Musculoskeletal Conditions

Question 1

Introduction of Musculoskeletal System

Answer 1

1. Bone length occurs in the epiphyseal plates at the ends of bones; when the epiphyses close, growth stops.
   a. Damage to the epiphyseal plates can disrupt bone growth.
2. Bone healing occurs much faster in the child than in the adult, because the child’s bones are still growing.
   a. The younger child, the faster the bone heals.
   b. Bone healing takes approximately 1 week for every year of life up to age 10.
3. Orthopedic anomalies may interfere with the funciton of other organ systems.
4. The most common fractures in the child are clavicular and greenstick.
   a. Clavicular fractures are common following vaginal birth, because the shoulders are the widest part of the body.
   b. Greenstick fractures of the long bones are related to the increased flexibility of the young child’s bones; the compressed side bends and the tension side fractures.
   c. Spiral fracture (in non-ambulatory patients especially) possibly indicates child abuse - break travels around the bone.
   d. Compound fracture (open - the skin is broken by the bone).
   e. Comminuted fracture is when the bone breaks into several pieces.

Question 2

What happens when there is damage to the epiphyseal plates?

Answer 2

Disruption to bone growth.

Question 3

When are clavicular fractures most commonly seen?

Answer 3

Clavicular fractures are common following vaginal birth, because the shoulders are the widest part of the body.

Question 4

How do greenstick fractures happen?

Answer 4

Greenstick fractures of the long bones are related to the increased flexibility of the young child’s bones; the compressed side bends and the tension side fractures.

Question 5

What is most concerning about spiral fractures?

Answer 5

Spiral fracture (in non-ambulatory patients especially) possibly indicates child abuse - break travels around the bone.

Question 6

What is a compound fracture?

Answer 6

Compound fracture (open - the skin is broken by the bone).

Question 7

What is a comminuted fracture?

Answer 7

Comminuted fracture is when the bone breaks into several pieces.

Question 8

General Assessment of Musculoskeletal Deviation

Answer 8

1. Assess history and mechanism of injury.
2. Assess function in the affected part (as long as fracture is not suspected).
   a. Determine the range of motion.
   b. Note the amount of weight the child can bear.
   c. Assess gross and fine motor abilities.
3. Assess thie quality of bone and tissue; check whether the correct amount of ossification is present when evaluated by X-ray.
4. Determine whether all bones are correctly aligned.
5. Determine whether musculoskeletal response is bilateral and equal.
   a. Note whether both arms and legs are used.
   b. Note whether muscle response is brisk and strong.
6. Assess for pain; note whether the child is guarding a body part.
7. Assess for muscle tone, degree of weakness, reflexes, pulses, sensation in affected extremities.
8. Determine the relationship of the child’s body size and weight to the defect.
9. Note whether the child has an adequate and even spread of adipose tissue.
10. Note the child’s autonomy and independence in terms of mobility and skills.

Question 9

Cast care

Common Orthopedic Interventions

Answer 9

Plaster cast
1. Turn the cast frequently to dry all sides; use palms to lift or turn a wet cast to prevent indentations.
2. Expose as much of the cast to air as possible, but, cover exposed parts.
3. Be aware of discomfort to the child as chemical changes in the drying of a cast result in temperature extremes against the child’s skin.
4. After it is dry, maintain a dry cast; wetting the plaster cast will soften it and may cause skin irritation (for fiberglass casts, assure that inner matting stays dry).

Fiberglass casts
Can either be water proof or not waterproof. A waterproof cast would never be used for a compound fracture due to increased risk for infection.

1.Smooth out the cast’s rough edges, and petal it with tape (for fiberglass, cover edges with Moleskin).
2.Assess circulation.
a. Note the color, pulses, sensation, movement, temperature, and edema of digits.
b. Note the child’s ability to wiggle the extremities without tingling or numbness.
3. Assess for any drainage or foul odor from the cast.
4. Prevent small objects or food from falling into cast.
5. Do not use powder on the skin near the cast; it becomes a medium for bacteria when it absorbs perspiration.
6. Before the cast is applied or removed, demonstrate the complete procedure on a doll, with the child’s assistance.

Question 10

How is a plaster cast applied? Describe maintenance needed.

