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Chapter 24The Child with a Musculoskeletal ConditionObjectivesDemonstrate an understanding of age-specific changes that occur in the musculoskeletal system during growth and development.Discuss the musculoskeletal differences between the child and adult and how they influence orthopedic treatment and nursing care.Describe the management of soft-tissue injuries. Discuss the types of fractures commonly seen in children and their effect on growth and development.Objectives (cont.)Differentiate between Buck’s extension and Russell pile a nursing care plan for the child who is immobilized by traction.Describe a neurovascular check. Discuss the nursing care of a child in a cast.List two symptoms of Duchenne’s muscular dystrophy.Describe the symptoms, treatment, and nursing care for the child with Legg-Calvé-Perthes disease.Objectives (cont.)Describe two topics of discussion applicable at discharge for the child with juvenile rheumatoid arthritis.Describe three nursing care measures required to maintain skin integrity for an adolescent child in a cast for scoliosis.Identify symptoms of abuse and neglect in children.Describe three types of child abuse. State two cultural or medical practices that may be misinterpreted as child abuse.OverviewMuscular and skeletal systems work togetherArises from the mesoderm in the embryoA great portion of skeletal growth occurs between the 4th to 8th weeks of fetal lifeSupports the body and provides for movementLocomotion develops gradually and in an orderly mannerObservation of the Musculoskeletal System in the Growing ChildAssessment of the musculoskeletal system includes Observation of gait and muscle tonePalpationROMGait assessment in children who can walkChildren who do not walk independently by 18 months of age have a serious delay and should be referred for further follow-upMusculoskeletal Differences Between a Child and an AdultObservation of GaitToddler who begins to walk has a wide, unstable gaitArms do not swing with the walking motionBy 18 months, the wide base narrows and walk is more stableBy 4 years of age, the child can hop on one foot and arm swings occurBy 6 years of age, the gait and arm swing is similar to the adultObservation of Gait (cont.)The nurse’s role is to reassure parents that unless there is pain or a problem with motor or nerve functions, many minor abnormal-appearing alignments will spontaneously resolve with activityObservation of Muscle ToneAssess symmetry of movement and the strength and contour of the body and extremitiesNeurological exam includes an assessment of reflexes, a sensory assessment, and the presence or absence of spasmsDiagnostic TestsRadiographic studies includeBone scansCT scansMRI scansUltrasoundLaboratory tests includeCBCESRMay help rule out septic arthritis or osteomyelitisHuman leukocyte antigen (HLA) B-27 May help diagnose rheumatological disordersTreatments for Musculoskeletal SystemArthroscopyBone biopsyTractionCastingSplints Characteristics of the Child’s Musculoskeletal System Bone is not completely ossifiedEpiphyses are presentPeriosteum is thickProduces callus more rapidly than in the adultLower mineral content of the child’s bone and greater porosity increases the bone’s strengthBone overgrowth is common in healing fractures of children under 10 years of age because of the presence of the epiphysis and hyperemia caused by the traumaPediatric TraumaSoft-tissue injuries includeContusionSprainStrainInjuries should be treated immediately to limit damage from edema and bleedingPreventionProper use of pedestrian safetyCar seat restraintsBicycle helmets and other protective athletic gearPool fencesWindow barsDeadbolt locksLocks on cabinet doorHealth PromotionPrinciples of managing soft-tissue injuries include RestIceCompressionElevationTraumatic Fractures and TractionA fracture is a break in a bone and is mainly caused by accidentCharacterized by Pain, tenderness on movement, and swellingDiscoloration, limited movement, and numbness may also occurFractures heal more rapidly in childrenThe child’s periosteum is stronger and thicker, less stiffness on mobilizationInjury to the cartilaginous epiphysis is serious if it happens during childhoodMay interfere with longitudinal growth of the boneTypes of FracturesBryant’s TractionUsed for the young child who has a fractured femurNote that the buttocks are slightly off the bed to facilitate countertractionActive infants may require a jacket restraint to maintain body alignmentBuck’s ExtensionA type of skin traction used in fractures of the femur and in hip and knee contracturesIt pulls the hip and leg into extensionCountertraction is supplied by the child’s bodyEssential that the child not slip down in bedBed should not be placed in high-Fowler’s positionUsed to reduce pain and muscle spasm associated with slipped capital femoral epiphysisRussell Skin TractionSimilar to Buck’s extension tractionA sling is positioned under the knee, which suspends the distal thigh above the bedPulls in two directionsPrevents posterior subluxation of the tibia on the femurTwo sets of weights, one at the head and one at the foot of the bedSkeletal TractionSafety AlertThe checklist for a traction apparatus includes Weights are hanging freelyWeights are out of reach of the childRopes are on the pulleysKnots are not resting against pulleysBed linens are not on traction ropesCountertraction is in placeApparatus does not touch foot of bedForces of TractionOvercoming the Effects of TractionSafety AlertChecklist