Chapter 44 Nursing Care of the Child with an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder Flashcards
Mobility
Refers to mechanisms that facilitate or impair a person’s ability to move
Neuromuscular System
The combination of the nervous system and the muscles working together to create movement
Function of Musculoskeletal System
Provides the body with form, support, stability, protection, and the ability to move
Components of Musculoskeletal System
Made up of bones, muscles, cartilage, tendons, ligaments, joints, & connective tissue
Alterations in Pediatric Neuromuscular System
Immaturity of the neurologic and musculoskeletal systems, place them at increased risk for the development of a neuromuscular and musculoskeletal disorder and may hinder the child’s growth and movement
Brain & Spinal Cord Development
Around 3 to 4 weeks gestation, the neural tube of the embryo begins to differentiate into the brain and spinal cord
- If the fetus suffers infection, trauma, malnutrition, or teratogen exposure during this critical period of growth and differentiation, brain or spinal cord development may be altered
The premature infant’s central nervous system is less mature than the term newborn’s
- Places infant at a higher risk of CNS insult w/in the neonatal period, which may result in delayed motor skill attainment or cerebral palsy
Compared with the adult, the child’s spine is very mobile, especially the cervical spine region
- Higher risk for cervical spine injury
Myelinization in Pediatric Patients
Myelinization is incomplete at birth
- Continues to progress and is complete by about 2 years of age
Myelinization proceeds in a cephalocaudal and proximodistal fashion, allowing the infant to gain head and neck control before becoming able to control the trunk and the extremities
- As myelinization proceeds, the speed and accuracy of nerve impulses increase
- Primitive reflexes are replaced with voluntary movement.
Muscular Development in Children
At birth (term or preterm), the muscles, tendons, ligaments, and cartilage are all present and functional
The newborn infant is capable of spontaneous movement but lacks purposeful control
- Full range of motion is present at birth. Healthy infants and children demonstrate normal muscle tone
- Hypertonia or hypotonia is an abnormal finding.
Deep tendon reflexes are present at birth and are initially brisk in the newborn and progress to average over the first few months.
- Sluggish deep tendon reflexes indicate an abnormality
The infant’s muscles account for approximately 25% of total body weight, as compared with the adult’s muscle mass, which accounts for about 40% of total body weight
Muscles grow rapidly in adolescence ->contributes to clumsiness, which places the teen at increased risk for injury
- In response to testosterone release, the adolescent boy experiences a growth spurt, particularly in the trunk and legs, and develops bulkier muscles
Female infants tend to have laxer ligaments than male infants, possibly due to the presence of female hormones
- Increased risk for developmental dysplasia of the hip (DDH)
Hypertonia
Increased muscle tone
Hypotonia
Low muscle tone
Measures to Promote Bone Health
Diet: Strong in Vitamin D, Calcium, and protein.
- School-age up need 1000mg Calcium daily (about 4 cups of milk a day)
- Adolescents need 1300 mg of Calcium a day.
Weight-bearing exercise increase bone density
Avoidance of Carbonated beverages: Decreases the bone’s ability to absorb calcium
Pediatric Bone Anatomy
Infant skeleton not fully ossified at birth
- Contains increased amounts of cartilage compared with adolescents and adults
- Lower mineral content than adult
Thick, strong periosteum (better shock absorber)
- Bones will often bend than break during an injury
Bone ossification (cartilage to bone) complete by adolescence
Growth plate end of long bone composed of epiphysis and physis (Epiphyseal growth plate)
- Can bend up to ~45 degrees before breaking
Growth plate is most vulnerable part of the bone
- Damage to this area can interrupt blood supply and cause growth failure
During fetal development the spine displays kyphosis
- Cervical lordosis, inward curvature, develops as the infant starts to hold the head up
When the infant or toddler assumes an upright position, the primary and secondary curves of the spine begin to develop
- The balance of the curves allows the head to be centered over the pelvis
During the toddler years, the period of early walking, lumbar lordosis may be significant (also termed toddler lordosis), and the toddler appears quite swaybacked and potbellied.