Answer 10

Plaster cast
1. Turn the cast frequently to dry all sides; use palms to lift or turn a wet cast to prevent indentations.
2. Expose as much of the cast to air as possible, but, cover exposed parts.
3. Be aware of discomfort to the child as chemical changes in the drying of a cast result in temperature extremes against the child’s skin.
4. After it is dry, maintain a dry cast; wetting the plaster cast will soften it and may cause skin irritation (for fiberglass casts, assure that inner matting stays dry).

Question 11

Hip-spica cast

Common Orthopedic Interventions

Answer 11

This is a cast extending from mid-chest to the legs. Traction is frequently applied after a hip-spica cast is applied. If a Pavlik harness does not work for correcting hip displasia, a Hip-spica cast is applied or corrective surgery.

1. The legs are abducted with a bar betweem them; never lift or turn the child with the crossbar.
2. Perform cast care as lited above but with additional measures.
   a. Place a disposable diaper under the edges to prevent the cast from getting wet and soiled. In addition, cna use a Poise pad inside the diaper to help absorb excess urine. Another diaper is then placed over the top of the diaper that is tucked in the edges of the cast (perineal area).
   (1)Edges of the cast should be petaled with moleskin (facilitates keeping the cast clean and dry). If a waterproof lining is used, only use HyFlex tape on the lining of the cast.
   b. Keep the cast level but on a slant, with the head of the bed raised.
   (1) Urine and stool will drain downward away from the cast.
   (2) A bradford frame can be used for this purpose.
   c. Reposition the child frequently to avoid pressure on the skin and the bony proinences; check for pressure as the child grows.

Question 12

Traction

Common Orthopedic Interventions

Answer 12

1. Purpose is to decrease muscle spasms and realign and position bone ends.
2. There are two different types of traction.
   a. Skin traction pulls indirectly on the skeleton by pulling on the skin via adhesive, moleskin, or an elastic bandage.
   b. Skeletal traction pulls directly on the skeleton via pins or tongs.
3. Keeping the child in alignment can be a challenge because of increased mobility and lack of understanding of the treatment.
4. Check that the weights hang free.
5. Check for skin irritation, infection at pin sites, and neurovascular response of the extremity.
6. Place on pressure-reducing surface (sheepskin, alternating pressure mattress, etc.).
7. Prevent constipation by increasing fluids and fiber.
8. Prevent respiratory congestion by promoting pulmonary hygiene using blowing games.
9. Provide pain relief, if necessary.
10. Provide developmental stimulation.
11. For Bryant’s traction.
    a. This is the only skin traction designed specifically for the lower extremities of the child under age 2; the child provides his or her own countertraction.
    b. Legs are to be kept straight and extend 90 degrees toward the ceiling from the trunk; both legs are suspended even if only one is affected.
    c. The buttocks are kept slightly off the bed to ensure sufficient and continuous traction on the legs.
    d. Traction is often followed by the application of a hip-spica cast.

Question 13

Braces

Common Orthopedic Interventions

Answer 13

Used for mild to moderate scoliosis curves less than 40%. Greater than 45% can have elective surgery - spinal fusion.

1. These appliances assist in mobility and posture and may be a plastic shell or a hetal-hinged appliance.
2. Provide good skin care, especially at the bony prominences.
3. Check to ensure accurate fit as the child grows.
4. When applying full body braces to a child with spasticity, put the feet in first.
5. Chest braces used for scoliosis extend from the iliac crest of the pelvis to the axilla; they must be fitted individually.
6. Chest braces are worn up to 23 hours a day, removed only for bathing and swimming.
7. Chest braces are worn over a thin t-shirt.

Question 14

Clubfoot (Talipes)

Answer 14

Overview
1. Clubfoot is a congenital disorder.
2. The foot and ankle are twisted and cannot be passively manipulated into correct position.

Assessment
1. Assess for talipes varus (inversion of the ankles, with the soles of the feet facing each other).
2. Assess for talipes valgus (eversion of the ankles, with the feet turning out).
3. Assess for talipes equinus (plantar flexion, as if pointing one’s toes).
4. Assess for talipes calcaneus (dorsiflexion, as if walking on one’s heels).
5. Assess for a combination of positions; most cases are equinovarus.

