Lecture 5 The child with problems in locomotion

Question 1

Musculoskeletal Differences in Children

Answer 1

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

Question 2

_ is the leading cause of death in children older than 1 year

Answer 2

Trauma.

Question 3

Injuries by age group

Answer 3

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.

Question 4

Neurovascular assessment - six Ps

Answer 4

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

Question 5

Most common injuries in infants

Answer 5

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.)

Question 6

Most common injuries in childhood

Answer 6

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.

Question 7

Most common injuries in older childhood

Answer 7

Femur. Automobile accidents, bicycle accidents, falls.

Question 8

Most common injuries in adolescents

Answer 8

Knee injuries, often related to sports involvement.

Question 9

Clinical manifestations of fracture

Answer 9

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.

Question 10

Bend/plastic deformation

Answer 10

Child’s bone must bend at a 45 degree angle before it will break) - bone will continue to grow in an arced manner.

Question 11

Buckle/torus

Answer 11

Compression from both sides - incomplete break, more common in younger children.

Question 12

Greenstick fracture

Answer 12

Bent bone with an incomplete fracture.

Question 13

Complete (oblique) fracture

Answer 13

Bone fragments that are divided.

Question 14

Epiphyseal Injuries

Answer 14

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

Question 15

Cast care at home

Answer 15

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.

Question 16

Skin care after removal of the cast

Answer 16

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.

Question 17

Uses of traction

Answer 17

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)

Question 18

Purpose of traction

Answer 18

To provide equilibrium at the site of the fracture.

Question 19

3 components of traction

Answer 19

1. Traction: forward force produced by attaching weight to distal bone fragment; adjust by adding or subtracting weights.
2. Countertraction: backward force provided by body weight; increase by elevating foot of bed.
3. Frictional force: provided by patient’s contact with the bed.

Question 20

Manual traction

Answer 20

applied to the body part by the hand placed distally to the fracture site

Question 21

Skin traction

Answer 21

Pulling mechanisms are attached to the skin with adhesive material or elastic bandage
Requires intact skin; do not use if the skin is damaged.

Question 22

Skeletal traction

Answer 22

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.

Question 23

Buck’s traction is a type of _

Answer 23

Skin traction.

Question 24

The triangle bar is a type of _

Answer 24

Skeletal traction.

Question 25

The goal of cervical traction is to _

Answer 25

Fatigue the neck muscles and cause the vertebral bodies to gradually separate.

Question 26

Distraction

Answer 26

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

Question 27

External fixation

Answer 27

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.

Question 28

Most serious complication associated with traction

Answer 28

Pulmonary embolus AEB shortness of breath and chest pain. Interventions: Elevate head of bed, apply oxygen, call doctor.

Question 29

What is a physiologic effect of immobilization on children?

Answer 29

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.]

Question 30

What finding is characteristic of fractures in children?

Answer 30

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.]

Question 31

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?

Answer 31

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.]

Question 32

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?

Answer 32

Soak in a bathtub.

Question 33

When does idiopathic scoliosis become most noticeable?

Answer 33

During the preadolescent growth spurt.

Question 34

What is the primary method of treating osteomyelitis?

Answer 34

Intravenous antibiotic therapy. [Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus infection. The treatment of choice is antibiotics.]

Question 35

What nursing intervention is most appropriate when caring for the child with osteomyelitis?

Answer 35

Move and turn the child carefully and gently to minimize pain.

Question 36

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?

Answer 36

“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.]

Question 37

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, what should the nurse explain?

Answer 37

Frequent, serial casting is tried first.

Question 38

Congenital (Developmental) Dysplasia of the Hip

Answer 38

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.

Question 39

Manifestations of developmental dysplasia of the hip

Answer 39

1. Positive Ortolani maneuver.
2. Asymmetrical lower extremity skin folds.
3. Discrepancy in limb length.

Question 40

Osteogenesis imperfecta

Answer 40

*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

Question 41

Legg-Calve-Perthes Disease

Answer 41

Avascular necrosis of femoral head
10% to 15% of cases have bilateral hip involvement
Most have delayed bone age

Question 42

Osteomyelitis

Answer 42

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.