for the patient in tractionBody in alignmentHOB no higher than 20 degreesHeels of feet elevated from bedROM of unaffected parts at regular intervalsAntiembolism stockings or foot pumps as orderedNeurovascular checks performed regularly and recordedSkin integrity monitored regularly and recordedPain relieved by medication is recordedMeasures to prevent constipation are providedUse of trapeze for change of position is encouragedInfections Related to Skeletal TractionCarries the added risk of infection from skin bacteria that may cause osteomyelitisMeticulous skin and pin care is essentialNeurovascular ChecksDone to check for tissue perfusion of the toes or fingers distal to the site of an injury or the castThe check includesPeripheral pulse rate and qualityColor of extremityCapillary refill timeWarmthMovement and sensationHow to Test for Nerve DamageCasts and SplintsCan be made from a variety of materialsChild is at increased risk for Impaired skin integrityCompartment syndromeProgressive loss of tissue perfusion because of an increase in pressure caused by edema or swelling that presses on the vessels and tissuesIf not carefully monitored, significant complications can occurNursing Care of a Child in a CastMaterial used determines positioning of effected extremity for up to 72 hours Elevate effected extremity on a pillowPerform frequent neurovascular checksTeach cast care and how to support cast, safe transfers to/from chair/bed, how to use crutches safely, when a cast is too loose or too tightOsteomyelitisAn infection of the bone that generally occurs in children younger than 1 year of age and in those between 5 and 14 years of ageLong bones contain few phagocytic cells to fight bacteria that may come to the bone from another part of the bodyInflammation produces an exudate that collects under the marrow and cortex of the boneOsteomyelitis (cont.)Common organismsStaphylococcus aureus in children older than 5 years of ageAccounts for 75% to 80% of casesHaemophilus influenzae most common cause in young childrenMay be preceded by a local injury to the boneOsteomyelitis (cont.)Vessels in affected area are compressedThrombosis occursLeads to ischemia and painCollection of pus under the periosteum of the bone can elevate the periosteumCan result in necrosis of that part of the boneLocal inflammation and increased pressure can cause painAssociated muscle spasms can cause limited active ROMOsteomyelitis (cont.)DiagnosticsElevated WBC and ESRX-ray may initially fail to reveal infectionBone scan may be more reliableTreatmentIntravenous antibiotics for several weeksIf pus is present, it is drained and bone is immobilizedEarly passive ROM once splint is removed may be orderedPain reliefDiversional and physical therapyDuchenne’s or Becker’s Muscular Dystrophy (MD)Group of disorders in which progressive muscle degeneration occursDuchenne’s MD is most commonOnset is generally between 2 and 6 years of ageA history of delayed motor development during infancy may be evidencedDuchenne’s or Becker’s Muscular Dystrophy (MD) (cont.)Additional signs and symptomsCalf muscles in particular become hypertrophiedProgressive weakness as evidenced byFrequent fallingClumsinessContractures of the ankles and hipsGower’s maneuver to rise from the floorIntellectual impairment is commonDuchenne’s or Becker’s Muscular Dystrophy (MD) (cont.)DiagnosticsMarked increase in blood creatine phosphokinase levelMuscle biopsy reveals a degeneration of muscle fibers replaced by fat and connective tissueMyelogram shows decreases in the amplitude and duration of motor unit potentialsECG abnormalities are also commonDuchenne’s or Becker’s Muscular Dystrophy (MD) (cont.)Disease progressively worsensDeath usually from cardiac failure or respiratory infectionNursing care is primarily supportive to prevent complications and maintain quality of lifeChild may experience depression because he or she cannot compete with peersSlipped Femoral Capital EpiphysisAlso known as coxa veraSpontaneous displacement of the epiphysis of the femurOccurs most often during rapid growth of the preadolescent and is not related to traumaSymptoms include thigh pain and a limp or the inability to bear weight on the involved legBuck’s extension traction is used to minimize further slippage until surgical intervention can take placeLegg-Calvé-Perthes Disease (Coxa Plana)One of a group of disorders called the osteochondroses in which the blood supply to the epiphysis, or end of the bone, is disruptedTissue death that results from inadequate blood supply is termed avascular necrosisAffects the development of the head of the femurMore common in boys 5 to 12 years of ageHealing occurs spontaneously over 2 to 4 yearsLegg-Calvé-Perthes Disease (Coxa Plana) (cont.)Symptoms include Painless limpLimitation of motionX-ray films and bone scans confirm the diagnosisSelf-limiting, heals spontaneously with the use of ambulation-abduction casts or braces that prevent subluxationSome may require hip joint replacementOsteosarcomaPrimary malignant tumor of the long bonesMean age of onset is 10 to 15 years of ageChildren who have had radiation therapy for other types of cancer and children with retinoblastoma have a higher incidence of this diseaseMetastasis occurs quickly because of the high vascularity of bone tissueLungs are primary site of metastasisOsteosarcoma (cont.)ManifestationsExperiences pain and swelling at the siteMay be lessened by flexing the extremityPathologic fractures can occurDiagnosisConfirmed by biopsyRadiological studies help