skin checks and bathing. The caregivers need to learn to change a diaper without removing the harness. Feeding is done in the upright position while carefully supporting the lower extremities, to maintain abduction of the hips.
    The baby is seen frequently during this time so that the harness may be checked for proper fit and to examine the hip.
    At the end of this treatment, x-rays (or an ultrasound) are used to check hip placement.
    Caregivers need time to practice and demonstrate proper use of the Pavlik harness. Improper positioning of the infant’s hip can cut off the blood supply (causing avascular necrosis). The parents need to check for reddened or irritated areas near the harness and to check toes frequently for proper circulation. Wearing a long cotton undershirt under the halter protects the skin by reducing harness rubbing. Lotion, oils, or powder should not be used under the harness.
    Caregivers need to be encouraged to hold and cuddle the child as much as possible despite the bulky harness. They should bring experiences to the child for developmental stimulation.
  • One in 20 babies with DDH will need more than the harness to fix the problem. Sometimes, despite the Pavlik harness, the hip may continue to be partially or completely dislocated.
    If this is the case, traction, casting, or surgery may be required.
    Bryant Traction—The purpose of traction is to stretch the soft tissues around the hip and to allow the femoral head to move back into the hip socket. Traction is most often used for approximately 10 to 14 days. The hips need to be slightly off the mattress with hips held in 45-60º of hip flexion. (A nice picture on page 1325 of the book.)
    Surgery and castingIf the other methods are not successful, or if DDH is diagnosed after the age of 3 months, surgery may be required to put the hip back into place manually, also known as a "closed reduction.”
    If successful, a special cast (called a hip spica cast) is put on the baby to hold the hip in place. The spica cast is worn for approximately three to six months. The cast is changed frequently to accommodate the baby's growth and to ensure the cast's rigidity, as it may soften with daily wear.
    The cast remains on the hip until the hip returns to normal placement. Following casting, a special brace and physical therapy exercises may be necessary to make the muscles around the hip and in the legs stronger.
  • Monitor the child’s neurovascular status frequently (CMS) and teach the family the signs of neurovascular compromise (5 P’s).
    Also, fever, wound drainage, and discomfort may be signs of infection and should be reported promptly.
    For the infant in a spica cast, the coarse, rough edges of the cast cause irritation and need to be trimmed. All edges should be covered with moleskin or waterproof tape to form a waterproof barrier between the diaper and skin. Irritation of the lower torso and legs can be avoided by tucking a disposable diaper up into the cast edges so that the plastic is between the baby and the cast. Change diapers frequently and tuck a disposable diaper beneath the entire perineal opening in the cast to keep the cast clean and dry.
    Provide environmental and developmental stimulation. The child may have
  • “A” is correct
  • Legg-Calve-Perthes Disease usually occurs in young boys age 4-8. It is not too common (1 in 12,000 children; affects boys four times more often than girls). It is characterized by periods during which the blood supply to the femoral head is interrupted. If untreated, the femoral head can become necrotic and deformed.
    Bones require their own blood supply which travels through the periosteum to the inner bone marrow.
    Legg-Calve-Perthes disease is a bone disease that affects blood supply to the top of the long leg bone inside the hip socket. The blood supply to the bone gets interrupted, and the bone tissue dies and collapses (avascular necrosis). The bone breaks across the top. The blood supply will come back and the bone regrow, but sometimes there are long-term problems.
    The first clues that a boy has Legg-Calve-Perthes disease are pain in his thigh or knee and a stiff hip on the affected side. It's painful for the boy to move his leg to the side and he will walk with a limp. Eventually, the thigh muscles may become wasted (atrophied) from lack of use.
  • Usually just 1 leg is affected.
    The disorder causes a flattening of the top of the femur (the ball of the head of the femur).
    X-rays will usually show the flattening at the top of the leg.
  • Treatment goal: Prevent permanent deformity and avoid severe degenerative arthritis.
    Idea is to maintain the spherical shape of the femoral head as it regenerates.
    Treatment: the femur head is put back into the socket and held there, until the top of the head regenerates.
    In some cases, treatment consists of bed rest, stretching exercises, and frequent check-ups. Keep leg abducted, no weight bearing.
    Some children will need a brace or cast to keep the affected hip from moving around. This allows the leg bone to grow back in the right shape (round at the top). The brace keeps the hip bone in the socket by abducting the leg. No weight bearing is allowed. The child must wear the brace for 1-3 years. Non-weight-bearing exercises are needed to maintain muscle integrity.
    In severe cases, surgery is needed to fix deformity in the hip and make the top of the leg bone have a round shape.
    The older the child when the disease starts, the more problem he will have with it, and the greater the chance that he'll have arthritis in that hip. Whatever treatment is used, the child will need to have x-rays taken every 3-4 months. It takes 2-3 years for the leg bone to fully heal.
    If it’s not corrected, then the child will have a permanent defect. The child will walk with a limp, might fall a lot, and will complain of chronic pain.
  • Psychosocial issues—returning to school with a brace. Leg-Calve-Perthes disease primarily affects boys with an average age of 6 years. These school-age boys are industrious and independent. Participation in as many school-related activities or alternatives as possible. Emphasize hobbies and other creative activities that promote normal development. These may include horseback riding , which promotes hip abduction; swimming to increase mobility; handcrafts to promote fine motor skills; and computer activities to stimulate cognitive development.
    Home care: Educate parents on the proper use of the brace—to keep leg abducted; no weight bearing. ROM exercises very important.
    Physical therapy is given to keep the muscles from contracting and wasting away.
    Educate parents: how to perform circulation, movement and sensation checks.
    Educate parents: safety issues. Child is at risk for falls.
    Educate parents: skin care. Parents need to check bony prominences. Use mild soaps such as Dove during bathing; no moisturizers. Use rubbing alcohol on pressure areas to toughen them up; do not massage.
  • “A” is correct.
  • “A” is correct.
  • “B” is correct. Limping, pain, and limited hip ABDUCTION are the clinical manifestations of LCPD.
  • Slipped capital femoral epiphysis (SCFE) occurs when the femoral head is displaced from the femoral neck at the epiphyseal plate. In other words, the head, or "ball," of the thigh bone (referred to as the femoral head) slips off the neck of the thigh bone at the growth plate. An analogy commonly used to describe this condition is that it can be like a scoop of ice cream slipping off the top of a cone. This condition causes the hip joint to become painful and stiff.
    SCFE usually develops in overweight adolescents, most commonly boys between the ages of 8 to 16 years. It occurs in boys 2-3 times more frequently than girls.
    The cause is not known. It is commonly seen during the adolescent growth spurt. Other contributing factors are trauma and obesity.
    The slippage eventually causes the femoral head to lose its blood supply, decay, and collapse.
    It can be acute with symptoms of less than 3 weeks duration or a gradual, chronic displacement.
    The first symptom may be stiffness or mild pain in the hip. However, the pain may seem to come from the knee. The pain improves with rest and worsens with walking or moving the hip. Later, a limp develops, followed by hip pain that extends down the inner thigh to the knee. The affected leg is usually twisted outward.
  • X-rays of the affected hip show a slippage or separation of the head of the thighbone from the rest of the bone. Early diagnosis is important because treatment becomes more difficult and gives less satisfactory results later.
    Treatment: surgery (fixation of epiphysis with screws or pins)
    Physical therapy: following surgery, to help strengthen the hip and leg muscles)
  • Everyone's spine has curves. These curves produce the normal rounding of the shoulder and the sway of the lower back.
    The condition of side-to-side (lateral) spinal curves is called scoliosis.
    A spine with scoliosis has abnormal curves that look more like an "S" or a "C" than a straight line. In scoliosis, there is also a 3-dimensional deformity. Some of the vertebral bones rotate slightly, turning like a corkscrew. This makes the person's waist or shoulders appear uneven.
    This disorder often gives the appearance of the person leaning to one side though it should not be confused with poor posture. The curve is compensatory in an effort to maintain an erect posture.
    Deformity is not confined only to the spine—the rib cage and pelvis may also be misshapen.
    observed to have a lateral or side-to-side curvature, the person might have a condition called scoliosis. This disorder often gives the appearance of the person leaning to one side though it should not be confused with poor posture.
  • Scoliosis is the most common disorder of the spine.
  • The clinical manifestation of scoliosis is a visible curve of the spine.
    Mild to severe C or S lateral curvature.
    Uneven waist or shoulders.
    Rib hump; hip asymmetry.
    The first signs of scoliosis may be uneven hemlines or pant legs or clothes that fit at an angle such as this girl’s panty line.
    Pain is rare in children with scoliosis.
    Severe deformity may produce backache, fatigue, and dyspnea.
