1. The Child with a Musculoskeletal Condition
Chapter 24
The Child with a Musculoskeletal Condition

2. Musculoskeletal System
Supports the body
Provides for movement
Develops gradually and in an orderly manner in children
A marked slowing down of growth is always a signal for investigation

3. Newborn notes Limited ROM of hips Legs maintain a flexed position
Newborn spine a “C” shape
Feet usually turn inward or outward
Feet appear flat r/t fat arch

4. Observation of Gait
Children who don’t walk independently by 18 mo are delayed
Beginning walker unstable, but improves by 18 mo.
Toe walking after 3 yrs. can indicate a muscle problem
Young children appear bowlegged or knock-kneed until age 5
Usually toeing (pointing of the toe inward) in will clear by age 4

5. Tests & treatments
X-rays (radiographs) are taken to confirm suspected pathologic condition
Bone scans can see things not apparent on x-ray
CT shows cross-section
MRI has no radiation; produces detailed pictures
Ultrasound to r/o other causes

6. Pediatric Skeletal System
Epiphyses are present to allow for growth
Bone healing is rapid in children due to the thickened periosteum; a callus is formed quickly. Also a generous blood supply.
Approximate healing time:
Neonate: 2-3 weeks
Preschool: 4 weeks
School-age: 6 weeks
Adolescence: weeks

7. Trauma/Soft Tissue Injuries
Contusion
tissue tearing resulting in hemorrhage, edema, pain
Hematoma
escape of blood into soft tissue
Sprain
when ligament is torn away from bone. Swelling, disability, pain.
Strain
microscopic tear to muscle or tendon occurring over time

8. Prevent trauma!
Parents are responsible for maintaining a safe environment for their children
Nurses are responsible for educating parents & teachers on how!
Car seats, pedestrian safety, bicycle helmets, pool fences, window bars, locks.

9. Soft tissue injuries Treat immediately to limit damage
Cold pack & elastic wrap to reduce edema, bleeding & pain
On & off every 30 minutes
Elevate limb above heart
Frequent neuro checks
RICE them!
Rest
Ice
Compression
Elevation

10. Fractures A fracture is a break in a bone
s/s: pain, tenderness with movement, swelling; discoloration, limited ROM, numbness
Simple:
Bone is broken, but skin over it isn’t
Compound:
Wound in the skin over bone; increased risk of infection
Spiral:
Caused by a forceful twisting motion
Greenstick:
One side of bone broken, one side bent
More common in children

11. Types of fractures

12. Fractures Diagnosis & treatment: X-ray most reliable source Traction
bilateral views taken for children to compare sides
Traction
used when the cast can’t maintain alignment of the bone fragments
Traction aligns the injured bone by the use of weights & counteraction. Immobilization until the bones fuse

13. Types of traction Bryant traction
Used for treating fractures of the femur in children 2 years of age or under 20 to 30 pounds
N.I.:
be sure traction ropes are intact and in the wheel grooves of the pulleys
Legs should right angles to the body
buttocks lifted off the bed
continuous traction is necessary
the weights must hang free

14. Types of traction Russell Traction
Russell traction: a sling is positioned under the knee to suspend the distal thigh above the bed.
Skeletal traction: with a pin inserted into the bone and traction applied to the pin
Skeletal Traction

15. Types of Traction Buck’s Traction
Used in fractures of femur, hip, knee
Pulls hip/leg into extension
Used preoperatively
Reduces pain and muscle spasms
Keep patient feet off of the foot of the bed
Primary nursing responsibility is to inspect skin regularly
Risk for impaired skin integrity r/t immobility

16. Checking circulation
The nurse performs a neurovascular check to see if toes are warm and that their color is good.
A serious complication of traction is Volkmann’s ischemia, which occurs when the circulation is obstructed.

