Chapter 44

lordosis, kyphosis

toddlers may have ______ and be potbellied. as child develops, spine is more adult-like. adolescences may have postural ____

nursing care for a child in traction

Appropriate application and maintenance of _____ but also on promoting normal growth and development and preventing complications Apply skin ______ over intact skin only so that the pull is effective Prepare skin with appropriate adhesive before applying the ______ tapes to ensure the tapes adhere well, preventing skin friction. After application of tapes, apply the elastic bandage or use the foam boot. Attach spreader block and then apply prescribed amount of weight via a rope attached to the spreader block. Ensure that the rope moves without obstruction and that the weights hang freely without touching the floor. In skeletal _______, apply weight via ropes attached to the skeletal pins. Treat pin sites as surgical wounds. Protect exposed ends of the pins to avoid injury. Whether skin or skeletal ______ is used, be sure that constant and even ______ is maintained.

idiopathic scoliosis

-unknown cause -infantile: occurs in first 3 years of life -juvenile: diagnosed between age 4 and 10 years, or prior to adolescence -adolescent: age 11-17 years

nursing assessment for osteomyelitis

Explore health history for risk factors and s/s. • Risk factors: impetigo, infected varicella lesions, furunculosis, recent trauma, infected burns, and prolonged intravenous line use Obtain history of current or recent antibiotic therapy and response Note history of irritability, lethargy, possible fever, and onset of pain or change in activity level. The child usually refuses to walk and demonstrates decreased ROM in affected extremity Inspect extremity for swelling. Palpate for local warmth and tenderness. Note point of tenderness over affected bone Labs/diagnostics may reveal: • Elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level • Positive blood cultures • Deep soft tissue swelling on radiography • Changes on ultrasound, CT scan, or MRI

nursing management for leg-calve perthes disease

Highly variable and depends on stage of disease and its severity. Administer anti-inflammatory meds, noting effect on pain. If activities are restricted, exercise the unaffected body parts. Assist family with use of brace if prescribed. Brace may be wiped with damp cloth if it becomes dirty Some children will be prescribed no trx other than avoiding contact or high-impact sports. Swimming and bicycling help maintain ROM with little risk. If mobility equipment is needed, educate child and family on use. If osteotomy is performed, provide routine postop care, including edu and support of child and family

pin care

Perform ____ _____ weekly after the first 48 to 72 hours. Perform earlier if large amounts of drainage is present, dressing becomes wet, or infection is suspected. The most effective solution may be chlorhexidine 2 mg/mL in alcohol. If child has sensitivity to this, use normal saline. Use a nonshedding material for cleaning. Cover sites with a nonshedding dressing. Teach children and their families along with instructions on the signs and symptoms of infection before discharge

Pavlik harness

-reduces and stabilizes the hip by preventing hip extension and adduction and maintaining the hip in flexion and abduction. -successful in majority of infants younger than 6 mo if it is used on a full-time basis and applied properly.

casts

-serve to hold bone in reduction, preventing deformity as the fracture heals -Constructed from hard material, traditionally plaster, but now more commonly fiberglass -Hard nature keeps bone aligned so that healing can occur more quickly -Choice of material and type will be determined by physician or NP or orthopedic surgeon

therapeutic management for osteomyelitis

-Aspiration is necessary to confirm diagnosis and ID specific microorganism. Trx includes a 4-6 week course of antibiotics. Some children may receive 1-2 weeks of IV antibiotics and then switched to oral for the rest of the trx. -Surgical debridement is rarely necessary -Early trx may prevent complications of bone destruction, fracture, and growth arrest. Additional complications include recurrent infection, septic arthritis, and systemic infection

interventions for maximizing physical mobility

-Assess child's ability to move based on injury or disease and within limits of prescribed treatment to determine baseline. -Prior to prescribed exercise or major position changes, ensure that pain medication is given: relief of pain increases child's ability to tolerate and participate in activity. -Encourage gross and fine motor activities to facilitate motor development. -Collaborate with physical therapy, occupational therapy, and speech therapy to strengthen muscles and promote optimal mobility. Support therapy activities by using same equipment and technique to help rehabilitate musculoskeletal deficits, improve mobility, facilitate motor development, and allow for maximum functioning. -Use passive and active range-of-motion (ROM) exercises and teach child and family how to perform them to prevent contractures, facilitate joint mobility and muscle development (active ROM), and help increase mobility. -Praise accomplishments and emphasize child's abilities to improve self-esteem and encourage feeling of confidence and competence. -Teach child and family necessary care related to mobility issues so the family can continue with these measures at home.

