The Child WITH A MUSCULOSKELETAL condition CHAPTER 24

Musculoskeletal system

Differences between: child and adult Child: bone not completely ossified open epiphyses thicker periosteum periosteum produces callus more rapidly lower mineral content w/greater porosity increases bone strength

Child bone structure Ossification – process of bone formation (hardening of bone tissue) Open epiphyses – Thicker periosteum – produces callus more rapidly Lower mineral content – greater porosity increases bone strength

Observation of Gait Toddler – wide, unstable gait, arms do not swing 4 years-can hop on one foot, arm swings w/walking 6 years – gait resembles adult Toe walking after 3 years can indicate muscle problem.

Skin Traction Three types: 1. Bryant’s traction 2. Buck’s traction 3. Russell traction Often used for the lower extremities Causes immobility Reduces the fracture and keeps bones in proper alignment Aligns injured bones by use of weight and countertraction Pulls the hip and leg into extension Reduces pain and muscle spasms

Bryant’s traction

Buck’s Extension

Russell Traction

Soft tissue injuries Treatment – Application of cold pack and wrap with ACE elastic Elastic wrap – reduces edema, pain, and bleeding. Should be applied at alternating 30-minute intervals. Elevating extremity to reduce edema Priority – perform frequent neurovascular checks to ensure adequate tissue perfusion. Contusion – tearing of subcutaneous tissue resulting in hemorrhage Sprain – caused by torn or stretched ligament with possible damage to blood vessels, muscles, and nerves Strain – microscopic tear to muscle or tendons that results in edema and pain Managing soft tissue injuries: Rest Ice Compression Elevation

Bandaging lower extremity

Checklist for patient in traction Body in alignment Head of bed no higher than 20 degrees Heels of feet elevated from bed ROM on unaffected parts Neurovascular checks performed regularly Skin integrity Pain assessment and relief Constipation measures Use of trapeze

Traumatic fractures Simple fracture – bone is broken, but skin is intact Compound fracture - wound in skin occurs with broken bone, with added danger of infection Greenstick fracture – incomplete fracture – one side of bone is broken but other side is bent This fracture is common in children (bones are flexible, soft, and more likely to splinter Spiral fractures – caused by a manual forceful twisting motion of the femur Child abuse is suspected if injury does not correlate with x-ray

Treatment with traction Bryant’s traction – used for treating fractures of femur in:  children less than 2 years old or lighter than 20 to 30 lbs Weight and pulleys extend the limb, the legs are suspended vertically. Weight of child supplies the counteraction.

Buck’s skin traction (Buck’s extension) Used in older children – skeletal muscles act as a splint for the fracture It aligns the injured bone by the use of weights and counteraction. Immobilization is maintained until the bones fuse. Used for fractures of the femur and in hip and knee contractures. Pulls hip and leg into extension Child’s body supplies counteraction, it is essential that child does not slip down in bed and that the bed is not placed in high-Fowler’s position Review Nursing Tip, page 561

Russell Traction Similar to Buck’s extension: A sling is positioned under the knee, which suspends the distal thigh above the bed Skin traction is applied to the lower extremity Pull is in two directions, vertically from the knee sling and longitudinally from foot plate

Nursing responsibilities of traction Observe traction ropes for intactness and in wheel groves of pulleys Body in alignment Elastic bandages should not be too loose or too tight Jacket restraint may be used in Bryant’s traction to prevent child from turning side to side Continuous traction is necessary Perform frequent neurovascular checks for tissue perfusion to toes or fingers distal to an injury or cast and includes:  peripheral pulse rate and quality  color  capillary refill time  warmth  movement and sensation Cyanosis, numbness, or irritation from attachments; tight bandages, severe pain, hypoxia or absence of pulse rates in the extremities are immediately reported Volkmann’s ischemia – a serious complication of any traction which occurs when the circulation is obstructed. Special precautions to prevent choking and aspiration during mealtime are a priority nursing responsibility. A fractured pan is used and careful I & O are kept. Deep breathing exercises Diversional therapy

A child in traction Be familiar with the nursing diagnosis related to a child in traction, Nursing care plan 24-1, page 565 Know which ones are priority nursing diagnosis and rationale.

Assessing for compartment syndrome A priority nursing responsibility when caring for a child with a fracture who is in traction or who has a cast or Ace bandage in place is to perform neurovascular checks. Review Skill 24-1, page 563. Compartment syndrome – progressive loss of tissue perfusion caused by increase in pressure resulting from edema or swelling that presses on the vessels and tissue. Circulation is compromised, neurovascular checks are abnormal. Can be caused by a cast that is too tight and compromises circulation or by excessive edema that causes ischemia.

osteomyelitis Infection of the bone that generally occurs in children younger than 1 year of age and those 5 and 14 years of age. The inflammation produces an exudate that collects under the marrow and cortex of bone.

osteomyelitis Vessels in affected area are compressed, thrombosis occurs, producing ischemia and pain. The collection of pus under the periosteum of the bone can elevate the periosteum, which can result in necrosis of that part of the bone. Pain can be caused by local inflammation and increased pressure from the distended periosteum. Treatment: IV antibiotics are prescribed for 4-6 week period. High doses require nursing monitoring for toxic responses and to ensure long-term compliance. Joint may be drained of pus arthroscopically or surgically. Weight bearing should be avoided.