  • Detection is easy and doesn’t require x-rays. It is often first discovered during routine screening by the school nurse or a physician’s office. Adolescent girls are at greatest risk. All children ages 9 through 15 should be screened for scoliosis. Curvature progresses with growth, so early screening is important to stop it from getting worse. Usually picked up in the 5th to 7th grades, just before puberty.
    Objective signs may be seen with the child or adolescent undressed and bending from the waist.
    Things to look for:
    Rib hump when the child is bending forward.
    Asymmetric rib cage.
    Uneven shoulders or hips.
    Prominence of the scapula or hip.
    Pain is rare in children with scoliosis, but the child might complain of pain during growth spurts.
    Difference in the space between the arms and the trunk with the child standing.
    Apparent leg-length discrepancy (uneven hemlines or pant legs).
    The child with a positive screening is referred to a physician. X-rays of the thorax confirm the diagnosis of scoliosis.
  • “C” is correct—around the 5th grade, right before puberty.
  • Compensatory curvature—body’s attempt to maintain an erect posture.
    Children with scoliosis require long-term monitoring because the curvature becomes progressively worse over time.
    Treatment for scoliosis depends on extent of the curve:
    Spinal exercises (<20º)
    Bracing (20-40º)
    Surgery (>40º)
  • Bracing is used to stabilize curves 20-40º.
    The brace has to worn for about 1-2 years, 18-23 hours a day.
    Time out for hygiene (taking a bath or shower).
    Skin needs to be meticulously monitored for signs of breakdown.
    Same types of interventions as for cast.
  • Child must deal with altered body image and comply with treatment.
    Should always wear a 100% cotton, seamless T-shirt underneath the brace to protect the skin. She should pull down on the shirt to remove all wrinkles once the brace is applied. The girl can wear her bra under the T-shirt. Underpants and remaining clothes go over the brace once it is on.
    Proper skin care is most important to prevent soreness or raw skin. Wash the skin that is covered by the brace once or twice a day. The skin should be examined closely for pink or red areas. After washing the skin should be dried thoroughly before putting on a clean T-shirt. Avoid using creams, lotions, or powders under the brace because they can macerate the skin.
    Clean the inside and outside of the brace daily with mild soap and water and rinse and let dry for 20 to 30 minutes.
  • Harrington rod is a metal rod that is inserted into the spine to stop progression of curvature. Operation is accomplished through incisions in the back (posterior fusion). It is extreme fixation of the spinal segments—decreased spinal motion. Also results in cessation of growth of fused vertebrae. For this reason, surgery is delayed as long as possible to allow maximal skeletal growth.
  • Monitor for S/S shock—increased HR, RR; decreased BP
    Monitor for infection: redness at incision site, pus drainage; increased temperature; skin warm, flushed; elevated WBC. Doctor may prescribe prophylactic antibiotic.
  • “B” is correct.
  • “B” is correct. Most often detected in girls between the ages of 10 and 13 years.
  • Most infections in children begin in the metaphysis area, which has a sluggish blood supply. Eventually the infection may penetrate the bone cortex and periosteum. This leads to abscess formation.
  • The infecting organism spreads through the bloodstream or by a penetrating injury to the bone. Most often it is the result of vascular spread of bacteria. Most common infectious agent in all ages is staph aureus.
    External fixation devices and skeletal traction can lead to osteomyelitis.
  • To limit the spread of infection and to promote healing, the child is placed on complete bed rest. The extremity may be immobilized with a splint or split cast. Surgical intervention is necessary if an abscess is present or if the infection fails to respond to antibiotics.
    Monitor the child’s neurovascular and pain status frequently.
    Review labs for multiple antibiotics – kidney and liver function, CBC, ESR.
  • “B” is correct. Most common between the ages of 1 and 12.
  • “B” is correct. At least 6 weeks, often IV the whole time.
  • “B” is correct.
  • Osteo—means bone
    Genesis—means begin or origin
    Imperfecta—not perfect
    Osteogenesis imperfecta (OI) is an inherited disorder, known as brittle bone disease. Abnormally brittle bones predispose to frequent fractures, deformity, and delayed growth. Individuals with OI have defective collagen. Collagen is the protein that gives the bones strength and structure.
    Since collagen is the protein of connective tissue, cartilage and bone, many other disorders can result besides fragile bones. There can be abnormalities that involve the eyes (blue sclerae), ears, teeth, joints, and skin.
    It is relatively rare and many people don't know this disorder exists. It only occurs in 1 in 10,000-20,000 births and affects boys and girls equally. In fact, some parents who are not aware that their child has OI, have been accused of child abuse when they are unable to explain their child's excessive number of fractures.
    The severity of OI varies widely from case to case. Individuals with OI can experience as few as ten fractures in a lifetime or several hundred. They may be completely ambulatory or they may rely entirely on a wheelchair for mobility.
  • Because of the child’s appearance, people may assume that the child is cognitively impaired. Children with OI most often have normal or above normal intelligence. In some instances, trauma to the skull during delivery can lead to brain damage and mental retardation.
    OI has no cure.
    Prevention: Highest priority is given to preventing fractures and maintaining muscle and joint integrity. Gentle turning, passive ROM exercises, daily skin care, and thorough assessment of high-stress areas of the body are necessary to protect the child from fractures and related complications.
  • Moderately severe osteogenesis imperfecta
    This 21-month-old boy has had multiple fractures and has begun to develop permanent deformities of his limbs.
  • The goal is for optimal functioning and mobility for each child. Want to maximize the child’s independence and mobility while minimizing the risk of fractures.
    Good nutrition; avoid excessive weight gain which can stress the musculoskeletal system. Emphasize high-calcium foods; calcium, and vitamin D supplements.
    Chronic illness may place incredible stress on the child and family, especially if repeated hospitalizations are involved. A home health nursing referral may be needed.
    Safety issues—parents will need assistance with dressing and bathing the child. Special clothing may be required. Review principles of cast care, if needed, and assessment of neurovascular status. The parent can’t use corporal punishment on this child. The nurse should also review the principles of safety during play and normal activities.
  • “A” is correct.
  • Overuse syndrome associated with sports-related activities. The muscles and tendons are immature and leads to pain and swelling in the knees.
    The hallmark sign is pain that is aggravated by activities that require kneeling, running, or climbing stairs. Also, the child will have difficulty shifting from a squatting position to a standing position without a lot of pain.
    Treatment: drastically cut down on time spent playing until the pain has been gone for 2 to 4 months. The child will need to avoid sports or any activity that requires deep knee bending.
    "RICE":
    R=Rest the knee from the painful activity.
    I=Ice the affected area for 20 minutes, 3 times a day.
    C=Compress the painful area with an elastic bandage.
    E=Elevate the leg.
    NSAIDS such as aspirin or ibuprofen (brand names: Advil, Motrin, Nuprin) may reduce the pain and swelling.
    If these treatment steps don't work, braces may be necessary to reduce tension on the tendons and muscles around the knees.
  • It is believed that Osgood-Schlatter disease results from the pull of the large powerful muscles in the front of the thigh (called the quadriceps). The quadriceps join with the patellar tendons, which run through the knee and into the tibia, to connect the muscles to the knee. When the quadriceps contract, the patellar tendons can start to pull away from the shin bone, causing pain.
    This problem becomes more noticeable during activities that require running, jumping or going up or down stairs. It's most common in young athletes who play football, soccer or basketball or are involved in gymnastics and ballet.
    Osgood-Schlatter disease usually goes away with time. When the child stops growing, the pain and swelling should go away because the patellar tendons become much stronger. Only rarely does Osgood-Schlatter disease persist beyond the growing stage.
  • Juvenile arthritis is a chronic condition that causes inflammation in one or more joints and begins before the age of 16.
    Systemic disorder, affecting connective tissue of the body. Autoimmune inflammatory disease with no known cause. Autoimmune response may be related to a viral infection or genetic predisposition; girls are affected more than boys.
    The symptoms must be present for at least 6 weeks.
    Juvenile arthritis is one of the more common chronic diseases in children. Affects 1:1000-1500 children under age 16. Most frequently children between 2-5 or between 9-12 yrs of age. May disappear in adolescence or may continue on as a chronic disease.
    It is the leading cause of blindness and disability in children.
  • A typical synovial joint has a joint capsule, a synovial membrane, synovial fluid, a joint cavity, and articular cartilage. The synovial membrane closely surrounds the joint and forms a joint cavity. The synovial membrane secretes synovial fluid that lubricates the joint.
    Articular cartilage covers the articular surfaces of synovial joints to prevent excess wear and tear as they move against each other.
    JA results in chronic inflammation of the synovial membrane. As the synovium becomes inflamed, excessive fluid is produced. Synovial fluid should be clear and viscous, but now it is thin and watery. The cartilage wears down, which leads to wear and tear on the bone itself and pain, which limits joint mobility. The child may limp, especially upon awakening. The child will not be as active as normal and will be reluctant to use the stiff limb.