osteomyelitis

-Bacterial infection of the bone and soft tissue surrounding the bone. The long bone metaphysis is the most common location. -S. aureus is the most common infecting organism with MRSA infection on the rise. -Children usually present for evaluation within a few days to a week of onset of s/s, though some may present later -Acquired hematogenously (spread through the blood) -Bacteria from bloodstream mainly invade the most rapidly growing portion of the bone. The invading bacteria trigger an inflammatory response, formation of pus and edema, and vascular congestion. -Small vessels thrombose and the infection extends into the metaphyseal marrow cavity. As the infection progresses the inflammation extends throughout the bone and blood supply is disrupted, resulting in death of the bone tissues

health history for scoliosis

-Child or adolescent will not usually report back pain, but mild discomfort is associated with idiopathic until curve becomes severe. Often family recognizes asymmetry in hips or shoulders or child is screened for scoliosis at school and determined to be at risk -Explore child's current or past medical hx -Family history -Recent growth spurt -Physical changes related to puberty -Determine age of development secondary sex characteristic and age of menarche, as these signs of pubertal development indicate the expected velocity and length of remaining growth

nursing assessment for leg-calve perthes disease

-Explore health hx for short stature, delayed bone maturation, related trauma, or family hx of disease. -Note painless limp, which may be intermittent over a period of months. -Mild hip pain and may be referred to knee or thigh -Pain may be aggravated by exercise -Observe for Trendelenburg gait -Perform ROM, noting internal rotation of the hip and limited abduction -Muscle spasm may result with hip extension and rotation -Hip x-rays are obtained to eval the extent of epiphyseal involvement. MRI or bone scan be be used to rule out other disorders. Ultrasound and arthrograms may also be helpful.

congenital clubfoot

-Foot resembles head of a golf club. Half of all cases are bilaterally, males are more often affected. Exact etiology is unknown. -goal of trx is functional foot. starts soon after birth. weekly manipulation with serial cast changes, then changes every 2 weeks. may need corrective shoes or braces or surgery. after surgery, foot is immobilized with cast for up to 12 weeks, then AFOs for several years. -Note family hx of foot deformities and obstetric hx of breech position. Inspect foot for position at rest. Perform active ROM, noting inability to move foot into normal positioning at midline. X-rays are obtained to determine bony abnormality and note progress during trx -perform neurovascular assessments and cast care, provide emotional support, educate family on cast care and use of orthotics

patho of MD

-Gene mutation from absence of dystrophin, a protein that is critical for maintenance of muscle cells. Gene is x-linked recessive, so mainly boys are affected and they receive the gene from their mom (women are carriers, but have no s/s) -Hips, thighs, pelvis, and shoulders are affected initially, then as disease progresses, all voluntary muscles as well as cardiac and respiratory muscles are affected -Often late in learning to walk -Toddlers usually have pseudohypertrophy (enlarged appearance) of the calves -Often clumsy, fall often -Difficulty climbing stairs, running, and cannot get up from the floor in the usually fashion -Walks on tip toes or balls of feet with rolling or waddling gait -Balance is disturbed significantly, child's belly may stick out when shoulders are pulled back to stay upright and keep from falling over -During school-age years, it becomes difficult for child to raise his/her arms -Between ages 7-12, nearly all boys lose ability to ambulate, and by teen years any activity of arms, legs, or truck requires assistance or support. Most have normal intelligence, buy may exhibit a specific learning disability

osteogenesis imperfecta

-Genetic bone disorder that results in low bone mass, increased fragility of bones, and other connective tissue problems such as joint hypermobility, resulting in instability of the joints. All of these contribute to fracture occurrence. May occur in the teeth too Disorder usually occurs as a result of a defect in the collagen type 1 gene, through an autosomal dominant inheritance pattern, but some are autosomal recessive. Ranges from mild to severe connective tissue and bone involvement. -Moderate to severe are more likely to have fractures, short stature common. Additional problems include early hearing loss, acute and chronic pain, scoliosis, and resp problems

therapeutic management for leg-calve perthes disease

-Goal is to maintain normal femoral head shape and to restore appropriate motion. Treatment includes anti-inflammatory meds to decrease muscle spasms around hip joint and relieve pain. Activity limitation may be prescribed, and sometimes bracing, casting, or traction recommended to contain femoral head. Serial x-ray follow-up determines progress of disease. If surgery becomes warranted, which is rarely done, then osteotomy may be performed. -Complications include: joint deformity, early degenerative joint disease, persistent pain, loss of hip motion or function, and gait disturbance.