to confirmTreatmentRadical resection or amputation surgeryPhantom limb pain can occur because nerve tracts continue to “report” painEwing’s SarcomaMalignant growth that occurs in the marrow of the long bonesMainly occurs in older school-age children and early adolescentsWhen metastasis is present, prognosis is poorPrimary sites for metastasis are lungs and long bonesTreatmentRadiation therapy and chemotherapyJuvenile Idiopathic Arthritis (JIA)Formerly known as juvenile rheumatoid arthritis (JRA)Most common arthritic condition of childhoodSystemic inflammatory disease involving joints, connective tissues, and visceraNo specific tests or cures for JIADuration of symptoms is important, particularly if they have lasted longer than 6 weeksJuvenile Idiopathic Arthritis (JIA) (cont.)Three distinct methods of onsetSystemic (or acute febrile)PolyarticularPauciarticularJuvenile Idiopathic Arthritis (JIA) (cont.)SystemicOccurs most often in children 1 to 3 years of age and 8 to 10 years of ageIntermittent spiking fever (above 103° F) persisting for over 10 daysNonpruritic macular rashAbdominal painElevated ESR and C-reactive protein Juvenile Idiopathic Arthritis (JIA) (cont.)PolyarticularInvolves five or more jointsOften hands and feetBecome swollen, warm, and tenderOccurs throughout childhood and adolescencePredominantly seen in girlsJuvenile Idiopathic Arthritis (JIA) (cont.)PauciarticularLimited to four or fewer jointsGenerally in larger joints such as hips, knees, ankles, and elbowsOccurs in children younger than 3 years of age (mostly in girls)May be at risk for iridocyclitis, an inflammation of the iris and ciliary body of the eyeSymptoms include redness, pain, photophobia, decreased visual acuity, and nonreactive pupilsJuvenile Idiopathic Arthritis (JIA) (cont.)TreatmentGoals of therapy Reduce joint pain and swellingPromote mobility and preserve joint functionPromote growth and developmentPromote independent functioningHelp the child and family to adjust to living with a chronic diseaseJuvenile Idiopathic Arthritis (JIA) (cont.)Long-term disease characterized by periods of remissions and exacerbationsThe nurse helps the family by advocating for the child; in other words, helping the family to recognize the impact of the disease and by openly communicating with the child, family, and members of the health care teamTorticollis (Wry Neck)Neck motion is limited because of shortening of the sternocleidomastoid muscleCan be congenital (most common) or acquiredAcute or chronicAssociated with breech and forceps deliveryMay be seen in conjunction with other birth defects, such as congenital hip dysplasiaTorticollis (Wry Neck) (cont.)Symptoms are present at birthInfant holds head to the side of the muscle involved with chin tilted in opposite directionHard, palpable mass of dense fibrotic tissue (fibroma), not fixed to the skinResolves by 2 to 6 months of agePassive stretching, ROM, and physical therapy may be indicatedAcquired is seen in older children, may be associated with injury, inflammation, neurological disorders, and other causesScoliosisScoliosis (cont.)More common in girls Two typesFunctional—caused by poor postureStructural—caused by changes in the shape of the vertebrae or thoraxUsually accompanied by rotation of the spineHips and shoulders may appear to be unevenScoliosis (cont.)TreatmentAimed at correcting curvature and preventing severe scoliosisCurves up to 20 degrees do not require treatmentCurves 20 degrees to 40 degrees require the use of a braceCurves greater than 40 degrees and patients in whom conservative therapy were not successful require hospitalizationSpinal fusion is performedSports InjuriesSports-specific examinations are given for those involved in strenuous activity on entry into middle school or high schoolCommon injuries includeConcussion“Stingers” or “burners”Injured kneeSprain or strained ankleMuscle crampsShin splintsSports Injuries (cont.)Sports at higher risk for injury includeGymnasticsWrestlingFootball/SoccerHockeyBasketballVolleyballRunningSkiing or snowboardingFamily ViolenceAffects children of all social classes IncludesSpousal and child abuseNeglect Maltreatment Child AbuseChild Abuse (cont.)Types of child abuseEmotional abuseEmotional neglectSexual abusePhysical neglectPhysical abuseLegalReporting suspected abuse or neglectAll persons who report suspected abuse or neglect are given immunity from criminal prosecution and civil liability if the report is made in good faithKnow what your state laws mandate for health care providersNursing Interventions for Abused and Neglected Children and AdolescentsTeach child anxiety-reducing techniquesAssist child in managing his or her feelingsTeach child assertiveness skillsAssist child in developing problem-solving skillsAssist child in value-building and clarificationAssist child in enhancing his or her coping mechanismsAssessing for Child AbuseCultural and Medical IssuesA culturally sensitive history is essential in assessing children suspected to be victims of abuseSome cultural practices can be interpreted as physical abuse if the nurse is not culturally aware of folk-healing and ethnic practicesDocument all signs of abuse and interactions as well as verbal comments between the child and parentChild protective services should oversee any investigation that is warrantedQuestion for ReviewWhat nursing assessments are involved in a neurovascular check?ReviewObjectivesKey TermsKey PointsOnline ResourcesReview Questions ................
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