Interventions
1. Assist with the application of a series of plaster boot casts to gradually stretch and realign the angle of the foot.
2. If corrective devices are ordered, have the child keep the devices on as much as possible; stress the importance of this to the parents.
3. Prepare for surgery, if necessary.

Question 15

What is talipes varus?

Answer 15

Inversion of the ankles, with the soles of the feet facing each other.

Question 16

What is talipes valgus?

Answer 16

eversion of the ankles, with the feet turning out

Question 17

What is talipes calcaneus?

Answer 17

dorsiflexion, as if walking on one’s heels

Question 18

What is talipes equinus?

Answer 18

plantar flexion, as if pointing one’s toes

Question 19

Developmental Dysplasia of the Hip/Congenital Hip Dysplasia

Answer 19

Overview
1. Abnormal development of the head of the femur and acetabulum; present at birth.
2. Occurs when the head of the femur is still cartilaginous and the acetabulum is shallow; the head of the femur comes out of the hip socket.
3. May be from the fetal position in utero, a breech delivery, genetic predisposition, or laxity of the ligaments
4. Occurs in varying degrees of dislocation, from partial subluxaiton to complete
5. Can affect one or both hips

Assessment
1. Assess for restricted abduction of the hips.
2. Assess for Barlow maneuver (bring thighs to midline with knees flexed at 90 degrees and press on knees to feel head of femur dislocate from acetabulum) and Ortolani’s click (may be felt by the fingers at the hip area as the femur head snaps out and back in the acetabulum).
a. Palpable during examination with the child’s legs flexed and abducted.
3. Note the appearance of a shortened limb on the affected side (telescoping) when the child is supine.
4. Note asymmetrical skinfolds in gluteus from telescoping and dislocation.
a. The affected side exhibits an increased number of folds on the posterior thigh when the child is supine with the knees bent.
b. Flattened buttocks appear on the affected side when the child is prone.
5. Assess for Trendelenburg’s sign in older children (when the child stands on the affected leg, the opposite pelvis dips to maintain erect posture).

Interventions
1. Be aware that the goal of treatment is to enlarge and deepen the socket by pressure.
2. Gently stretch and maintain the legs in an abducted position for at least 3 months, using a Pavlik harness, which keeps the hips and knees flexed and the hips abducted.
3. If harness is not effective child may need a hip-spica cast or corrective surgery.

Question 20

What causes developmental dysplasia of the hips?

Answer 20

1. Abnormal development of the head of the femur and acetabulum; present at birth.
2. Occurs when the head of the femur is still cartilaginous and the acetabulum is shallow; the head of the femur comes out of the hip socket.
3. May be from the fetal position in utero, a breech delivery, genetic predisposition, or laxity of the ligaments

Question 21

What is the Barlow Maneuver

Answer 21

Bring thighs to midline with knees flexed at 90 degrees and press on knees to feel head of femur dislocate from acetabulum.

Done to assess for dysplasia of the hips.

Question 22

What is Ortolani’s click?

Answer 22

May be felt by the fingers at the hip area as the femur head snaps out and back in the acetabulum.

Done to assess for dysplasia of the hips.

Question 23

What is Trendelenburg’s sign?

Answer 23

In older children (when the child stands on the affected leg, the opposite pelvis dips to maintain erect posture).

Question 24

Legg-Calve-Perthes Disease

Answer 24

Overview
1. Self-limited Idopathic ischemic avascular necrosis of the femoral head, resulting in degenerative changes from a disturbance of circulation to the femoral capital epiphysis.
2. Affects the preschool and school-age child.

Assessment
1. Review the child’s history for a limp and hip pain or pain referred to the knee.
2. Assess for limited hip motion.
3. Be aware that the disease must be differentiated from synovitis.

Interventions
1. Tell the parents that treatment lasts 2 to 3 years as revascularization occurs.
2. Be aware that the younger the child, the better the prognosis for recovery and the natural remodeling of the joint.
3. Tell the parents that the child must avoid weight bearing until reossification occurs; this relieves pressure from the head of the femur and increases blood flow to the area, thus preventing degeneration.