nursing management for osteogenesis imperfecta

-Handle child carefully and teach family to avoid trauma. -Ensure safe mobility. Reinforce PT and OT recommendations for promotion of fine motor skills and independence in ADLs, as well as use of adaptive equipment and appropriate promotion of mobility. Adapted physical education is important to promote mobility and maintain bone and muscle mass. If child is ambulatory, even with adaptive equipment, walking is a good form of exercise. Swimming and water therapy are appropriate, allowing for independent movement with little fracture risk. -Use caution when inserting an IV and/or taking BP because pressure on arm or leg can lead to fracture and bruising

patho for scoliosis

-In rapidly growing adolescent, the involved vertebrae rotate around vertical axis, resulting in lateral curvature. The vertebrae rotate to convex side of curve, with spinous processes rotating toward the concave side. Wedge-shaped vertebral bodies and discs develop because growth is suppressed on concave side of curve. As the curve progresses, the shape of thoracic cage changes and respiratory and cardiovascular compromise may occur (main complications of severe)

physical assessment for scoliosis

-Mainly inspection and observation. Auscultate heart and lungs to determine compromise related to severe curvature -Observe child at risk, sitting, and standing for evidence of poor posture. Inspect child's back in standing position. Note asymmetries such as shoulder elevation, prominence of one scapula, uneven curve at waistline, or a rib hump on one side. Measure shoulder levels from the floor to the acromioclavicular joints. Note difference between height of the high and low shoulder in centimeters. View child from the side, noting abnormalities in spinal curve. With child bending forward, arms hanging freely, note asymmetry of the back. Note leg-length discrepancy if present. -During neurologic examination, balance, motor strength, sensation, and reflexes should all be normal

cast removal

-May be frightened, prepare with age-appropriate terminology: -The cast cutter will make a loud noise -The skin or extremity will not be injured (demonstrate by touching the cast cutter lightly to your palm). -The child will feel warmth or vibration during cast removal.

therapeutic management for scoliosis

-trx aimed at preventing progression of curve and decrease impact on pulm/cardiac function. based on age, future growth, severity. -brace for curve 25-40 degrees, surgery if greater -surgery includes rod placement and bone grafting, partial spinal fusion

Therapeutic Management for MD

-No cure -The use of corticosteroids may slow progression: Prednisone -Calcium supplements and vitamin D are prescribed to prevent osteoporosis -antidepressants -Braces or orthoses and mobility and positioning aids are necessary. As the muscles deteriorate, joints may become fixated, resulting in contractures, which restrict flexibility and mobility and cause discomfort. Sometimes contractures require surgical tendon release. Spinal curvatures result over time. Scoliosis or kyphosis develop more frequently. Surgical spinal fixation with rod implantation is often required by adolescence. Additional complications include pulmonary, urinary, or systemic infections, depression, learning or behavioral disorders, aspiration pneumonia, cardiac dysrhythmias, respiratory insufficiency and failure

physical examination for MD

-Observe ability to rise from the floor. A hallmark finding is presence of Gowers sign: the child cannot rise from the floor in standard fashion because of increasing weakness. Observe child's gait. Determine effectiveness of cough -Listen to heart and lungs. Note tachycardia, which develops as heart muscles weaken. Note adequacy of breath sounds, which may diminish with decreasing respiratory function. Note muscle strength with resistance testing. Palpate muscle tone

plaster cast care

-Protect cast from moisture -Requires 24-48 hours to dry (fiberglass takes about a few minutes, will cause warm feeling inside cast), do not cause depressions in cast while drying, can cause skin pressure and breakdown -Only handle drying cast with open palms

muscular dystrophy, duchenne MD

-Refers to a group of inherited conditions that result in progressive muscle weakness and wasting. The muscles affected are primarily the skeletal muscles. 9 different types, but all include muscle weakness over the lifetime; it is progressive in all cases but more severe in others. Most often diagnosed in childhood and affect a variety of muscle groups. -Inheritance varies based on type. Genetic mutation results in absence or decrease of a specific muscle protein that prevents normal function of muscle. The skeletal muscles are affected, yet there are no structural abnormalities in the spinal cord or the peripheral nerves ____ ____ ____ (more common) is universally fatal, usually by age 20-25. Due to advances in medical care, some may live into their 40s or 50s -Incidence is 1:3500 live male births