  • Joint inflammation—painful, stiff, swollen, warm to the touch,  ROM.
    Intermittent joint pain > 6 weeks in more than one joint.
    Stiffness worse in the morning or after rest period.
    Uveitis (inflammation of eye structures)—can cause blindness.
    JA can be a mild condition that causes few problems over time, or it can be much more persistent and cause permanent joint and tissue damage.
  • Uveitis, a form of eye inflammation, is associated with juvenile arthritis and can cause blindness. Periodic eye examinations are needed to screen for this and prevent blindness.
  • Goal: reduce disease activity, maintain musculoskeletal function, and promote normal development.
  • Want to avoid permanent deformity to a joint and contractures. Physical and occupational therapy can help prevent disability.
    When the joints are inflamed, limit mobility and stress on the joints—Splints, proper positioning of inflamed joints.
    An individualized exercise program helps prevent contractures and deformities. When the joints are not inflamed, maintain ROM to joints. Low resistance exercises like swimming or walking are recommended. Don’t want high-resistance exercises such as jogging, gymnastics, or aerobic dance. Inactivity can lead to muscle wasting and flexion deformity. Once there is permanent deformity to a joint, the child will need adaptive devices.
    Heat helps reduce joint stiffness and muscle spasm. Swimming in a heated pool is an excellent intervention.
    The child may be affected by absenteeism from school, reduced participation in peer activities or limited career options. Children should participate in regular school activities, extracurricular activities and family responsibilities, as much as possible.
  • The immediate goal of drug therapy is to reduce inflammation, relieve pain and swelling, and maximize function. Long-range goals are to prevent damage to joint structures.
    NSAIDs and Salicylates are the first line of medication used in juvenile arthritis and are the mainstay of the initial therapy. Examples are ibuprofen, naproxen, and aspirin. NSAIDs must be taken for at least three to four weeks to tell whether they are helping control pain and inflammation. What side effects of aspirin would you be on the outlook for? (gastric irritation, bleeding, bruising, bleeding gums, bloody stools, ulcers).
    For children who don’t respond well to NSAIDs and who have severe disease, slower acting antirheumatic drugs (SAARDs) such as hydroxychloroquine, sulfasalazine, gold salts, or penicillamine can be given alone or in combination with the NSAIDs. Frequent lab tests are necessary to monitor side effects of these powerful medications.
    Crippling disease: certain chemotherapy drugs to knock-out the immune system. Risk for infection and severe side effects. Some childhood immunizations may have to be postponed.
    Corticosteroid (prednisone) is limited in the treatment of juvenile arthritis.
  • “B” is correct.
  • Muscular dystrophy—progressively degenerative inherited diseases that affect the muscle cells, causing weakness and atrophy (wasting away of the muscle tissue). Born with it (congenital), genetic.
    Still have full sensation, just lose movement.
    Several types—the most common is Duchenne.
  • Duchenne—onset is early childhood.
    First appears after walking is achieved (ages 3-7 years). Frequent falls, easily tired when walking, running, or climbing stairs.
    The child has a waddling, wide-based gait. The disease gradually weakens the skeletal or voluntary muscles, those in the arms, legs and trunk. The calf muscles are weak and hypertrophied. Fat is replacing muscle tissues, so the muscles look bigger. Child often has lordosis and scoliosis. Disease progresses slowly from lower extremities to upper extremities but will eventually affect all voluntary muscles.
  • Loss of walking happens by age 9-12 years and the boy will need a wheelchair. By the early teens, the boy's heart and respiratory muscles will also be affected. Death occurs in the late teens or early twenties from cardiopulmonary complications. With aggressive management, including being on a ventilator, young men with DMD may survive into their late twenties.
    No cure. Some of the choices the client and family may face during the later stages of his disease are: whether and what kind of assisted ventilation to use; whether to have a tracheostomy; code status; and whether to receive nourishment by gastrostomy tube.
    Family needs education, support, anticipatory guidance, grieving issues.
  • Children with muscular dystrophy have generalized muscle weakness. They compensate for weak lower extremities by using the upper extremity muscles to raise themselves to a standing position.
    Child must use the Gower maneuver to rise from the floor (child puts hands on knees and moves the hands up his legs until standing erect). Notice the wide-based gait and lordosis.
  • Females may be carriers and pass on defect to their male children.
    Affected males can pass the gene only to their daughters, not their sons.
    One-half of the male children of a carrier will have the disease. The other half will be normal. One-half of her daughters will be carriers.
    Girls have two X chromosomes, so if a gene on one of them is defective, the other can take over. But boys only have one X and one Y chromosome, meaning that if a gene on the X chromosome has a problem, there is not another X chromosome to take over. The disease will manifest.
  • Supportive care; physical therapy and braces to help maintain mobility and prevent contractures.
    Most children are wheelchair bound by 12 years of age; death usually occurs during adolescence from respiratory or cardiac failure.
  • “A” is incorrect.
  • “C” is correct.
  • Musculoskeletal injuries in children will affect muscles, bones, joints, and tendons, all of which are necessary for movement and therefore are critical to a child’s development.
    Musculoskeletal injuries are classified according to the mechanism, the location, and the force of the injury.
    Strains, sprains, dislocations, and fractures are the most common MSK injuries in children.
    Children's bones are less brittle than adults' bones and they may deform or buckle as a result of trauma, rather than break. A child's ligaments are relatively stronger than an adult's, and sprains are unusual in children.
    Many musculoskeletal problems occur because of vigorous motor activities that are part of a child’s daily life, but the rapid growth of the skeletal system plays a significant role as well.
    Most musculoskeletal problems in children are short-term. Bone healing in children usually is very rapid, with the patient's age affecting the rate of healing. In most cases, closed reduction followed by a short time in a cast restores normal function to a child's extremity.
  • Fracture: break in a bone
    Most happen because of a single and sudden injury or bone diseases that result in brittle bones.
    Diagnosis: usually by x-ray
  • Bones in children are very flexible, difficult to break. Children’s bones tend to bend or buckle. Bones can bend 45º before actually breaking. Fractures in small children require a really forceful blow.
    Most common sites of fractures in children are the clavicle, tibia, ulna, and femur, with the distal forearm fractures the most common type.
  • Fractures in infancy: rare. Think child abuse.
    Fractures in children usually result from increased mobility and immature motor and cognitive skills.
    Common during childhood and adolescence.
    Peak incidence: age 5-9 years (boys and girls).
    Pediatric fractures: major causes.
    Trauma (falls, motor vehicle crashes, sports injuries, child abuse). Accidental injury is the leading cause of death in children of all ages.
    Falls. Because children attempt to protect themselves when they fall, the outstretched arm receives the full force of the fall. This causes upper extremity fractures.
    Bone diseases that result in abnormally fragile bones.
  • “A” is correct.
  • You should suspect a broken bone if: -The child can't move the injured part. -The part is deformed, or appears to be out of shape. (one leg shorter than the other) -Movement is painful. -Sensation is lacking (can't feel anything) -The skin is swollen and bruised.
    Physiological splinting—where the muscles tighten up around the broken bone area after the injury and the muscles actually try to set the bone in the position it was in. Can be very painful and the child won’t want to move the injured extremity.
  • “A” is correct.
  • Pediatric fractures are seldom complete breaks. Bones in young children bend much like the soft branch of a beech tree, developing cracks without actually breaking (green-stick fracture).
    Greenstick fracture is most common childhood fracture. Break occurs through the periosteum on one side of the bone while only bowling or buckling on the other side. It breaks, but it is hinged on one side.
    Spiral fracture – seen frequently with child abuse cases.
  • Closed fracture—the skin is not broken.
    Open fracture—the skin is broken. Have to worry about infection.
  • If a fracture occurs and disturbs the growth plate, then growth in the bone will be hampered or stop entirely, depending on the severity of the injury. One leg may be shorter than the other.
  • When a bone is fractured, it may require a reduction or realignment to put the ends of the fracture back into place.
    Reduction involves manipulating the fracture or displaced ends of the bone into proper alignment, and then holding the realigned bone in place.
    Closed reduction—Without cutting open the fracture site, the doctor uses the sense of touch to feel the fracture beneath the skin and, with the help of x-rays, realigns the bone. Once the bone is back in position, a cast immobilizes the area. Simple or closed fractures are treated by closed reduction. Hospitalization is seldom needed and most of these fractures heal without complications.
    Open reduction—A doctor surgically exposes the fracture site, manipulates and realigns the exposed bones, and inserts an internal metallic device such as a plate or pin to maintain alignment while healing occurs. Hospitalization is required and the child is monitored for postoperative complications. There will be a surgical site to monitor and dressing changes. Assess wound for odor and drainage. Chart the size and appearance of the wound. Remember, always use strict aseptic technique—sterile gloves.