Duchenne’s muscular dystrophy Progressive muscle degeneration occurs. Most common type in childhood. Sex-linked inherited disorder that occurs in boys only. Calf muscles become hypertrophied Dystrophin, a protein in skeletal muscle is missing.

Duchenne’s muscular dystrophy Manifestations: Frequent falls Clumsiness Contractures of ankles and hips Gowers’ maneuver As condition gets worse, wheelchair confinement may be necessary

Duchenne’s muscular dystrophy Treatment and Nursing Care: Prednisone Mainly supportive to prevent contractures and maintain quality of life Children may appear passive, withdrawn and depressed

Legg-calvÉ-perthes disease (coxa plana) Affects the development of he head of the femur osteochondroses – blood supply to the epiphysis is disrupted Avascular necrosis It is seen in boys between 5 and 12 years of age Unilateral in 85% of cases Healing occurs spontaneously during 2-4 years; marked distortion of head of femur may lead to an imperfect joint or degenerative arthritis of the hip later in life.

Legg-calvÉ-perthes disease (coxa plana) Treatment – Self-limiting, heals spontaneously but slowly Involves keeping the femoral head deep in the hip socket while it heals and preventing weight bearing

Ewing’s sarcoma Malignant growth that occurs in the marrow of the long bones Occurs mainly in older school age children and early adolescents Primary sites of metastasis are the lungs and long bones

Ewing’s sarcoma Treatment and Nursing Care: Tumor is sensitive to chemotherapy & radiation Child is warned against vigorous weight bearing on the involved bone during therapy to help prevent pathological fractures

Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) Most common arthritic condition of childhood Systemic autoimmune disease that involves the joints, connective tissues, and viscera Not a rare disease Cause is unknown, but autoimmune response is believed to be cause.

Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) Manifestations & types: 1. Oligo Arthritis – 4 or fewer joints & uveitis in 30% of cases 2. Polyarthritis – 5 or more joints & uveitis in 10% of cases 3. Systemic arthritis – fever, rash, and joint inflammation with 10% of cases w/uveitis. Manifested by intermittent spiking fever above 39.5ºC (103ºF) persisting for more than 10 days, nonpurulant macular rash, abdominal pain, elevated ESR

Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) Treatment – Goals of therapy: Reduce joint pain & swelling Promote mobility & preserve joint function Promote growth & development

Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) Nursing Care: Physical and occupational therapy preserve joint function & mobility Using a supportive, flat mattress is helpful while resting in bed Resting splints during sleep prevent flexion contractures from developing Moist heat and exercise in the morning are helpful to relieve stiffness and pain Whirlpool baths and hot packs also relieve stiffness and pain

Torticollis (wry neck) Neck motion is limited and cervical spine is rotated because of shortening of the sternocleidomastoid muscle Congenital or acquired Most common is when sternocleidomastoid muscle is injured during birth Manifestations: infant holds head to the side of the muscle involved, chin tilted in opposite direction Treatment: ROM exercises, physical therapy and surgical correction of condition

scoliosis S-shaped curvature of the spine More common in girls during adolescence. Untreated progressive scoliosis may lead to back pain, fatigue, disability, heart & lung complications Skeletal deterioration does not stop with maturity and may be made worse by pregnancy

scoliosis Two types – 1. functional 2. structural Functional – caused by poor posture Structural – caused by changes in shape of the vertebrae or thorax Usually accompanied by rotation of the spine Hips & shoulders appear uneven Patient cannot correct condition by standing in a straighter position

scoliosis Signs/symptoms: Develop slowly and not painful Detection usually by incidental screening by school nurse Shoulders are different heights with one higher than the other, one-sided rib hump and a prominent scapula are seen Asymmetry is seen from the back when child leans forward

scoliosis Treatment: Aimed at correcting & preventing more severe scoliosis Curves between 20 and 40 degrees require use of a Milwaukee brace. The brace is worn about 23 hours/day and is worn over a t-shirt to protect skin. Transcutanous electrical muscle stimulation (TENS) & exercise have also proven to be effective

Child abuse Serious physical, neglect and maltreatment National Center on Child Abuse and Neglect, reports the following situations increasing: Emotional abuse –intentional verbal acts that result in destruction of self-esteem Emotional neglect-social or emotional isolation of a child Sexual abuse – act by a person to a child for sexual gratification Physical neglect – failure to provide basic needs (food, clothing, shelter, cleanliness) Physical abuse – deliberate infliction of injury on a child Be culturally sensitive when assessing/evaluating for child abuse. Check for impetigo, Mongolian spots, severe diaper rashes. “Coining” of body by Vietnamese causes welts on the body Burning small areas to treat enuresis by Asian cultures Forced kneeling is common in Caribbean culture Garlic preparations used by Yemenite Jews causes blisters on wrists