developmental dysplasia of the hip

-Refers to abnormalities of the developing hip that include dislocation, subluxation, and dysplasia of the hip joint. In ____, the femoral head has an abnormal relationship to the acetabulum. May affect one or both hips. The dysplastic hip may be provoked to subluxation or dislocated and then reduced again. -dislocation in utero may be normal, but when happens repeatedly, then structural changes in hip anatomy occur. The hip can develop normally only if femoral head is appropriately and deeply seated within the acetabulum. Continued dysplasia of hip leads to limited abduction of hip and contracture of muscles. More common in females. Mechanical factors (breech, oligohydramnios). -Genetics: greater incidence in native americans, eastern European. Very low rates among people of African or Chinese heritage -Complications: avascular necrosis of the femoral head, loss of range of motion, recurrently unstable hip, femoral nerve palsy, leg-length discrepancy, and early osteoarthritis.

leg-calve perthes disease

-Self-limiting condition that involves avascular necrosis of the femoral head. It most often affects children between ages 4 and 8 but can occur as early as 18 mo and up until skeletal maturity. -Affects males more often -Etiology is unknown, but interruption of blood supply to femoral head results in bone death, and the spherical shape of femoral head may be lost. Swelling of soft tissues around the hip may occur. As new blood vessels develop, the area is supplied with circulation, allowing bone resorption and deposition to take place. During this period or revascularization, which takes 18-24 months, the bone is soft and more likely to fracture. Over time, the femoral head reforms.

gore-tex

-a special material that can be used to line casts and make them waterproof. These casts can get completely wet in the bath, in the shower, or during swimming. These casts cannot be used for all types of fractures, fractures where skin pins are in place under the cast, or recently manipulated fractures. These casts also have an increased cost that may not be covered by insurance. -if cast lined with this, do not petal it

physical assessment for DDH

-asymmetry of thigh or gluteal folds with infant in prone position. Document shortening of affected femur observed as limb-length discrepancy. Older children may exhibit Trendelenburg gait, due to weakness of the hip abductors the childs trunk is shifted over the affected hip during ambulation -Note limited hip abduction while performing passive ROM. Abduction should ordinarily occur to 75 degrees and adduction to within 30 degrees with infant's pelvis stabilized. positive barlow and ortolani

head trauma

-frequent cause or disability in childhood -common cause: falls, MVA, pedestrian/bike accidents, child abuse -get a detailed hx with details surrounding event and focus on ABCs then neuro (LOC, pupillary response, any seizure activity) -lab/diagnostics: x-ray, CT, MRI, test clear liquid d/c for glucose for CSF -inflicted or nonaccidental ____ ____ is leading cause of traumatic death and morbidity during infancy in the US

therapeutic management of DDH

-goal is to maintain hip joint in reduction so that femoral head and acetabulum can develop properly -infants younger than 6 mo: Pavlik harness -4mo to 2 years often require closed reduction with skin or skeletal traction first to stretch soft tissues. spica cast worn for 12 weeks after to maintain reduction. abduction brace after spica cast -children older than 2 or who have failed to respond to prior trx require open surgical reduction followed by period of casting -follow up occurs until age of skeletal maturity

nursing management for MD

-promoting mobility -maintaining cardiopulmonary function -maximizing quality of life

ortolani maneuver

1. place newborn in supine position and flex hips and knees to 90 degrees at the hip. 2. grasp inner aspect of thighs and abduct the hips while applying upward pressure 3. listen for any sounds. there should be no clunk heard or felt when legs are abducted. such sounds indicates the femoral head hitting the acetabulum as the femoral head re-enters the area, suggesting DDH

barlow maneuver

1. with newborn still lying supine and grasping the inner aspect of the thighs, adduct the thighs while applying outward and downward pressure to thighs 2. feel fro the femoral head slipping out of the acetabulum; also listen or feel for a clunk

click

a higher-pitched _____ may occur with flexion or extension of hip. do not confuse this benign, adventitial sound with a true "clunk"

narcotic analgesics

Actions/Indications: Act on receptors in the brain to alter perception of pain. Relief of moderate to severe pain associated with injuries, orthopedic procedures Nursing Implications: Assess pain location, quality, intensity, and duration. Assess respiratory rate prior to and periodically after administration. Monitor sedation level. May cause nausea, vomiting, constipation, pupil constriction

corticosteroids

Actions/Indications: Anti-inflammatory and immunosuppressive action Duchenne muscular dystrophy, myasthenia gravis, dermatomyositis Nursing Implications: Administer with food to decrease GI upset. May mask signs of infection Do not stop treatment abruptly or acute adrenal insufficiency may occur. Monitor for Cushing syndrome. Dosage may be tapered over time.