17. Effects of traction

18. Neurovascular Assessment
Pain
Record location & quality of pain
Compartment syndrome is a serious complication to consider if pain does not respond to medication; is a progressive loss of tissue perfusion.
Pulse
Compare quality to unaffected side
Movement/Sensation
Numbness or tingling should be reported
Color
cyanosis of site distal to fracture can indicate venous stasis
Capillary refill
less than 3 seconds
Warmth

19. Safety Alert The checklist for a traction apparatus includes
Weights are hanging freely
Weights are out of reach of the child
Ropes are on the pulleys
Knots are not resting against pulleys
Bed linens are not on traction ropes
Countertraction is in place
Apparatus does not touch foot of bed

20. Safety Alert Checklist for the patient in traction Body in alignment
HOB no higher than 20 degrees
Heels of feet elevated from bed
ROM of unaffected parts at regular intervals
Antiembolism stockings or foot pumps as ordered
Neurovascular checks performed regularly and recorded
Skin integrity monitored regularly and recorded
Pain relieved by medication is recorded
Measures to prevent constipation are provided
Use of trapeze for change of position is encouraged

21. Osteomyelitis An infection of bone usually by staph
Usually r/t a local injury to the bone such as open fx, a burn or contamination during surgery.
Can be r/t skin abrasion, abscessed teeth or otitis media.
S/s: Hx of trauma or infection.
Fever, restless, localized inflammation & increased pressure cause pain, r/t purulent drainage in bone marrow.
Treatment & Nursing Care:
IV antibiotics for 4 to 6 weeks & pain relief

22. Bone Tumors Osteosarcoma A primary malignant tumor of the long bones
2 most frequent malignant tumors in the child are osteosarcoma & Ewing’s sarcoma.
Usually occur yo.
Symptoms: pain & swelling at site; later, pathological fx may occur
Treatment: radical resection or amputation
Ewing’s Sarcoma
Cancer of the bone marrow in the long bones
Occurs mostly in older school age and early adolescent.
Treatment: Tumor is sensitive to radiation and chemotherapy
so amputation is generally not recommended

23. Juvenile Idopathic Arthritis
A systemic inflammatory dx affecting joints, connective tissues, & viscera.
Peak onset is 1-3 yr & 8-10 yr.
Goals of therapy
reduce joint pain & swelling
promote mobility, growth & development
promote independent functioning
help child & family adjust to a chronic dx.
Meds: NSAIDs, immune suppressant drugs, methotrexate, IV immunoglobins, antirheumatics
Occupational & physical therapy; psychological support
Morning tub baths, warm soaks & moist heat packs. No pillow or small flat pillow to promote body alignment

24. Scoliosis
Lordosis Kyphosis Scoliosis

25. Scoliosis Two Types Treatment and Nursing Interventions
Functional - usually caused by poor posture, not spinal dx
Structural - caused by changes in shape of vertebrae or thorax
Treatment and Nursing Interventions
Curves up to 20 degrees don’t require tx.
20 to 40 degree curves require a Milwaukee brace worn over a tee-shirt 23 hours a day.
Scoliosis Screening
examine the spine from the front, side & back while adolescent stands erect & then observing the back when bent over. Look for general body alignment & asymmetry

26. Milwaukee brace

27. Sports Injuries
Sports-specific examinations are given for those involved in strenuous activity on entry into middle school or high school
What are some prevention measures?
Common injuries include
Concussion
“Stingers” or “burners”
Injured knee
Sprain or strained ankle
Muscle cramps
Shin splints

28. Child abuse Emotional abuse Emotional neglect Sexual abuse
verbal acts that destroy child’s self-esteem
Emotional neglect
intentional omission of verbal or behavioral actions that are necessary for dev of healthy self-esteem
Sexual abuse
act performed on a child for gratification of adult
Physical neglect
failure to provide basic needs of child
Physical abuse
deliberate infliction of injury on a child

29. Child Abuse

30. Nursing interventions
Identify high-risk infants & parents during prenatal & perinatal periods
Both verbal & non-verbal communications are important
Keep factual & objective records
An abused child is approached quietly; preparation for tx explained in advance; praise used when appropriate
Nurse must acknowledge there are always two victims in child abuse

31. Assessing for child abuse

32. Assessing for child abuse
Bruises heal in various stages by color:
1 to 2 days – swollen, tender
Up to 5 days – red/purple
5 to 7 days – green
7 to 10 days – yellow
10 to 14 days – brown
Be suspicious of multiple bruises in various stages of healing!

33. Legal Reporting suspected abuse or neglect
All persons who report suspected abuse or neglect are given immunity from criminal prosecution and civil liability if the report is made in good faith
Know what your state laws mandate for health care providers

34. Nursing Interventions for Abused and Neglected Children and Adolescents
Teach child anxiety-reducing techniques
Assist child in managing his or her feelings
Teach child assertiveness skills
Assist child in developing problem-solving skills
Assist child in value-building and clarification
Assist child in enhancing his or her coping mechanisms

35. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.