  • There are three basic types of internal fixators: screws, plates held with screws and intramedullary rods.
    Following placement of the internal fixator, the surgical wounds are closed with sutures or staples.
    A soft dressing or cast is applied to protect the limb.
  • The external fixation device stabilizes a broken bone with hardware that can be seen outside the body.
    It promotes healing of complex fractured bones of legs, hands and pelvis.
    External fixation keeps bone in place with a system of pins and wires connected to a rigid frame.
    It can be built in many shapes and fixes a variety of broken bones.
    External fixators allow for periodic changes in alignment and length of the bone. This device is commonly used in children and when the skin over the fracture has been damaged. It is also used to lengthen bones (epiphyseal plate fractures where bone growth has stopped).
    External fixation devices are becoming so common in the treatment of fractures that traction is infrequently used. No cast is necessary because the bones are held rigidly by the apparatus.
    Since the skin is not covered with a cast, the skin can be cared for in the same manner as the skin of an open wound without a fracture.
    The fixation device is removed when the fracture is healed.
    Meticulous assessment of entry sites is necessary. Pin care is necessary to prevent infection (read over page 1346 about pin care). Use sterile technique, ½ strength hydrogen peroxide. Rinse site with sterile water or saline.
  • When the ends of the bone are aligned, the injured bone requires support and protection while it heals. Retention entails the application of a device or mechanism that maintains alignment until healing occurs.
    Healing takes place when the tissues produce a substance called callus, which binds the bony fragments together.
    Plaster of paris casts may be used to immobilize smaller fractures in extremities (such as a broken arm), whereas traction may be necessary to immobilize larger areas, such as a fractured thigh bone.
    The time required to heal a fracture varies with age, the location, type of fracture, and the blood supply to the area. Fractures heal more rapidly in children—a fracture that take 3 weeks to heal in a 4-year-old would take up to 3 months to fully mend in her mother.
  • The purpose of traction is to reduce and align. Traction is a pulling force. Traction pulls opposite from the body usually.
    Pulleys, strings, weights should hang free. Can only come off or be adjusted with a doctor’s order. Never change weight unless you have a doctor’s order.
    Read nursing diagnoses on page 1393. Number 7 is the most important: maintain traction integrity by ensuring all weights and pulleys are hanging free and are not touching the floor or the bed. Do not release the traction without a physician’s order.
  • Traction can either be applied directly to the skin (skin traction) or through pins inserted into bones (skeletal traction)
    Skin traction—more circulatory complications, because you have a device applied directly to the skin’s surface. The skin can be injured from pressure being applied for extended periods of time.
    The amount of weight that can be used on skin traction is limited.
    A thorough assessment of the traction apparatus, as well as the extremity should be conducted at least once a shift as a preventative measure.
  • Skeletal traction—device going directly to the bone; usually uses pins.
    Skeletal traction does have the disadvantage of complications associated with pin insertion, and infections can come from the sites of pin insertion. There is an avenue directly to the bone, so you have to worry about infection. Osteomyelitis is the most serious complication of skeletal traction. Bone infection is hardest to cure; hard to get antibiotics to the bone.
    Pin sites usually need to be cleaned every shift. Usually cleaned with half-strength hydrogen peroxide, antibiotic ointment, and gauze. Check frequently for bleeding, inflammation, or infection.
    Know the differences between skin and skeletal traction.
  • Buck’s traction—the most common—has a “boot;” often used preoperatively to prevent muscle spasms; fractures, hip disorders, contracture, muscle spasms. Lower extremity in unilateral Buck's extension traction is aligned in a foam boot or circular wrap and traction applied by the free-hanging weight.
    Unless otherwise ordered, the mattress should be flexed at the knee (20-30 degrees) to maintain a neutral hip.
    Bryant Traction—used to treat development dysplasia of the hip and fractured femurs. Sacrum should be off the mattress. Intermittent traction. Mainly used in children younger than 2 or 3 years. It is not being used frequently because of the increased risk of circulatory compromise.
  • Russell traction—used to stabilize fractured femurs until callus forms. Is continuous. Knee should be slightly flexed and supported by the sling.
    Cervical traction—used to treat muscle or nerve irritation of the shoulders or upper arms. May be continuous or intermittent. Elevate HOB 20-30º for correct alignment.
  • Crutchfield tongs—used to stabilize fractures or displace vertebrae in cervical and thoracic areas. Tongs are inserted on either side of the head through drill holes. The child must maintain straight body alignment as traction pull is always along the axis of the spine.
    Balanced suspension—suspends and immobilizes a leg without applying traction to the body. Applied to a hip, tibia, fibula, or femur. The leg is supported by a Pearson attachment and a Thomas splint. A Thomas splint is a padded ring that fits around the upper leg; a Pearson attachment meets the Thomas splint at the knee and supports the lower leg. A canvas sling may be used to further support the lower leg.
  • 90/90 Femoral Traction—most commonly used traction for complicated fractures of the femur. A pin or wire is inserted through the distal femur; the lower leg may be casted. Most effective in children more than 6 years old. Has to wear for 2-3 weeks until a strong-enough callus forms; then a spica cast will be put on.
    Dunlop Traction—used to treat complicated fractures of the humerus. A pin is inserted through the distal humeral fragments and the elbow is flexed 90º.
  • “A” is correct.
  • “A” is correct.
  • After the cast or traction is applied, neurovascular assessment should be performed at least every 1-2 hours during the first 48 hours.
    Circulation (which is skin color and temperature, quality of pulses, and capillary refill), movement and sensation of the extremity, show neurovascular status and should be assessed carefully.
    Compare the quality of the pulse distal to the affected site with the pulse in the unaffected extremity.
  • “D” is correct.
  • Seen in closed (simple) fractures (no breaks in the skin). More likely to occur after a severe injury (much swelling, internal bleeding). Most common sites are the lower leg and the forearm.
    The muscles and nerves of the upper and lower extremities are enclosed in compartments that are surrounded by tough, inelastic fascia. Any internal swelling or bleeding will cause pressure to rise in these unyielding, closed spaces. The increased pressure cuts off circulation to the muscles and nerves within the compartment and can result in paralysis and necrosis of tissue. If high pressure continues for more than 4-6 hours, there will be irreversible damage.
    With an open fracture, or pins going into the bones, compartment syndrome won’t occur—because excess tissue fluid can escape.
  • Compartment syndrome is the most serious complication of fractures, casts, or traction. It is an orthopedic emergency. This can result in long-term disability, amputation, or paralysis if not caught early.
    Signs/Symptoms:
    Severe pain that is unrelieved by narcotics. Make a distinction between pain of the fracture and burning sensations distal to the fracture. There is intense, disproportionate pain in the limb, often burning in quality, worsened by flexion or extension. Especially in a forearm fracture, if extending the fingers produces pain, notify the physician immediately. Sudden relief of the severe pain might not mean that the pt is getting better; rather, the nerves may be dying.
    Pallor/ cyanosis.
    Pulselessness or decreased pulse—notify physician.
    Paresthesia—Burning/tingling sensation, progressing to numbness.
    Paralysis—Loss of movement
    Swelling.
    Diminished capillary refill.
    Management---Relieve compression.
    ***ASSESSMENT BEFORE NARCOTICS***
    It is important to document exactly how you left the extremity at the end of your shift (CMS intact, no pain).
  • “A” is correct.
  • If compartment syndrome is occurring, they will cut the cast off. Will perform a fasciotomy, if necessary, to relieve pressure.
  • Soft-tissue injuries: Sprains, strains
    Soft tissues are the tissues found under the skin. Soft tissues are more resilient, or flexible, in children.
    Strains or sprains are uncommon children. Until the child reaches puberty, ligaments and tendons are stronger than bones. The growth plates, or epiphyses, are weaker than the ligaments and will usually separate before a ligament will tear.
    Review page 1341, “Strains, Sprains, and Dislocations.”
    Strain: stretching or tearing of either a muscle or a tendon (usually from overuse).
    Strain: stretching or tearing of a ligament (when a joint is twisted or traumatized, usually by falls, sports injuries, or motor vehicle crashes).
    Treatment of soft-tissue injuries is summarized in the acronym RICE:
    For the first 24-36 hours:
    •Rest
    •Immobilization
    •Ice/(20 min on/ q1-4 hours) several daysApply ice for no longer than 20 minutes every 1 to 4 hours for 24 to 36 hours.
    •Compression (Ace wrap)
    •Elevation
    NSAIDs (no aspirin) to alleviate pain and reduce inflammation.
  • “A” is correct.
  • “B” is correct.
  • Osteosarcoma or osteogenic sarcoma is the most common bone malignancy in children, and a very aggressive tumor. Primary site of origin is the osteoblast (bone-forming cells). The primary site is the upper part of the shaft of the long bones, particularly the femur and humerus. 50% of the cases affect the femur.