acetaminophen

Actions/Indications: Blocks pain impulses in response to inhibition of prostaglandin synthesis. Relief of mild pain if used alone, moderate or severe pain if used with a narcotic analgesic Nursing Implications: Often combined with a narcotic such as codeine or oxycodone for increased analgesic effect Monitor pain levels and response to medication.

baclofen (oral or intrathecal)

Actions/Indications: Central-acting skeletal muscle relaxant; precise mechanism unknown Used to treat painful spasms and decrease spasticity in children with motor neuron lesions, such as cerebral palsy and spinal cord injury Nursing Implications: Assess motor function. Monitor for a decrease in spasticity. Observe for mental confusion, depression, or hallucinations. Dosage must be tapered before discontinuing because withdrawal symptoms may occur.

bisphosphonates

Actions/Indications: Increase bone mineral density, decrease incidence of fractures in moderate to severe osteogenesis imperfecta. Nursing Implications: IV: given at 4-month intervals, causes a decrease in serum calcium level, influenza-like reaction with first IV dose Oral: side effects include heartburn, regurgitation, and upper abdominal discomfort.

NSAIDs (ibuprofen, ketorolac)

Actions/Indications: Inhibit prostaglandin synthesis, having a direct inhibitory effect on pain perception. Relief of mild to moderate pain, treatment of Legg-Calvé-Perthes disease Nursing Implications: Monitor for nausea, vomiting, diarrhea, and constipation. Administer with water or food to decrease GI upset.

botulin toxin

Actions/Indications: Neurotoxin produced by Clostridium botulinum that blocks neuromuscular conduction Relief of spasticity in cerebral palsy, occasionally for torticollis Nursing Implications: Injected into the muscle by an advanced provider. May cause dry mouth

benzodiazepines (diazepam, lorazepam)

Actions/Indications: -Anticonvulsant; enhance the inhibition of GABA -Used adjunctively for relief of skeletal muscle spasm associated with cerebral palsy, paralysis resulting from spinal cord injury, traction, and casting Nursing Implications: Monitor sedation level. May cause dizziness Paradoxical excitement may occur. Assess for improvements in spasticity.

skin care after cast removal

Brown, flaky skin is normal and occurs as dead skin and secretions accumulate under the cast. New skin may be tender. Soak with warm water daily. Wash with warm soapy water, avoiding excessive rubbing, which may traumatize the skin. Discourage the child from scratching the dry skin. Apply moisturizing lotion to relieve dry skin. Encourage activity to regain strength and motion of extremity.

caring for a child in a pavlik harness

Do not adjust the straps without checking with the physician or nurse practitioner first. Until your physician or nurse practitioner instructs you to take the harness off for a period of time each day, it must be used continuously (for the first week or sometimes longer). Change your baby's diaper while he or she is in the harness. Place your baby to sleep on his or her back. Check skin folds, especially behind the knees and diaper area, for redness, irritation, or breakdown. Keep these areas clean and dry. Once the baby is permitted to be out of the harness for a short period, you may bathe your baby while the harness is off. Long knee socks and an undershirt are recommended to prevent rubbing of the skin against the brace. Note location of the markings on the straps for appropriate placement of the harness. Wash the harness with mild detergent by hand and air dry. If using the dryer, use only the air fluffing setting (no heat). Call the doctor if: Your baby's feet are swollen or bluish. The harness appears too small. Skin is raw or a rash develops. Your baby is unable to actively kick his or her legs.

nursing management for DDH

Earlier recognition with earlier harness use results in better correction of anomaly. Excellent assessment skills and reporting of any abnormal findings are critical. Initially, the infant will need to wear Pavlik harness continuously. HCP makes all appropriate adjustments to harness when applied so that the hips are held in optimal position for appropriate development. Teach parents use of harness and assessment of baby's skin. If started early, harness usually continues for about 3 mo. Breastfeeding can continue throughout the harness trx period, but creative positioning may be needed -For infants or children diagnosed later than 6 mo or those who do not improve with harness use, surgical reduction may be performed. Postop casting followed by bracing or orthotic use is common. Caring for child in postop period is similar to care of any child in cast. Pain management and monitoring for bleeding ire priority. Teach families care of cast at home

labs/diagnostics for MD

Electromyography (EMG) demonstrates that the problem lies in the muscles, not the nerves. Serum creatine kinase levels are elevated early in the disorder, when significant muscle wasting is actively occurring. Muscle biopsy provides definitive diagnosis, demonstrating the absence of dystrophin. DNA testing reveals presence of the gene.