Question 25

Slipped Capital Femoral Epiphysis

Answer 25

Overview
1. The proximal femoral epiphysis is displaced.
2. Displacement is associated with a puberty growth spurt or an adolescent who is overweight; growth hormones may weaken the epiphyseal plate.

Assessment
1. Review the child’s history for a limp.
2. Ask about pain in the groin or knee.
3. Note that the foot turns outward during gait; there is limited internal rotation and hip abduction.

Interventions
1. Prepare for surgical stabilizaiton of the femoral head either by a Shelf Procedure or Pinning to maintain femoral head in the acetabulum.
2. Teach the obese child and the parents that weight loss will decrease stress on the bones.
3. Continuously assess the opposite hip since the condition may recur there; teach the parents to maintain this assessment.

Question 26

Scoliosis

Answer 26

Overview
1. Scoliosis can be nonstructural/functional/postural
a. A nonprogressive C curve may exist from some other deformity, such as unequal leg length.
b. When the child bends forward at the waist to touch toes, the curve in the spinal column disappears.
c. Treatment may be shoe lifts, postural ecercises, or corrective lenses, if the problem is caused by poor vision resulting in a head tilt.
2. Commonly identified at puberty and throughout adolescence, especially among females.
3. Ceases to progress when bone growth ceases
4. Is structural and progressive in most cases
5. Additional curvatures of the spine:
a. Kyphosis is protrusion/convex angulation of the spine or “humpback.”
b. Lordosis is accentuation of the lumbar curvature of the spine or “swayback”; it is normal in toddlers and pregnant women.

Assessment of structural scoliosis
1. A progressive S curve with a primary and compensatory curvature can be seen when the child is standing; this can result in spinal and rib changes on X-ray.
2. When the child bends forward with the knees straight and the arms hanging down toward the feet (Adams- bend test), the spinal curve fails to straighten.
3. The hips, ribs, shoulders, and shoulder blades are asymmetrical.
4. X-rays assist in the diagnosis.
5. The curve often worsens with increased growth.
6. Assess for skin irritiation by braces.

Interventions
1. Braces are for mild to moderate curves that are less than 40%. Expect prolonged bracing, usually a chest brace; assure good skin cre is provided due to possible irritation from the braces; apply over a t-shirt and remove only for bathing. Is used to prevent any further curvature of the spine.
2. Provide emotional support to help the child feel attractive while wearing the brace.
3. Children with a curve of more than 45% can have elective surgery - Spinal Fusion.
a. If curvature of the spine results in lung rstrition, will need surgery.
b. Spinal fusion consists of instrumentation of the spine with rods and screw to attain alignment.
c. Long term effect may result in decreased spinal flexibility
d. The surgery may involve a bone graft from the iliac crest.
e. Postoperatively, measures should be taken to maintain spinal alignment to support healing of the fusion, including preventing lifting, twisting and bending.

Question 27

Osteogenesis Imperfecta

Answer 27

Overview
1. It is an autosomal dominant disorder of the connective tissue, involving bones, ligaments, and sclera, with different degrees of presentation.
a. The gene only has to be passed to the child from one parent.
2. The absence of normal adult collagen results in brittle bones, which are easily fractured; bone fragility begins to ease with puberty.
3. Symptoms may be confused with those of child abuse; this condition is no one’s fault.

Assessment
1. Review the child’s history for frequent fractures with abnormal healing (bones thickened, curved, or otherwise altered in shape with repeated improper healing).
2. Assess for impaired growth and development.
3. Observe for blue-tinged sclera and thin skin.
4. Check for bluish-gray teeth from hypoplasia of dentin.
5. Assess for deafness from otosclerosis.
6. Be aware that spinal deformities often occur as the child reaches maturity.
7. Be aware that immobility for healing of one fracture may predispose the child to another.

Interventions
1. Provide gentle handling in all child-care activities.
2. Be aware that pins may be used instead of casts.
3. Provide a padded and soft environment.

Question 28

Juvenile Idiopathic Arthritis (JIA)

Answer 28

Overview
1. It is an autoimmune disease of the connective tissue characterized by chronic inflammation of the synovia and possible joint destruction.
2. Episodes may recur with remissions and exacerbations.