    Seen in adolescent boys—nobody knows why.
    Pain will be in the upper part of the femur—intermittent pain, dully and achy.
    Pathologic fracture—bone becomes diseased, brittle, and it just breaks.
    The cure rate is about 75% for children without metastases at diagnosis. If there is metastases, then cure rate is only 20%--substantially poorer outcome. At the time of diagnosis, most children have metastases.
  • Treatment: Usually will want to do amputation, then chem.
    Nursing care:
    Dealing with an amputation post care.
    Do not elevate the stump—keep it straight.
    Control bleeding.
    Pt will have phantom pain.
    Chemotherapy—probably before and after.
    N/V, loss of hair
  • Ewing’s sarcoma is extremely malignant. By the time it is discovered, metastasis has already occurred in 90 per cent of children. The favorite site is the thigh bone (femur), also the pelvic bones and shoulder. It occurs most frequently between the ages of five and sixteen. The first symptom is usually a painful swelling of the bone and fever. The diagnosis is, as always, confirmed by a biopsy.
    The treatment consists of radiation and chemotherapy. Surgery may be used in certain cases to try to remove the cancer and some of the tissue around it. Surgery may also be used to remove any tumor that is left after chemotherapy or radiation therapy. Both of these bone cancers occur in males more than females.
  • Pediatric musculoskeletal nurs 3340 fall 2014

    1. 1. Alterations in Musculoskeletal Function in Children Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE
    2. 2. Objectives  Describe pediatric variations in the musculoskeletal system  Plan nursing care for children with structural deformities of the foot, hip, and spine  Recognize signs and symptoms of infectious musculoskeletal disorders and refer for appropriate care  Collaborate with families and other healthcare providers to plan care for children with musculoskeletal disorders that are chronic or require long-term care
    3. 3. Objectives Cont’d…  Plan nursing interventions to promote safety and developmental progression in children who require braces, casts, traction, and surgery  Provide nursing care for fractures and other sports injuries, including teaching for injury prevention and evidence-based nursing interventions for the child who has sustained a fracture or other sports injury
    4. 4. Overview of the Musculoskeletal System
    5. 5. Musculoskeletal System  The structures of the musculoskeletal system work together to provide support and produce movement  Anatomy:  Bones  Cartilage-type Tissue  Joints  Muscles http://www.coj.net/NR/rdonlyres/ehzhwybcke723qmg3jwxbebdvvqxdo2t5xi2yjwfk44kcyizjirshuk24wsvhabdx3go3j35xe7nriwdbhqlylleyrh/Girls-playing-soccer.jpg
    6. 6. Bones: Rigid Framework  206 in human body  Long bones  Short bones  Flat bones  Irregular bones  Sesamoid bones McKinney text, p. 1403
    7. 7. Long Bones  Epiphysis (epiphyses)  Growth of long bones occurs at the epiphyses  Epiphyseal plate  Diaphysis: shaft  Medullary cavity: marrow, hematopoiesis  Periosteum: blood supply London text, p. 1319
    8. 8. Bone Remodeling: Maintaining Strong, Healthy Bone  Resorption  Osteoclasts:  Dissolve old bone  Release calcium into the blood stream  Formation  Osteoblasts:  Build new bone  Remove calcium from the blood stream http://www.medes.fr/Eristo/Osteoporosis/OsteoCBImage.html
    9. 9. Cartilage-Type Tissues: Cushions, Joins Bones and Muscles Cartilage—cushions Ligaments—bone to bone Tendons—muscles to bone http://www.manordrug.com/FLA/kneeguide.htm
    10. 10. http://www.allaboutarthritis.com/image/stock_image/ankle_ligaments_MMG.jpg Tendons, Ligaments, and Cartilage
    11. 11. Articular System (Joints)  Where two bones meet  Allow the skeleton to move  Ligaments and cartilage  Synovial—freely movable (knee)  Amphiarthrotic—slightly movable (symphysis pubis)  Synarthrotic—immovable (skull) http://www.octc.kctcs.edu/gcaplan/anat/Notes/Image585.gif
    12. 12. Skeletal (Striated) Muscle: Voluntary, Active Movement
    13. 13. Function of the Musculoskeletal System  Protection  Support  Motion  Storage of minerals  Manufacture red blood cells http://www.childrens-specialties.com/images/12intrike.jpg
    14. 14. Pediatric Differences in MSK  Fetus: closely-packed connective tissue—> cartilage—> bone (ossifies)  Infant’s bones: soft  Fractures in children < 1 year old: rare (think abuse or disease) http://www.worldwideposters.com/mc/fw8736t.jpg
    15. 15. Pediatric Differences in MSK  Child’s bones more plastic (more force required to break): will buckle or bend first  Child’s bones heal faster  Soft tissue more resilient  Ligaments and tendons are stronger than bones: dislocations, sprains less common http://bryankuntz.com/babyGlobe_a.jpg
    16. 16. Assessment of the Musculoskeletal System in Children
    17. 17. Assessment Parameters  Complete health history  Family history  Nutrition  Any trauma?  Developmental delays  Pain  Structural abnormalities  Physical limitations/ lifestyle alterations  Mobility aids  Physical assessment  Structural abnormalities  Posture and gait  Muscle symmetry, mass, tone, strength  Circulation (color, temperature, pulses, capillary filling, edema in each extremity)  Movement (ROM in all joints)  Sensation (pain, can feel)
    18. 18. Selected Gross Motor Milestones for Age
    19. 19. Normal Development of Posture and Spinal Curves
    20. 20. Laboratory Studies/ Diagnostic Tests  Radiologic and other imaging studies to assess bones and joints:  X-ray (most common)  CT scan  MRI  Other important procedures include:  Bone scan  Arthrography  Arthroscopy  Joint aspiration  Ultrasound  Diagnostics (CK assay, RA assay, CRP assay, ESR)
    21. 21. Common Nursing Diagnoses  Impaired Physical Mobility  Pain  Risk for Delayed Growth and Development  Risk for Impaired Skin Integrity  Risk for Injury  Risk for Noncompliance  Diversional Activity Deficit
    22. 22. Disorders of the Feet and Legs
    23. 23. Metatarsus Adductus  Most common congenital foot deformity  Inward turning of the forefoot at the instep  Hindfoot is not affected  Genetic factors, intrauterine positioning  Foot can be manually straightened out http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9052.jpg
    24. 24. Metatarsus Adductus: Treatment  Depends on degree of foot flexibility  Most resolve spontaneously or with passive stretching exercises  Serial casting - each used to stretch the forefoot to a more neutral position http://www.rn.com/main.php?uniq=477363&command=manage_courselist&data%5Bsubmit_value%5D=Display%20Entry&data%5Bcourselist%5D%5Bid%5D=229
    25. 25. Clubfoot (Congenital Talipes Equinovarus)  Congenital malformation affecting foot, ankle, lower leg  True structural defect  Cannot be straightened  Three areas:  Midfoot directed downward (equinus)  Hindfoot turns inward (varus)  Forefoot curls toward heel (adduction) London text, p. 1321 http://www.drfoot.co.uk/pictures/clubfootrepair.jpg
    26. 26. Clubfoot  Genetic predisposition  Multifactorial etiology  1:1000 births  Males > females, 2:1  May be unilateral (one foot) or bilateral (both feet)  Apparent at birth McKinney text, p. 1414
    27. 27. Clubfoot—Casting  Treatment begun as soon after birth as possible  Serial manipulation and casting q weekly for 8-12 weeks  Variable response  Recurrence common  Long-term follow-up  Surgery may be necessary if casting unsuccessful http://www.vh.org/pediatric/provider/orthopaedics/Clubfoot/Fig22.html
    28. 28. Clubfoot—Surgery  Surgery is required if manipulation does not correct the clubfoot  3-12 months of age  Releasing tight ligaments or lengthening tendons to allow bones to adopt a normal position  Foot is seldom completely normal after treatment
    29. 29. Question  Metatarsus adductus is known as clubfoot.  A. True  B. False
    30. 30. Question  Nonsurgical management of clubfoot requires serial casting.  A. True  B. False
    31. 31. Question  Long-term follow-up for clubfoot is not necessary after corrective surgery.  A. True  B. False
    32. 32. Question  An infant's clubfoot cannot be manipulated into proper alignment.  A. True  B. False
    33. 33. Question  Julie's child has clubfoot. She asks the nurse what kind of treatment she can expect her daughter to go through. The best response by the nurse is:  a. Treatment will begin when your daughter is about six months old.  b. It usually requires about one year of treatment to resolve the problem.  c. There is no formal treatment; clubfoot resolves spontaneously.  d. When serial casting is used as the method of treatment, the cast is changed every one to two weeks for 8 to 12 weeks until maximum correction is achieved.