health history for MD

Examine health hx for family hx of neuromuscular disorders. Note pregnancy and delivery hx, as info may be helpful in ruling out a pregnancy problem or birth trauma as a cause for motor dysfxn. Determine status of developmental milestone achievement, will learn to walk but overtime will be unable to do so. Determine progression of disease. Inquire about functional status and need for assistive or adaptive equipment such as braces or wheelchairs. Determine skills related to ADLs. Note hx of cough or frequent resp infections, which occur as resp muscles weaken. While talking with family and child, determine whether psychosocial issues such as decreased self-esteem, depression, alterations in socialization, or altered family processes might be present

nursing assessment for osteogenesis imperfecta

Health hx, may reveal fam hx, a pattern of frequent fractures, screaming associated with routine cares and handling of newborn. Inspect eyes for sclerae that have blue, purple, or gray tint. Note abnormalities of primary teeth. Inspect skin for bruising and note joint hypermobility with active ROM. Lab tests may include a skin biopsy or DNA tests

nursing management for osteomyelitis

Focus on assessment, pain management, and maintenance of IV access for admin of antibiotics. Individualize care based on child and family's response to illness. Maintain bed rest initially to prevent injury and promote comfort. Administer antipyretics as ordered if child is febrile in initial stage of illness. Encourage use of unaffected extremities by providing developmentally appropriate toys and games. Instruct child and family on safe and proper use of crutches or walker if prescribed. Some children will be discharged home on IV antibiotics, while others will finish an oral antibiotic course. Teach parents on proper admin of meds and maintenance of a peripherally inserted central cath or central line at home if child is finishing the antibiotic course IV

therapeutic management of osteogenesis imperfecta

Goal is to decrease incidence of fractures and maintain mobility. Bisphosphonate admin is used for moderate to severe disease. Fracture care is often required. PT and OT prevent contractures and maximize mobility. Standing with bracing is encouraged. Lightweight splints or braces may allow child to bear weight earlier. Severe cases may require surgical insertion of rods into long bones

cold therapy

Explanation: application of ice bags, commercial cold packs, or cold compresses Indications: most often used in acute injuries to cause vasoconstriction, decreasing pain and swelling Nursing Implications: Apply for 20-30 minutes, then remove for 1 hour, and then reapply for 20-30 minutes. Discontinue when numbness occurs. Place a towel between the cold pack and the skin to prevent thermal injury.

fixation

Explanation: surgical reduction of a fracture or skeletal deformity with an internal or external pin or fixation device Indications: fractures, skeletal deformities Nursing Implications: no additional care, if external: perform pin care as prescribed. assess for excess drainage or pin slippage, notify PCP or NP if occurs. velcro or snaps on sleeves and pant legs help with dressing

splinting

Explanation: temporary stiff support of injured area Indications: temporary fracture reduction, immobilization and support of sprains Nursing Implications: similar to cast care. some are removable and are replaced when the child is up out of bed. teach family appropriate use

health history for DDH

Family history, Female gender, Oligohydramnios or breech birth, Native American or Eastern European descent, Associated lower limb deformity, metatarsus adductus, hip asymmetry, torticollis, or other congenital musculoskeletal deformity, Previously undiagnosed older children may complain of hip pain

Gower's sign

First the child must roll onto his hands and knees. Then he must bear weight by using his hands to support some of his weight, while raising his posterior. The boy then uses his hands to "walk" up his legs to assume an upright position.

orthotics, braces

Explanation: Adaptive positioning devices specially fitted for each child by the physical or occupational therapist or orthotist. Used to maintain proper body or extremity alignment, improve mobility, and prevent contractures Indications: Cerebral palsy, spinal cord injury, spina bifida, muscular dystrophy, spinal muscular atrophy; Used to immobilize a body part or prevent deformity through positioning. Used to treat developmental dysplasia of the hip and scoliosis; also may be used for a period of time after cast removal. Nursing Implications: Provide frequent assessments of skin covered by the device to avoid skin breakdown. Cotton undergarment worn under the brace helps to maintain skin integrity. Follow the therapist's schedule of recommended "on" and "off" times. Encourage families to comply with use.