Pauciarticular JIA
1. Asymmetrical involvement of fewer than five joints, usually affecting large joints such as the knees, ankles, and elbows.
2. May lead to iridocyclitis (scarring and adhesions of the iris and ciliary body), resulting in cateracts and loss of vision.

Polyarticular JIA
1. Symmetrical involvement of five or more joints, especially hands and weight-bearing joints, such as hips, knees, and feet
2. Involvement of the temporomandibular joint, which may cause earache; involvement of the sternoclavicular joint, which may cause chest pain

Systemic disease with polyarthritis
1. This involves the lining of the heart and lungs, blood cells, and abdominal organs.
2. Exacerbations may last for months.
3. Fever, rash, and lymphadenopathy may occur.

Assessment
1. Assess for signs and symptoms of inflammation around the joints.
2. Check for stiffness, pain, and guarding of the affected joints.
3. Note that blood tests show an elevated erythrocyte sedimentation rate and anti-CCP antibodies. (A very small percent have a positive antinuclear antibody and the presence of rheumatoid factor, but this is so rare that the name was changed from Juvenile Rheumatoid Arthritis to JIA).
4. Assist in the slit-lamp evaluation for iridocyclitis (inflammation of the iris and anterior chamber of the eye).

Interventions
1. Teach the child that stress, climate, and genetics can influence exacerbations.
2. Administer low-dose corticosteroids or nonsteroidal anti-inflammatory drugs, such as naproxen and ibuprofen; low-dose methotrexate may be used as a second-line medication.
3. Assist with exercise and range-of-motion activities.
4. Apply warm compresses or encourage the child to take a warm bath in the morning.
5. Apply splints.
6. Stress the need for preventive eye care.
7. Provide assistance devices, if necessary; encourage the normal performance of daily activities.
a. May require additional time to perform activities of daily living, especially upon awakening.

Question 29

Duchenne’s Muscular Dystrophy

Answer 29

Overview
1. One of may muscular deterioration disorders that progress throughout childhood
2. Genetic; sex-linked recessive; occurs only in males
3. Absence of a protein in the muscles

Assessment
1. Assess for delayed motor development.
2. Note the disorder’s progression
a. Begins with pelvic girdle weakness, indicated by a waddling gait and falling.
b. Proceeds to muscle weakness and wasting; progresses to the shoulder girdle; lordosis may occur
3. Observe for Gower’s sign (use of hands to push self up from floor and standing up by ‘walking’ up one’s legs with one’s hands and arms due to lack of hip and thigh muscle strength).
4. Note decreased ability to perform self-care activities.
5. Assess for eventual contractures and muscle hypertrophy.
6. Note fibrous degeneration and fatty deposits on muscle biopsy.
7. Assess for cardiac or pulmonary failure.

Interventions
1. Ensure that the child remains as active adnd independent as possible.
2. Perform range-of-motion exercises.
3. Apply splints as necessary.
4. Provide emotional support to the parents; initiate genetic counseling.

Question 30

Hernias and Hydroceles

Answer 30

Overview
1. Hernias are a muscle weakness cuasing the protrusion of an organ through the abnormal masculature.
a. Umbilical hernia is failure of the umbilical muscles to close at birth resulting in protrusion of the omentum and intestine through the navel.
b. Inguinal canal hernia is weakness where the testes descended from the abdomen into the scrotum; failure of the proximal portion of thee inguinal canal to atrophy resulting in protrusion.
2. An irreducible hernia is a protrusion that will not return to its normal position.
3. An incarcerated hernia occurs when the abdominal contents become trapped and irreducible.
4. A strangulated hernia occurs when the herniated intestines become twisted and edematous resulting in intestinal obstruciton and ischemia.
5. A hydrocele is a collection of peritoneal fluid in the scrotal sac; it may be communicating or noncommunicating.

Assessment
1. Assess for an increase in the size of the hernia (protrusion) as the child strains, coughs, or cries.
2. Note that the condition is usually present without pain.
3. Observe for symptoms of incarceration (pain, irritability, intestingal obstruction due to the loop of bowel becoming occluded so that solids cannot pass).