    34. 34. Genu Varum/ Genu Valgum  Varus: an abnormal position of a limb that involves bending inward toward the midline of the body  Valgus: an abnormal position of a limb that involves bending outward away from the midline of the body http://www.planete-ortho.com/fr/images/genuVarum.jpg
    35. 35. Genu Varum/ Genu Valgum  Genu varum (bowlegs): knees are widely separated and lower legs turned inward  Genu valgum (knock- knees): knees are close together and lower legs directed outward http://www.arthrosedugenou.com/francais/sympt_arthrose.htm
    36. 36. Genu Varum/ Genu Valgum  Genu Varum:  Normal 2 to 3 years of age; beyond abnormal  Cause: Blount disease, rickets  Genu Valgum:  Normal 4 to 5 years years of age; beyond abnormal  Treatment:  Most resolve on own  Braces  Osteotomy and casting
    37. 37. Question  Genu varum is a normal variation in toddlers.  A. True  B. False
    38. 38. Question  Genu valgum is almost always secondary to other disorders.  A. True  B. False
    39. 39. Casts  Provides support  Maintains anatomic position  For bone healing or correction of a deformity  Plaster of paris or fiberglass  Most casts applied on an outpatient basis
    40. 40. Cast Care—Drying  Be especially careful with the cast for the first 1-2 days (can easily crack or break)  Elevate the casted extremity on a pillow above the level of the heart  Reposition every 2-4 hours to ensure thorough drying (plaster cast)  Can take 48 hours for a plaster cast to harden
    41. 41. Cast Care—Drying  While the cast is wet, handle it gently with the hands cupped, palm sides up (no fingertips)  If you lift the extremity, support it by the holding the joint above and the joint below  Once dry, the cast should sound hollow and be cool to the touch  Avoid getting the cast wet (no swimming, baths, or showers)  Cover with plastic and waterproof tape to keep dry (if necessary)
    42. 42. Care for the Child in a Cast  Circulation, movement and sensation (CMS) checks q 15-30 minutes for 2 hrs, then q 1-2 hrs thereafter for first 24-48 hrs  Check the skin around the cast edges for irritation, rubbing, or blistering  “Petal” edges of the cast if necessary  Circle any drainage or bleeding noted through cast material  Elevate the cast above heart level (especially for the first 48 hrs)
    43. 43. Care for the Child in a Cast  Keep the cast dry  Cleanse the skin just under the cast edges with rubbing alcohol  Do not pour powder, lotion, oils, or perfume into the cast (will cake)  Do not allow the child to place anything inside the cast
    44. 44. Instruct the Parent to Contact the Provider if…  Foul, unusual odor  Tingling, burning, numbness  Fingers or toes swell, inability to move  Fingers or toes turn blue or white  Drainage through cast  Sudden, unexplained fever
    45. 45. Instruct the Parent to Contact the Provider if…  Unusual fussiness, unable to console  Pain that is not relieved  Any objects such as coins, rocks, or small toys get under the cast  Cast slippage  Cast crumbles, cracks or breaks  Cast becomes wet or soggy and soft
    46. 46. Disorders of the Hips
    47. 47. Developmental Dysplasia of the Hip (DDH)  Congenital abnormality of the hip socket  Formerly ‘congenital hip dysplasia’  1-2 / 1000 births: most common congenital defect  Females > males, 4:1  Genetic predisposition  Multifactorial etiology  Breech birth, very large babies, spina bifida, CP
    48. 48. DDH  Femoral head either comes out of the hip socket (acetabulum) or does not fit properly  Mild, moderate or severe  Usually affects one joint
    49. 49. Normal Hip Joint vs DDH
    50. 50. DDH: Symptoms  Asymmetry of gluteal folds  Leg shorter  Limited abduction  Turned outward (externally rotated)  Wide space between legs  Difference in knee height (Allis sign)
    51. 51. DDH: Symptoms  Older child: gait abnormalities such as toe walking or limping, or the level of the pelvis may be unequal  The longer the disorder goes undiagnosed, the more severe the clinical manifestations and difficult to treat
    52. 52. DDH—Ortolani and Barlow’s Maneuvers  Performed with the newborn in a quiet, relaxed state on a firm surface, with hips and knees flexed at a 90º angle  Positive test—“Clunk” or palpable dislocation  Means hip is dislocated or unstable
    53. 53. DDH—Pavlik Harness  For infants < 3 months  Pavlik harness—a brace that places the hips in flexion and abduction  Centers the head of the femur in the hip socket by keeping the knees and hips flexed and the hips abducted  Makes hip goes back into the joint and keeps it there  Worn 23º/day for 3-4 mos  Until x-ray shows hip is stable
    54. 54. DDH—Traction and Surgery  Skin traction (Bryant Traction) and/or surgery is used if the harness is not successful or if the child is older than 3 months  Traction stretches the soft tissue and moves the femoral head back into the hip socket  Surgery may be performed to put the hip back into place manually  A hip spica cast is used to keep the hip in the joint after the operation
    55. 55. DDH—Hip Spica Cast Care  Monitor neurovascular status (CMS)  Assess for fever, wound drainage, and discomfort  Standard cast care  Elevate the cast above the level of the heart to decrease swelling  Rough edges can be padded to protect the skin from scratches  Check for cracks or breaks in the cast  Keep the cast clean and dry  Cover the cast during feedings to prevent spills from entering the cast  Tuck a disposable diaper beneath the entire perineal opening in the cast to keep the cast clean and dry  Do not use the abduction bar on the cast to lift or carry the baby  Perform ROM exercises  Provide environmental and developmental stimulation
    56. 56. Question  When developmental dysplasia of the hip is diagnosed:  A. Treatment is begun immediately  B. Treatment is postponed until the child is able to bear weight  C. Surgery is scheduled as soon as the child weighs 10 pounds  D. Bilateral casting is done at 1 month of age
    57. 57. Legg-Calvé-Perthes Disease (LCPD)  A deterioration of the head of the thighbone (femur) due to insufficient blood supply to the area  Avascular necrosis of the femoral head  Boys 4-8 yrs  Painful limp, limited abduction
    58. 58. LCPD—Diagnosis  Usually unilateral  Flattening of the top of the femur  Diagnosis by X-ray, bone scan, or MRI http://www.uwec.edu/kin/majors/AT/aidil/images/leggsap.JPG
    59. 59. LCPD—Treatment  Treatment goal: avoid permanent deformity and degenerative arthritis  Femur head is put back into the socket and held there  Bedrest, stretching exercises  Activity restrictions  Bracing (abduction, no weight bearing)  Non-weight-bearing exercises  Surgery (osteotomy)
    60. 60. LCPD—Toronto Brace
    61. 61. LCPD—Nursing Care  Psychosocial issues  Educate parents on purpose, application, and care of the brace  Educate parents: CMS checks  Safety issues  Skin care
    62. 62. Question  LCPD can result in arthritis and skeletal deformities.  A. True  B. False
    63. 63. Question  LCPD results in avascular necrosis of the femoral head.  A. True  B. False
    64. 64. Question  Limping and limited hip adduction are clinical manifestations of LCPD.  A. True  B. False
    65. 65. Slipped Capital Femoral Epiphysis (SCFE)  Femoral head displaced from femoral neck at growth plate  Adolescent growth spurt  Overweight boys, ages 8- 16  Acute vs chronic  S/S: limp, pain, limited ROM
    66. 66. SCFE—Diagnosis and Treatment  X-ray  Early diagnosis important  Goal: stabilize femoral head; retain hip function  Treatment:  Surgery  Steel pin to hold the femoral head onto the femur to prevent it from slipping further  Physical therapy  Following surgery, to help strengthen the hip and leg muscles
    67. 67. Disorders of the Spine
    68. 68. Scoliosis  Abnormal lateral curvature of the spine  S or C-shaped  Compensatory  3-dimensional, with rotation of the vertebrae  Misshapen spine, rib cage, and pelvis
    69. 69. Scoliosis—Incidence  Most common spinal deformity  10% of children  Runs in families  Most frequently affects adolescent girls, ages 10- 13  Common in children with neuromuscular disorders
    70. 70. Scoliosis—Manifestations  Visible curve of spine  Mild to severe “C” or “S” lateral curvature  Uneven waist or shoulders (scapula)  Rib hump  Asymmetrical hips  Usually no pain  Severe cases: reduced vital capacity (shortness of breath)
    71. 71. Scoliosis—Screening/ Diagnosis
    72. 72. Question  Screening for scoliosis is done:  A. Prenatally  B. In the newborn period  C. During the school-age years  D. In middle adolescence
    73. 73. Scoliosis—Treatment • Curve 10-20º - Slight curve, spinal exercises • Curve 20-40º - Brace • Curve > 40º - Surgery • Curve > 80º - Respiratory compromise • Requires long-term monitoring, because the curvature will progressively worsen over time
