Lecture 5 The child with problems in locomotion Flashcards
Musculoskeletal Differences in Children
Epiphyseal growth plate present
Bones are growing (heal) faster
Bones are more pliable (takes more force to do injury to a child’s bones).
Periosteum thicker and more active
Abundant blood supply to the bone
The younger the child, the faster the healing
_ is the leading cause of death in children older than 1 year
Trauma.
Injuries by age group
Infancy – large head; Head projects the rest of the body forward in MVAs.
School-age – bone growth outpaces muscle growth, risk-taking behaviors, trouble controlling movements, awkward phases.
Adolescence – risk-taking, sports participation after injury, repetitive injuries become an issue because children may not want to sit out or they may continue to participate despite injury.
Neurovascular assessment - six Ps
Pain (and point of tenderness)
Paresthesia (sensation distal to the fx.)
Pallor
Paralysis (movement distal to the fx.)
Pulse (distal to the fx.)
Pressure - teach child and parents to be aware of pressure points, especially if traction/casted
Most common injuries in infants
MVA and abuse (B-5 = Acronym for what should raise the level of suspicion regarding abuse: Bumps, bruises, breaks, burns, and injuries that occur in the bathroom.)
Most common injuries in childhood
Forearm and clavicle. Forearm extension injuries; half of all clavicular fractures occur in children less than 10 years of age. Not as common in older children.
Most common injuries in older childhood
Femur. Automobile accidents, bicycle accidents, falls.
Most common injuries in adolescents
Knee injuries, often related to sports involvement.
Clinical manifestations of fracture
Generalized swelling
Pain or tenderness
Diminished functional use (occurs rapidly due to muscle tightening around the site of the fracture).
May have bruising, severe muscular rigidity, crepitus.
Crepitus = Grinding sound, bone-on-bone - complete fracture.
Bend/plastic deformation
Child’s bone must bend at a 45 degree angle before it will break) - bone will continue to grow in an arced manner.
Buckle/torus
Compression from both sides - incomplete break, more common in younger children.
Greenstick fracture
Bent bone with an incomplete fracture.
Complete (oblique) fracture
Bone fragments that are divided.
Epiphyseal Injuries
Weakest point of long bones is the cartilage growth plate (epiphyseal plate)
Frequent site of damage during trauma, but healing is usually prompt.
May affect future bone growth - angular deformations may occur.
Treatment may include open reduction and internal fixation to prevent growth disturbances
Cast care at home
Elevate extremity to prevent edema (teach). Teach 6 Ps to child and parents. Extremity should not be in a dependent position for more than 30 minutes. Do not allow water to get inside the cast - maceration of the skin, fungal infections. Parents of younger children - monitor toys, crayons, etc. - these may get into the cast and cause skin breakdown. Do not place pencils, combs, etc. down the cast to relieve itching.
Skin care after removal of the cast
Insensible water loss may occur through the skin under the cast - white, puffy skin - this is normal, teach the parents not to scrub the skin, only wash gently.
Uses of traction
Provide rest for an extremity
Help prevent or improve contracture deformity
Correct a deformity
Treat a dislocation
Allows position changes and (re-)alignment (unique advantage of traction)
Provide immobilization
Reduce muscle spasms (rare in children)
Purpose of traction
To provide equilibrium at the site of the fracture.
3 components of traction
- Traction: forward force produced by attaching weight to distal bone fragment; adjust by adding or subtracting weights.
- Countertraction: backward force provided by body weight; increase by elevating foot of bed.
- Frictional force: provided by patient’s contact with the bed.
Manual traction
applied to the body part by the hand placed distally to the fracture site
Skin traction
Pulling mechanisms are attached to the skin with adhesive material or elastic bandage
Requires intact skin; do not use if the skin is damaged.
Skeletal traction
applied directly to skeletal structure by pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture
Long-term use. Easier for the child to move with this type of traction.
Stress is placed on the bone itself rather than the skin.
Buck’s traction is a type of _
Skin traction.
The triangle bar is a type of _
Skeletal traction.
The goal of cervical traction is to _
Fatigue the neck muscles and cause the vertebral bodies to gradually separate.
Distraction
Process of separating opposing bone to encourage regeneration of new bone in the created space
Can get more length out of the extremity - new bone grows in the space.
Can be used when limbs are unequal in length and new bone is needed to elongate the shorter limb
External fixation
A system of wires, rings and telescoping rods that permits limb lengthening to occur by manual distraction – can result in a gain of up to 15 cm
Can also be used to correct angular or rotational defects, as well as immobilize fractures
No full weight bearing until the distraction is complete; cast will be on for 4-6 weeks.
Most serious complication associated with traction
Pulmonary embolus AEB shortness of breath and chest pain. Interventions: Elevate head of bed, apply oxygen, call doctor.
What is a physiologic effect of immobilization on children?
Circulatory stasis can lead to thrombus and embolus formation. [The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. With the loss of muscle contraction, there is a decreased venous return to the heart. Calcium leaves the bone during immobilization, leading to bone demineralization and increasing the calcium ion concentration in the blood.]
What finding is characteristic of fractures in children?
Rapidity of healing is inversely related to the child’s age. [Healing is more rapid in children. The younger the child, the more rapid the healing process. Nonunion of bone fragments is uncommon except in severe injuries. The epiphyseal plate is the weakest point of long bones and a frequent site of injury during trauma.]
A 7-year-old child has just had a cast applied for a fractured arm with the wrist and elbow immobilized. What information should be included in the home care instructions?
Elevate casted arm when both upright and resting. [The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return.]
A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What technique should the nurse suggest to remove this material?
Soak in a bathtub.
When does idiopathic scoliosis become most noticeable?
During the preadolescent growth spurt.
What is the primary method of treating osteomyelitis?
Intravenous antibiotic therapy. [Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus infection. The treatment of choice is antibiotics.]
What nursing intervention is most appropriate when caring for the child with osteomyelitis?
Move and turn the child carefully and gently to minimize pain.
The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. What statement by the parent would indicate a correct understanding of the teaching?
“I should gently massage the skin under the straps once a day to stimulate circulation.” [To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a Pavlik harness, the parent should gently massage the skin under the straps once a day to stimulate circulation. The parent should not apply lotions or powder because this could irritate the skin. The parent should not remove the harness, except during a bath, and should place the diaper under the straps.]
A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what should the nurse explain?
Frequent, serial casting is tried first.
Congenital (Developmental) Dysplasia of the Hip
Abnormality in the development of the proximal femur, acetabulum, or both.
Girls affected 6:1
More frequently seen in caucasian children; more common in breech presentations.
Treat within first 2 months - Pavlik harness, hip surgery.
Manifestations of developmental dysplasia of the hip
- Positive Ortolani maneuver.
- Asymmetrical lower extremity skin folds.
- Discrepancy in limb length.
Osteogenesis imperfecta
*Autosomal dominant* condition in which the child does produce enough *collagen* Demineralization, cortical thinning Multiple fractures with pseudoarthrosis Exuberant callus formation Blue sclera Wide sutures Pre-senile deafness
Legg-Calve-Perthes Disease
Avascular necrosis of femoral head
10% to 15% of cases have bilateral hip involvement
Most have delayed bone age
Osteomyelitis
Inflammation and infection of bony tissue
May be caused by exogenous or hematogenous sources
*Typically in children younger than 10; Staph aureus is the most common causative organism in non-neonates. In neonates - group B strep.