Interventions
1. Tell parents that home measures such as belly bands and abdominal binders are not effective.
2. Remember that the abdominal muscles often strengthen as the child grows and the hernia and hydrocele may resolve without treatment.
3. Nonoperative reduction of an incarcerated hernia is attempted before surgical repair, with the contents of the hernia gently manipulated back into the abdomen followed by application of an ice pack.
4. Be aware that if the hernia does not resolve, surgical intervention may be required (herniorrhaphy); this is usually done as an outpatient.

Question 31

After being told to sit on the floor cross legged, Andrew has difficulty getting himself off of the floor. What is this called?

a. A negative Barlow sign
b. A negative Ortolani maneuver
c. A positive Bowers sign
d. A positive Gowers sign

Answer 31

a

A Gowers sign is positive when a patient has to maneuver themselves using their hands on their legs then thighs to stand upright from a sitting position.

Question 32

Andrew’s difficulty getting himself off of the floor is a common sign of which of the following disorders?

a. Brachial plexus disorder
b. Ehlers-Danlos syndrome
c. Muscular dystrophy
d. Torticollis

Answer 32

c

Use of the Gower maneuver to rise from a sitting position is a medical sign that indicates weakness of the muscles of the lower limb(s). Among other anomalies, this type of proximal weakness is a sign of muscular dystrophy.

Question 33

Additional symptoms of muscle disorders include which of the following? Select all that apply.

a. Progressive loss of the ability to walk
b. Symmetrical muscle wasting
c. Weakness without loss of sensation
d. Wide and waddling gait

Answer 33

a, b, c, d

There are many types of neuromuscular disorders in children, including muscular dystrophies, which cause progressive and debilitating muscle weakness and atrophy. Some of the most common symptoms include:

Symmetrical muscle wasting and weakness without loss of sensation
Use of Gower maneuver to rise from a sitting position
Wide and waddling gait, with progressive loss of ability to walk by age 12

Question 34

Nursemaid’s Elbow

Answer 34

is a dislocation of the radial head from where it usually sits, can be caused by sudden jerking or pulling on the child’s hand. Caregivers should be instructed to never grab, lift or swing child by the hands or wrists in order to avoid repeat dislocation. Nursemaid’s Elbow is common in children under 4 due to lax joints and is not considered child abuse.

Question 35

An 18-month-old boy is seen in the clinic for the mother’s concern of constant tripping over his own feet. You observe that the child displays symptoms of Genu varum. Which of the following statements would you use to explain this finding to his mother?

a. Exaggerated lordosis in normal in toddlers.
b. Surgery will be necessary to repair this deformity.
c. The child should be evaluated for flatfoot.
d. This is a normal finding in children under 2 years of age.

Answer 35

D

ULearn Question

Question 36

The mother of a 3-week-old presents to the clinic because her baby is not moving his right arm. She reports that her pregnancy was normal, but the delivery was difficult, and the baby needed to be delivered with traction to the head. Swelling and tenderness on the right side of the baby’s neck was noted shortly after birth, but it resolved after the first week. Which of the following statements would be true in this situation?

a. Genu valgum will require surgical repair.
b. If flexible, metatarus adductus may remain until 6 months of age.
c. Recovery from torticollis of the newborn will depend on the underlying cause.
d. Symptoms from brachial plexus injury should resolve by 6 weeks of age.

Answer 36

D

ULearn Question

Question 37

A 12-year-old patient just returned from the operating room for repair of a fractured left femur. Upon the post-operative assessment, it is important to assess circulation by checking for pulses in which area?

a. Left brachial and femoral pulses
b. Left dorsalis pedis pulse
c. Left femoral pulse
d. Left radial artery pulse

Answer 37

B

The circulation distal to the operative site should be assessed post-surgery. When the left femur has been repaired, the left dorsalis pedis pulse should be checked.

ULearn Question

Question 38

A 6-month-old infant was admitted to the unit in preparation for surgery. As part of the pre-operative assessment, the clinician performs a complete history and physical. Birth history reveals this infant was born 10 weeks premature. Which of the following considerations should be taken with respect to the infants’ birth history?

a. Cyanosis
b. Fractures
c. Inflammation
d. Unexplained fevers

Answer 38

b

Premature birth can be associated with decreased bone density/demineralized bones can lead to fractures

ULearn Question

Question 39

Which of the following should be performed when assessing an infant for developmental dysplasia of the hip?

a. Galeazzi’s sign
b. Genu valgum
c. Gower maneuver
d. Ortolani maneuver

Answer 39

d

The Ortolani maneuver identifies a dislocated hip that can be reduced into the socket.