    74. 74. Scoliosis—Nursing Diagnoses  Deficient Knowledge  Ineffective Breathing Pattern  Risk for Injury  Pain, Anxiety  Impaired Physical Mobility  Disturbed Body Image  Interrupted Family Processes  Risk for Impaired Skin Integrity  Risk for Noncompliance  See CP pp. 962-964
    75. 75. Scoliosis—Bracing  Curvature 20-40º  Milwaukee brace: most common type  Plastic, metal, & a chin extension  From jaw to hips, stretching / pushing  Worn 23 hrs /day with time out for hygiene and skin care
    76. 76. Scoliosis—Bracing Cont’d…  Worn for 1-2 years  Brace must be adjusted with growth  Observe for skin breakdown  Should wear a light cotton tee shirt under the brace  Body image disturbances, reaction of peers
    77. 77. Scoliosis—Surgery  Spinal fusion: > 40º curve  Results in cessation of growth of fused vertebrae  Delayed as long as possible to allow maximal skeletal growth  Harrington rod (posterior fusion)—most common  Risk for injury (nerve damage, bleeding)  Risk for infection
    78. 78. Scoliosis—Postoperative Care  Immobilization on Stryker Frame postoperatively  Will be in hospital at least 5 days  CMS checks lower extremities q2 hrs for 1st 24º; then q4 hrs  Pulmonary hygiene: TCDB, IS  Position: log-rolling q2 hrs
    79. 79. Scoliosis—Postoperative Care  Monitor pain, shock, wound site, infection  Encourage participation in activities within limitations  Mesenteric artery syndrome: complication following surgery caused by mechanical changes in the position of the abdominal contents; causes vomiting and abdominal distension
    80. 80. Scoliosis—Case Example  This is a 13-year-old with a progressive right thoracic scoliosis measuring 55°  Postoperatively, the curve is reduced to 15°  Correction was by surgical implantation of metal rods
    81. 81. Question  Uncorrected scoliosis can result in:  A. Superior mesenteric artery syndrome  B. Reduced respiratory function  C. Fusion of the vertebrae  D. None of the above
    82. 82. Question  Scoliosis is most often detected in children between six and eight years of age.  A. True  B. False
    83. 83. Disorders of the Bones and Joints
    84. 84. Osteomyelitis (p. 967)  Infection of bone and marrow  Most often long bones of lower extremities  Acute or chronic  Most common: boys younger than 5 years  Bacterial, viral, fungal
    85. 85. Osteomyelitis  Two principle ways to contract:  Endogenous routes (organism spreads through bloodstream, abscessed teeth, skin infection over bone)  Exogenous routes (penetrating injury to bone, surgical procedures)  Pus pockets in bone (sequestrum): very resistant to antibiotics
    86. 86. Osteomyelitis with Draining Sinus
    87. 87. Osteomyelitis of Right Lower Humerus with Pus Pocket
    88. 88. Osteomyelitis  S/S: severe pain, impaired physical mobility  Diagnostics:  ↑ WBC, ESR, C-reactive protein  X-ray, bone scan  Needle aspiration, blood culture  Review Nursing Diagnoses, Planning, Interventions – pp. 968-969  Treatment:  Extended IV antibiotic therapy (6 weeks)  Multiple, broad-spectrum
    89. 89. Question  Osteomyelitis is most common in children between the ages of 16 and 18.  A. True  B. False
    90. 90. Question  Antibiotic therapy treatment for osteomyelitis most often lasts for one week.  A. True  B. False
    91. 91. Question  Areas of sequestrum are highly susceptible to antibiotics.  A. True  B. False
    92. 92. Osteogenesis Imperfecta (OI) (p. 971)  “Brittle bone disease”  Inherited disorder of collagen (autosomal dominant)  Wide variety of symptoms:  Osteoporosis  Frequent fractures  Blue sclerae  Discolored teeth  Deafness by early adulthood  Short height due to compression fractures of the spine  ↑ ROM of joints due to relaxed ligaments
    93. 93. OI—Nursing Considerations  Often normal or above normal intelligence  No cure  Often mistaken for child abuse  Highest priority: prevent fractures, maintain muscles and joints
    94. 94. OI—Often Mistaken for Child Abuse
    95. 95. OI—Nursing Considerations  Goal: optimal functioning and mobility  Good nutrition  Calcium, vitamin D, vitamin C  Coping with chronic illness  Safety issues
    96. 96. Question  Osteogenesis imperfecta is a connective tissue disorder of the bones characterized by defective collagen, the protein that gives the bones strength and structure.  A. True  B. False
    97. 97. Osgood-Schlatter Disease  Very common cause of knee pain in children ages 8-16 yrs  Bilateral knee pain, edema  Repetitive stress: sports-related activities  Running, jumping, climbing stairs  Treatment: avoid activities, elastic bandages for knees, ‘RICE’, NSAIDS, braces http://www.oapa.com/images/socc.gif http://emedicine.medscape.com/article/827380-overview
    98. 98. Osgood-Schlatter Disease http://www.runnersworld.co.uk/news/images/osgood-schlatter.gif
    99. 99. Juvenile Idiopathic/ Rheumatoid Arthritis (JRA) (pp. 666-668)  Chronic condition that causes inflammation in one or more joints and begins before the age of 16  Symptoms present ≥ 6 weeks  Autoimmune  Multisystem (connective tissue)  Leading cause of blindness and disability in children  Children 2-5 or 9-12 yrs of age  May disappear in adolescence
    100. 100. JRA—Pathophysiology  Synovial joints  Chronic inflammation of the synovial membrane  Destruction of the articular cartilage  Wear and tear on the bone, pain  Limited joint mobility
    101. 101. JRA—Manifestations  Periods of remission and exacerbation  Joint inflammation  Pain, warmth  Morning joint stiffness  Limited mobility of joints involved (stiff, bent joint)  Physical growth may be stunted during periods of exacerbation  Decreased activity level, weakness  Uveitis
    102. 102. JRA—Diagnostic Evaluation  Complete health history  Physical examination  No specific diagnostic tests for JA  Laboratory tests to help rule out other diseases  X-rays of bones and organs to check for infections, tumors or fractures  Uveitis—eye examinations
    103. 103. JRA—Nursing Goals  Read Nursing Diagnoses, Planning, Interventions – pp. 650-652  Keep the child free from injury  Pain control  Enhance physical mobility  Promote age-appropriate developmental behaviors
    104. 104. JRA—Therapeutic Management  Adequate rest  Referral to PT/ OT  Low resistance-exercise program, ROM exercises, to prevent contractures and deformities  Proper positioning of the affected joints to prevent MSK complications; Splints  Heat/ cold  Children should participate in regular school activities, extracurricular activities and family responsibilities, as much as possible
    105. 105. JRA—Drug Therapy  Reduce inflammation, relieve pain and swelling, maximize function  Medications: NSAIDs and Salicylates (ibuprofen, naproxen, ASA)  Severe disease: SAARDs (hydroxycholoroquine, sulfasalazine, gold salts, penicillamine)  Crippling disease: immunosuppressive agents (methotrexate, azathioprine, cyclophosphamide)
    106. 106. Question  In taking the history of a child with juvenile arthritis, the nurse would probably discover that the child is taking:  A. Acetaminophen  B. Aspirin  C. Morphine  D. Prednisone
    107. 107. Muscular Dystrophies
    108. 108. Muscular Dystrophy (MD) (p. 973)  Group of progressively degenerative inherited diseases  Muscles waste away  Various patterns of inheritance and age of onset  Duchenne muscular dystrophy (DMD)—most common type
    109. 109. Duchenne Muscular Dystrophy (DMD)  X-linked recessive disease; affects males (1: 3000 boys)  Onset early childhood —3-7 yrs  Waddling, wide-based gait  Calf hypertrophy  Lordosis, scoliosis
    110. 110. DMD  Loss of walking by 12 yrs—will need a wheelchair  Death: late teens, early 20’s  Cardiopulmonary complications (respiratory failure, heart failure, pneumonia)
    111. 111. Muscular Dystrophy—Gower’s Sign (p. 974)
    112. 112. X-Linked Recessive One-half of the male children of the mother carrier will have the disease.
    113. 113. DMD—Diagnostics  Serum creatine kinase (CK) levels elevated early stages  Electromyography  Muscle biopsy
    114. 114. DMD—Nursing Goals  Maintain physical activity  Promote respiratory function  Weight management  Reduce the impact of the disease on the child’s development
    115. 115. DMD—Nursing Care  Supportive care  Maintain mobility—good ROM, turn q2 hrs  Prevent foot drop, contractures (splints, orthotics)  Prevent obesity—reduced calorie diet  Respiratory—assess lungs, encourage to cough and deep breathe  Bowel—stool softeners, fiber, laxatives  Support family; referral for genetic counseling
    116. 116. Question  All of the following statements about Duchenne's muscular dystrophy are true except:  a. Duchenne's muscular dystrophy affects girls more than boys.  b. In children with Duchenne's muscular dystrophy, the calves appear large and strong, but in actuality they are weak because of infiltration of the muscles with fat and connective tissue.  c. Most deaths from Duchenne's muscular dystrophy are due to respiratory infections or cardiac failure.  d. There is no cure for Duchenne's muscular dystrophy.