PT, OT, SLP

Explanation: Physical therapy focuses on attainment or improvement of gross motor skills. Occupational therapy focuses on refinement of fine motor skills, feeding, and activities of daily living. Speech therapy is warranted for the child with a speech impairment or feeding difficulty related to oral muscular issues. Indications: Cerebral palsy, spina bifida, spinal cord injury, muscular dystrophy, spinal muscular atrophy; Restore function after injury or surgery; promote developmental activities when limb use is compromised, as in limb deficiency. Nursing Implications: Provide follow-through with prescribed exercises or supportive equipment. Success of therapy is dependent upon continued compliance with the prescribed regimen. Ensure that adequate communication exists within the interdisciplinary team.

crutches

Explanation: Ambulatory devices that transfer body weight from lower to upper extremities Indications: Used whenever weight bearing is contraindicated Nursing Implications: tops should reach 2-3 fingerbreadths below the axillae to prevent nerve palsy. Teach child appropriate ambulation or reinforce teaching if performed by physical therapist.

casting

Explanation: Application of plaster or fiberglass material to form a rigid apparatus to immobilize a body part Indications: fracture reduction, dislocations, deformities Nursing Implications: Assess frequently for neurovascular compromise, skin impairment at cast edges. Protect from moisture. Teach family how to care at home.

skeletal or cervical traction

Explanation: an application of a pulling force on an extremity or body part Indications: To minimize or prevent trauma to the spinal cord; Fracture reduction, dislocations, correction of deformities Nursing Implications: To maintain even, constant: • Ensure weights hang free at all times and ropes remain in the pulley grooves. • Keep weights out of child's reach. • Maintain prescribed weight. • Elevate head or foot of bed only with physician order. Monitor for complications: • Perform neurovascular checks at least every 4 hours. • Monitor neurologic status closely. • Assess for signs and symptoms of infection or impaired skin integrity. • Provide appropriate pin site care.

tibial torsion (aka genu varum)

In utero, the fetus' hips are usually flexed, abducted, and externally rotated, with knees also flexed and lower limbs internally rotated. This is normal. Legs straighten with passive motion, so should not be confused with bowlegs. usually resolves independently around 2-3 years old

talipes equinus

plantarflexion of the foot; the heel is raised and would not strike the ground in a standing position

scoliosis

Lateral curvature of spine that exceeds 10 degrees. It may be congenital, associated with other disorders, or idiopathic. Idiopathic is the majority of cases in adolescence. Etiology is unknown, but genetic factors, growth abnormalities, and bone, muscle, disc, or CNS disorders may contribute to its development. Early screening and detection has improved outcomes

cavus

plantarflexion of the forefoot on the hindfoot

Duchenne muscular dystrophy

Onset: early childhood (usually 3-6 years) Inheritance: x-linked recessive (affects only males) Muscle Involvement: generalized weakness, muscle wasting; limb and trunk first

petaling

Plaster casts require special trx of cast edge to prevent skin rubbing, accomplished through _______ • Cut rounded-edge strips of moleskin or another soft material with an adhesive backing and apply them to the edge of the cast

skeletal development

Skeleton not fully ossified at birth. Infant and young child's bones are more flexible and more porous and have lower mineral content than adults. Allows for greater shock absorption, so that bones will often bend rather than break when injury occurs. Thick, strong periosteum of child's bone allows for greater absorption of force than in adults, so the cortex of the bone does not always break, just buckles or bends. The skeleton contains increased amounts of cartilage compared to adolescents and adults

epiphysis

This area is vulnerable and structurally weak. Traumatic force applied to the _____ during injury may result in fracture in that area of the bone. Injury may result in early, incomplete, or partial closure of the growth plate, leading to deformity or shortening of the bone. 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

frank dislocation, subluxation, dysplasia

____ _____ of the hip may occur, in which there is no contact between the femoral head and acetabulum. _____ is a portion dislocation, where the acetabulum is not fully seated within the hip joint. _____ refers to an acetabulum that is shallow or sloping instead of cup shaped.

skeletal traction

application of force: to body part directly by fixation into or through the bone length of trx: allows for longer periods of traction amount of force: more

skin traction

application of force: to the skin via strips or tapes secured with ace bandages or traction boots length of trx: usually limited amount of force: less

genu valgum (knock knees)

as genu varum resolves, physiologic ___ ____ occurs. Children usually demonstrate symmetric ____ _____ by age 2 to 3 years. When knees are touching, the ankles are significantly separated, with lower portion of legs angled outward. By 7 to 8 years it resolves in most children.

osteogenesis imperfecta

blue/gray scleara is not diagnostic of ____ ____ but it is a common finding. however, there are some individuals with blue sclerae who do not have it. keep in mind that the sclerae of newborns tend to be bluish, progressing to white over the first few weeks of life

physis

cartilaginous area between the epiphysis and metaphysis

bone healing, heals

children have thick, strong periosteum with abundant blood supply, so _____ _____ 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 _____. Also, the closer the fracture is to the growth plate (epiphysis), the more quickly the fracture _____. 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.