ULearn Question

Question 40

Jack, a 5-year-old, is brought to the clinic by his mother. She reports Jack has been complaining about pain and stiffness in his hips and knees for the past two weeks. Which of the following should you include in your assessment of his lower extremities?

a. Inspection of Jack’s stance and gait as he walks toward and away from you.

b. Observation of Jack’s overall muscle strength and gait.

c. Palpating the curvature of his spine to identify any step offs.

d. Performing the Ortolani and Barlow maneuvers to assess his hips.

Answer 40

a

Assessment of the lower extremities in weight-bearing children includes noting stance and gait with simple movements.

ULearn Question

Question 41

Which of the following is accurate concerning osteomyelitis?

a. E. coli is one of the most common pathogens identified.
b. Smaller bones such as giners and toes are more commonly affected in children.
c. Bone injuries are not always implicated in osteomytelitis.
d. Management typically includes administration of antifungal medications.

Answer 41

c

Osteomyelitis can be due to an infection spreading from the bloodstreem as well as from bone injuries. Staphylococcus is the most common pathogen repsonsible for osteomyelitis. Long bones are more commonly affected in children. Most cases are managed with long term antibiotics as most cases are bacterial.

Question 42

Which of the following assessments would the nurse expect to see in an infant with developmental dysplasia of the hip?

a. Asymmetric gluteal folds
b, Symmetric gluteal folds
c. Trendelenburg’s sign
d. Bone growth disruption

Answer 42

a

Developmental dysplasia of the hip is a condition involving displacement of the femoral head from the acetabulum. In this condition, the acetabulum is not deep enough for the femoral head to remain in the proper position. Clinical manifestations include asymmetric gluteal folds, Ortolani’s sign (clicking of the femoral head and dislocation upon abduction in frog-leg position), and limited abduction of the affected hip. Trendelenburg’s sign is present in older children with developmental dysplasia of the hip who are ambulating. There is no disruption of bone growth.

Question 43

The nurse is preparing to teach a health maintenance class on bones. While reviewing the material, the nurse questions which of the following statements?

a. Most fractures in a 4-year-old will heal in 4 weeks.
b. Injuries that damage the epiphyseal plate usually result in infection.
c. Clavicular fractures are one of the most common fractures in children.
d. Toddlers with fractures tend to heal quicker than adolescents with fractures.

Answer 43

b

Injuries that damage the epiphyseal plate can result in bone growth abnormalities. In children under the age of ten, most fractures take approximately 1 week per year of age to heal. Bones heal faster in younger children. Clavicular fractures are one of the most common fractures in children.

Question 44

Three-month-old Ella has been diagnosed with developmental dysplasia of the hip and is to be placed in a Pavlik harness. Her parents appear hesitant and ask the nurse what its purpose is. Which of the following is the nurse’s best response?

a. “The Pavlik harness will help enlarge the hip socket by keeping Ella’s legs in an abducted position.”
b. “The Pavlik harness will help reduce the hip socket by keeping Ella’s legs in an abducted position.”
c. “The Pavlik harness will help enlarge the hip socket by keeping Ella’s legs in an adducted position.”
d. “The Pavlik harness will help reduce the hip socket by keeping Ella’s legs in an adducted position.”

Answer 44

a

The Pavlik harness helps to enlarge and deepen the hip socket by keeping the child’s legs in an abducted position.

Question 45

Andy is a 6-year-old with a fractured arm. The nurse helps apply a cast to Andy’s arm in the pediatrician’s office. Which of the following is most important to remember while helping with the application of the cast and caring for it afterwards?

a. Use only the fingertips while holding the cast.
b. Petal the rough edges by applying tape from the outside to the inside of the cast.
c. Assess the child’s ability to wiggle his fingers.
d. Encourage the use of powder to absorb any odors and help with discomfort.