As the child develops, the spine takes on more adult-like curves
- During adolescence thoracic kyphosis may become evident (posture)
Ossification
Conversion of cartilage to bone
Continues throughout childhood and is complete at adolescence
Kyphosis
Outward spinal curvature
Lordosis
Inward spinal curvature
Epiphysis
End of long bone
Physis
Cartilaginous area between the epiphysis & metaphysis
Growth Plate
Combination of the epiphysis (end of long bone) & physis
In infants, the epiphyses are cartilaginous and ossify over time. In children, the epiphysis is the secondary ossification center at the end of the bone
Growth of the bones occurs primarily in the epiphyseal region
- This area is vulnerable and structurally weak.
Traumatic force applied to the epiphysis during injury may result in fracture in that area of the bone.
Epiphyseal injury may result in early, incomplete, or partial closure of the growth plate, leading to deformity or shortening of the bone.
Epiphyseal growth continues until skeletal maturity is reached during adolescence.
- Production of androgens in adolescence gradually causes the growth plates to fuse, and thus long bone growth is complete
Fractures in Children
Fractures are a common injury in children
- Rare in infants
Clavicle is the most frequently broken bone in childhood, especially in those less than 10 years old
- Head is top heavy
What components do you include when describing a fracture?
Name bone affected
Note if open or closed
Note if distal or proximal
Part of bone injured: Epiphysis, metaphysis, diaphysis,
Physis (Salter Harris Classification)
Note if displaced or nondisplaced
Transverse, Oblique, Spiral, Depressed
Greenstick Fracture
Compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture
Spiral Fracture
Spiral appearance of fracture
Always investigate spiral fractures in children where mechanism of injury does not match fracture type, ESPECIALLY in non-ambulatory child
Buckle Fracture
Produced by compression of the porous bone and appears like a raised or bulging projection at the site
Open or Compound Fracture
Fractured bone protrudes through the skin
Stress Fracture
Tiny cracks in a bone
Caused by repetitive force, such as repeatedly jumping up and down or running long distances
Salter-Harris Classification System
Used to describe fractures involving the growth plate
These injuries have a higher possibility of difficult healing
Most common concern is:
- Growth arrest with thepotentialfor deformity and limb length discrepancy
Salter-Harris Fracture Type I
Fracture is through the physis, widening it
Salter-Harris Fracture Type II
Fracture is partially through the physis, extending into the metaphysis
Treatment for Salter-Harris Type I & II Fractures
Can be treated with closed reduction, casting, or splinting
The reduction should be performed carefully to avoid damage to or grating of the physis on any metaphyseal bone fragments
Salter-Harris Fracture Type III
Fracture is partially through the epiphysis, extending into the epiphysis
Salter-Harris Fracture Type IV
Fracture is partially through the epiphysis, extending into the epiphysis
Treatment for Salter-Harris Type III & IV
Usually require open reduction and internal fixation (avoiding crossing the physis)
Salter-Harris Fracture Type V
Crushing injury to the physis
Diagnosis may be delayed unless there is a high degree of clinical suspicion, and often the diagnosis is not made at the initial presentation
An emergent orthopedic consultation should be obtained if the fracture is recognized
As these fractures involve the germinal matrix, they have a potential for growth arrest
Bone Healing in Children
Bone healing occurs in the same fashion as in the adult, but because of the rich nutrient supply to the periosteum, it occurs more quickly in children
Children’s bones produce callus more rapidly and in larger quantities than do adults
As new bone cells quickly form, a bulge of new bone growth occurs at the site of the fracture
The younger the child, the more quickly the bone heals
- Also, the closer the fracture is to the growth plate (epiphysis), the more quickly the fracture heals
The capacity for remodeling (the process of breaking down and forming new bone) is increased in children as compared with adults. This means that straightening of the bone over time occurs more easily in children
What are the stages of bone healing?
1) Inflammatory Phase
2) Reparative Phase
3) Remodeling Phase
Inflammatory Phase
Reparative Phase
Remodeling Phase
Nursing Measures for Casts & Splints
Assess injury & determine if open fracture is present
Peripheral vascular checks w/ initial assessment & prior to & after any immobilization and/or reductions
Pain Management
- Pharmacological: Ibuprofen, aspirin, morphine if displaced
- Non-Pharmacological: Traction, ice, elevate the extremity, immobilize, play music & utilize other distraction techniques
Apply splint, ensure proper placement of splint padding and splint.
Educate patient and family regarding warning signs of compartment syndrome and care of cast or splint
- Warmth
- Sudden increase in pain
- Loss of sensation in affected extremity