    117. 117. Question  Of the following, which is the priority nursing intervention for the child with Duchenne's muscular dystrophy?  a. nutritional status  b. genetic counseling  c. respiratory status  d. renal status
    118. 118. Injuries to the Musculoskeletal System
    119. 119. Musculoskeletal Injuries in Children (p. 976)  Movement is critical to a child’s development  MSK injuries occur because of:  Vigorous motor activities  Rapid growth of skeletal system  Most are short-term http://www.wendychao.com/skate/wendy_skateboard_med.jpg
    120. 120. Fractures  Fracture: break in a bone  Most happen because of:  Sudden trauma  Bone disease (OI)  Diagnosis: usually by x-ray
    121. 121. Pediatric Fractures  One of most common childhood MSK injuries  Peak incidence: age 5-9 years (boys and girls)  Seldom complete breaks  Children’s bones tend to bend or buckle because of increased flexibility  Flexibility due to thicker periosteum and increased amounts of immature bone  Most common sites: clavicle, tibia, ulna, and femur (distal forearm)
    122. 122. Pediatric Fractures and Falls McKinney Text, p. 1424
    123. 123. Question  School-aged children are most at risk for musculoskeletal injury when compared to other age groups of children.  A. True  B. False
    124. 124. Fractures—Signs and Symptoms  Pain, tenderness around area  Deformity  Immobility, ↓ ROM  Loss of function of that part of the body  Swelling  Soft tissue injury  Bleeding under the skin (ecchymosis, hematoma)  Muscle spasm (physiological splinting)  Crepitus—grating sound heard when bone fragments are rubbing together
    125. 125. Question  Musculoskeletal pain associated with soft tissue damage fractures, muscle spasms, surgical procedures, and immobilization devices is one of the most severe types of pain that can be experienced.  A. True  B. False
    126. 126. Types of Fractures
    127. 127. Types of Fractures
    128. 128. Open Fractures
    129. 129. Epiphyseal Growth Plate  Epiphyseal growth plate: vulnerable area, weakest part of long bone  Absorbs shock, protecting joint surfaces from serious fractures  Damage to growth plate causes growth disruption, arrest, or uneven growth (in the child who has not reached skeletal maturity and is still growing)
    130. 130. Injuries to the Ephiphyseal Plate (p. 977)
    131. 131. Reduction—Setting the Bone  Reduction (realignment)—repositioning the bone fragments into normal alignment  Closed reduction—manual alignment of the bone fragments (without surgery)  Open reduction—surgical insertion of internal fixation devices (rods, wires, pins) to help maintain alignment while healing occurs
    132. 132. Fixation  Device put in bone to maintain alignment to aid in healing  Two types:  Internal fixation  External fixation
    133. 133. Reduction with Internal Fixation
    134. 134. Reduction with External Fixation
    135. 135. Retention—Support, Protection, & Alignment  Device or mechanism (cast, splint) for protection, support, & alignment  Supports bony callus which is forming to bind the bony fragments together
    136. 136. Hip Spica Cast  Close observation is needed to check for cast tightness and circulatory changes caused by swelling or by the normal growth process  The child must be turned regularly to prevent skin problems and to provide maximum comfort  Position the child with head and upper body elevated at all times
    137. 137. Traction  Application of force to stretch certain parts of the body in a specific direction  Consists of pulleys, strings, weights, and a metal frame attached over or on the bed  Can only come off or be adjusted with provider’s order  Review p. 982 (Table 29-4)
    138. 138. Traction—Purpose  Maintain corrected position (put bones, joints in proper position)  Stabilize fractured bones  Muscle spasms or nerve irritation  Most often temporary (can’t operate on the bone right away)  Disadvantage: prolonged immobilization, must be in hospital  Traction being replaced by early casting & pinning
    139. 139. Skin Traction  Traction can either be applied directly to the skin (skin traction) or through pins inserted into bones (skeletal traction)  Skin traction:  Noninvasive (force directly on body surface)  Limited pulling force (limited weight)  Young children (< age 2 or 3)  Continuous or intermittent  Short-term use  Risk for skin breakdown and circulatory compromise
    140. 140. Skeletal Traction  Skeletal traction  Invasive (metal device inserted into bone)  Greater pulling force  Older children  Always continuous  Long-term use  Risk for infection  Osteomyelitis—most serious complication  Pin care: ½ H202, saline, antibiotic ointment, gauze (p. 983)
    141. 141. Skin Traction Types
    142. 142. Skin Traction Types
    143. 143. Skeletal Traction Types
    144. 144. Skeletal Traction Types
    145. 145. Question  With Buck's extension traction, a boot or circular wrap is applied to the skin.  A. True  B. False
    146. 146. Question  Which of the following statements about traction is true?  a. Traction is the application of pulling force to a body part against a counter traction pull exerted in the opposite direction.  b. The process is used only to treat long bone fractures.  c. Skin traction has a high risk of infection due to needed breakdown of the skin barrier.  d. Traction causes muscle spasms and should be avoided in those types of fractures where muscle spasms are a common complication.
    147. 147. Neurovascular Assessment (p. 979) Circulatio n Movement Sensation Skin color Temperature Quality of pulses Capillary refill Can the child freely wiggle her toes, move her fingers? Any pain? Have the child close her eyes, and tell you which toe you are touching
    148. 148. Neurovascular problems Early detection may mean no or slight disability in the future Assess carefully & knowingly!
    149. 149. Question  What is the best way to assess sensory function in a 6-year-old child with a lower leg cast?  A. Ask, “Do you feel this?” when pressing down on the little toe.  B. Check capillary refill in the middle toe.  C. Tell the child to wiggle his toes.  D. Ask, “Which toe am I pinching?” when pinching the great toe.
    150. 150. Compartment Syndrome (p. 979)  Most serious complication of closed fractures  Occurs when swelling causes pressure to rise within closed spaces of an extremity  Increased pressure compromises circulation to muscles and nerves, causing paralysis and necrosis
    151. 151. Compartment Syndrome (p. 979)
    152. 152. 5 P’s = Orthopedic Emergency  Pain  Pallor  Pulselessness  Paresthesia  Paralysis ***ASSESSMENT BEFORE NARCOTICS***
    153. 153. Question  List the 5 “P’s” of vascular impairment  Pain  Pallor  Pulselessness  Paresthesia  Paralysis
    154. 154. Question  A child has a closed fracture of the right radius, with slight ecchymosis below the elbow. She complains of extreme pain. Her right hand is cooler than her left, and she cannot extend the fingers of her hand because they “burn.” She is probably experiencing:  A. Compartment syndrome  B. Epiphyseal injuries  C. Early signs of an infection  D. All the above
    155. 155. Treatment—Fasciotomy  Treatment consists of relieving pressure by removing the cast or by performing a fasciotomy (incision into the fascia to relieve pressure on the nerves and blood vessels)
    156. 156. Sprains, Strains (p. 977)  Uncommon in children  Soft tissues are resilient  Ligaments and tendons are stronger than bones  ‘RICE’ for 24-36°  NSAIDs (no aspirin) to alleviate pain and reduce inflammation
    157. 157. Question  In young children, sprains and strains are very uncommon because the growth plates, or epiphyses, are weaker than the ligaments and will usually separate before a ligament will tear.  A. True  B. False
    158. 158. Question  An appropriate intervention for a child’s sprained ankle is:  A. Aspirin and elevating the foot  B. Ice packs and rest  C. Elastic bandage wrap and acetaminophen  D. All of the above
    159. 159. Bone Cancer
    160. 160. Osteosarcoma (OS) (p. 740)  Most common bone malignancy in children  Very aggressive tumor  Originates in osteoblasts  Dx: biopsy  Seen in adolescent boys  50% cases—femur  Pain  Pathologic (“stress”) fractures  Tx: Amputation, chemo
    161. 161. OS—Nursing Care  Amputation care postoperatively  Do not elevate the stump; keep it straight  Control bleeding  Pt will have phantom-limb pain  Chemotherapy (before and after)  N/V  Loss of hair
    162. 162. Ewings Sarcoma (pp. 741-742)  Second most common bone tumor seen in children  Extremely aggressive  Dx: biopsy  Poor prognosis— metastasis has already occurred in 90% of children  Pain, swelling, fever  Tx: chemo, radiation, surgery

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