Answer 45

c

It is essential to assess the child’s ability to wiggle his fingers to monitor neurovascular status. The cast should be handled with the palms of the hands, not fingertips to avoid pressure areas. The cast should be petalled from inside to outside to avoid skin irritation. Powders should be avoided as it can absorb perspiration and lead to bacterial infection.

Question 46

Four-year-old Allysa is being cared for in the pediatric unit. She has been placed in skeletal traction until her femur fracture can be surgically corrected. Which of the following should be included in Allysa’s plan of care?

a. Limit fluids so that the discomfort of toileting can be minimized.
b. Give Allysa bubbles to blow.
c. Rearrange traciton weights every 4 hours.
d. Administer sedatives to help Allysa stay still and sleep more.

Answer 46

b

Blowing bubbles is an excellent diversional activity that also promotes lung expansion. Fluids should be encouraged to avoid constipation. Unless otherwise speficied, traction weights should not be rearranged. It is important to provide developmentally appropraite activities to control pain, but it is not necessary to sedate the child to have her stay still.

Question 47

The nurse is caring for Tim, a 5-year-old with Duchenne’s muscular dystrophy (MD). While documenting Tim’s assessment, the nurse notes that Gower’s sign was observed. Which of the following best describes Gower’s sign?

a. A waddling gait was noted when Tim ambulated.
b. Tim’s oxygen saturations drop while sleeping due to hypoventilation.
c. Muscle wasting and contractures are noted to Tim’s lower extremities.
d. While rising from a squatting position, Tim walks his hands up his legs.

Answer 47

d

Gower’s sign refers to a child who uses the strength of his hands and arms to “walk” up his own body from a squatting position. It is due to the muscle weakness of the lower extremities. A waddling gait is often noted in MD but it is not referred to as Gower’s sign. Although not referred to as Gower’s sign, a child with MD often does experience hypoventilation during sleep. Muscle wasting and contractures are often noted to the lower extremities of a child with MD, but it is not referred to as Gower’s sign.

Question 48

Tyler is a 13-year-old diagnosed with juvenile idiopathic arthritis (JIA). Tyler tells the nurse that he is “tired of being left out at school” and wants to join an activity. Which of the following is the nurse’s best response?

a. “You may want to try soccer as it includes a lot of running.”
b. “Football is a good sport ans it will help you run and stretch.”
c. “Swimming is a good way to exercise and stretch.”
d. “Have you thought about being a team helper? You could still be involved but not have any risks for injuries.”

Answer 48

c

Swimming is an excellent way for a child to exercise with low risks for contact injuries. Many children with JIA are discouraged from contact sports as it may lead to joint inflammation. Participating in an activity will help the adolescent meet his developmental needs of being involved with a peer group.

Question 49

The nurse is caring for 6-month-old Mikey, who has been diagnosed with osteogenesis imperfect (OI). Which of the following are assessments you would expect?

a. Blue-tinted sclera
b. Polycythemia
c. Cognitive impairment
d. Increased whitening of the teeth

Answer 49

a

Blue-tinted sclera, brittle teeth, and bones that fracture easily are all common assessments in OI. Cognitive impairment and polycythemia are not seen as a complication of OI.

Question 50

Polycythemia

Answer 50

Too many RBCs

Question 51

The nurse is caring for Molly, a 16-year-old who has just had a spinal fusion to correct scoliosis. Which of the following should the nurse include in Molly’s immeidiate plan of care during the first 24 hours after surgery?

a. Encourage the use of the inspirometer to avoid any pulmonary complications and ensure lung expansion.
b. Encourage Molly’s mother to assist with the administration of morphine via patient-controlled analgesia (PCA) pump while Molly is sleeping to assure a continuous level of analgesia.
c. Keep Molly flat on her back to maintain alignment for the first 24 hours.
d. Encourage Molly to ambulate the length of the hallway 2-3 times.

Answer 51

a

It is important to keep the lungs expanded and prevent any pulmonary complications in the post operative period. Only the child should be encouraged to use the PCA, as only she can determine her pain level. The child will be able to ambulate 8 hours after surgery. However, it is unrealistic to expect the child to be able to ambulate the length of the hallway during the first 24 hours.