Child abuse Assessing bruises: bruises heal in various stages – Swollen, tender: 1-2 days Red, purple: 2 to 5 days Green: 5 to 7 days Yellow: 7 to 10 days Brown: 10 to 14 days Nursing Care & Interventions: Identify high-risk infants and parents Observe parents and their abilities to cope – feeling overwhelmed Acknowledge that there are two victims – the child and the abuser Abuser leading isolated life Battered and neglected themselves May have unrealistic expectations about child’s intelligence & capabilities Role reversal – child becomes comforter Review Figure 24-14: Assessing for child abuse, page 575

Questions?

Review Questions for the NCLEX Examination A type of fracture in a young child that may be indicative of child abuse is:

Answer options Greenstick fracture of the tibia. spiral fracture of the femur. Pathological fracture of the fibula. Aligned fracture of the wrist.

Review Questions for the NCLEX Examination Question 2: A teenager who had a cast applied after a tibia fracture complains that his pain medication is not working and his pain is still a 9 or 10. The nurse notices some edema of the toes and a capillary refill of 6 seconds. The priority action of the nurse would be:

Answer options Call the health care provider immediately Check if there is an order for a stronger pain medication. Try nonpharmacological techniques of pain relief. Explain to the teen that a new fracture is expected to be painful the first day.

Review Questions for the NCLEX Examination Question 3: A “neurovascular check” for tissue perfusion includes which of the following observations (select all that apply)?

Answer options Pulse Color and capillary refill Movement and sensation Equal pupil size of eyes

Review Questions for the NCLEX Examination Question 4: An abnormal S-shaped curvature of the spine seen in school-age children is:

Answer options Sclerosis Sciatica Scabies Scoliosis

Review Questions for the NCLEX Examination Question 5: A yellow bruise is approximately:

Answer options 2 days old 5 to 7 days old 7 to 10 days old

Review Questions for the NCLEX Examination Question 6: A nurse is leading a discussion with a group of peers regarding different types of fractures. Which of the following is an open fracture?

Answer options 1. A fracture in which the fragments of the bone are separated 2. A fracture in which the broken bone penetrates the skin. A fracture in which there is a single break in the bone without penetration of the skin A fracture in which the fragments of the bone remain partially joined

Review Questions for the NCLEX Examination Question 7: In caring for a child in traction, which of the following interventions is the highest priority for the nurse?

Answer options The nurse should monitor for decreased circulation every 4 hours. The nurse should clean the pin sites at least once every 8 hours. The nurse should provide age-appropriate activities for the child. The nurse should record accurate intake and output.

Review Questions for the NCLEX Examination Question 8: The nurse is reinforcing client teaching with a child who has been placed in a brace to treat scoliosis. Which of the following statements made by the child indicates an understanding of the treatment?

Answer options “I am so glad I can take this brace off for the school dance”. “At least when I take a shower I have a few minutes out of this brace.” “Wearing this brace only during the night won’t be so embarrassing.” “When I start feeling tired, I can just take my brace off for a few minutes.”

Review Questions for the NCLEX Examination Question 9: The nurse is caring for a child after a motor vehicle accident in which the child fractured his arm. A cast has been applied to the child’s right arm. Which of the following actions should the nurse implement? Select all that apply.

Answer options Wear a protective gown when moving the child’s arm. Document any signs of pain. Check radial pulse in both arms. Monitor the color of the nail beds in the right hand.

Review Questions for the NCLEX Examination Question 10: The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother?

Answer options “Avoid all exercise during painful periods.” “The ROM exercises must be performed every day.” “Have the child perform simple isometric exercises during this time.” “Administer additional pain medication before performing ROM exercises.”

Review Questions for the NCLEX Examination Question 11: A 4-year-old child sustains a fall at home and is brought to the ER by the mother. After an x- ray, it is determined that the child has a fractured arm, and a plaster cast is applied. The nurse reinforces instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further teaching?

Answer options “The cast may feel warm as it dries.” “I can use lotion or powder around the cast edges to relieve itching.” “A small amount of white shoe polish can touch up a soiled white cast.” “If the cast becomes wet, a blow-dryer set on the cool setting may be used to dry it.”

Review Questions for the NCLEX Examination Question 12: The nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which is the priority when performing this procedure?

Answer options Taking the temperature Taking the blood pressure Checking the apical heart rate Checking the peripheral pulse in the affected arm

Review Questions for the NCLEX Examination Question 13: The nurse is assigned to care for a child who is in skeletal traction. The nurse need to avoid which action when caring for the child?

Answer options Keeping the weights hanging freely Ensuring that the ropes are in the pulleys Placing the bed linens on the traction ropes Ensuring that the weights are out of the child’s reach