ossification

conversion of cartilage to bone. continues through childhood and ends in adolescence

nighttime bending (charleston)

creates curve so severe that walking is not possible, so it can only be worn at night

Buck Traction

description: Skin traction for hip and knee contractures, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis. Used to rest an injured limb or to prevent spasms of injured muscles or joints Traction force delivered in straight line nursing implications: Remove traction boot every 8 hours to assess skin. Leg may be slightly abducted.

full spine x-ray

diagnostic used to determine degree of curvature in scoliosis

growth plate

epiphysis and physis in combo make up the _____ _____

Positive Barlow

feeling for or noting a "clunk" as femoral head dislocates

Positive Ortolani

feeling for or noting a "clunk" as femoral head reduces back into acetabulum

underarm, boston, wilmington

for low thoracic and thoracolumbar curves; less conspicuous, no visible neckpiece

milwaukee

for thoracic or major double curves; traditional, standard, had visible neckpiece with chin rest

forefoot adduction with supination

forefoot is inverted and turned slightly inward

infant, children

in ______ the epiphyses are cartilaginous and ossify over time. in ______ the epiphysis is the secondary ossification center at the end of the bone, where bone growth occurs primarily

talipes varus

inversion of the heel

traction

o Common method of immobilization, may be used to reduce and/or immobilize a fracture, to align an injured extremity, and to allow the extremity to be restored to its normal length. May also reduce pain by decreasing the incidence of muscle spasm. o Make sure weights aren't touching the floor o With skeletal _____, there is a risk of pin site infection or osteomyelitis

Ultrasound of hip allows for visualization of femoral head and the outer edge of acetabulum. Plain hip x-rays may be used in the infant or child older than 6 mo old

labs/diagnostics for DDH

epiphysis

the end of long bones

metatarsus adductus

newborns feet display in-toeing as a result of in utero positioning, resolves as musculoskeletal system matures

neurovascular checks

o Palpate the fingers or toes for warmth. Determine the capillary refill time. Note the presence of sensation or motion. Evaluate muscle strength. Palpate pulses distal to the injury, noting their strength and quality. o Color (note cyanosis or other discoloration) o Movement (note inability to move fingers or toes) o Sensation (note whether loss of sensation is present) o Edema o Quality of pulses o Signs of compromise: Increased pain Increased edema Pale or blue color Skin coolness Numbness or tingling Prolonged capillary refill Decreased pulse strength (or absence of pulse)

surgery for scoliosis

rods are fused to vertebrae and connected to a distracting rod to rotate the vertebral column

larger head size in relation to body, higher center of gravity, high activity level, curiosity, incomplete motor development, and lack of knowledge and judgement skills

what causes child to hit head more readily when involved in motor vehicle accidents, bicycle accidents, and falls?

nursing management for scoliosis: encouraging compliance with bracing

• Bracing is intended to prevent progression of curve but does not correct current curve. Although modern braces display an improved appearance, with no visible neckpiece, and can be worn under clothes, many adolescents are not compliant with brace wear. The brace must be worn 23 hours per day to prevent curve progression. Many factors may contribute to noncompliance, including discomfort associated with brace wear such as pain, heat, and poor fit. The family environment may not be conducive to compliance with brace wear, and teenagers are very concerned about body image • Inspect skin for evidence of rubbing by the brace that may impair skin integrity. Teach families appropriate skin care and recommend they chick the brace daily for fit and breakage. Encourage teen to shower during 1 hr break period brace is off, ensure skin is clean and dry before putting brace back on. Wearing cotton t-shirt under brace may decrease some discomfort associated with brace wear. Exercises to strengthen back muscles may prevent muscle atrophy form prolonged bracing and maintain spine flexibility

nursing management for scoliosis: promoting positive body image

• Encourage the teen to express his or her feelings or concerns about wearing the brace. Give the teen ways to explain scoliosis and its treatment to his or her peers. Wearing stylish baggy clothes may help the teen to conceal the brace if desired.

cast home care

• For the first 48 hours, elevate the extremity above the level of the heart and apply cold therapy for 20 to 30 minutes, then off 1 to 2 hours, and repeat. • Take your prescribed pain medication. • Assess for swelling, and have the child wiggle the fingers or toes hourly. • For itching inside the cast: o Never insert anything into the cast for the purposes of scratching. o Blow cool air in from a hair dryer set on the lowest setting or tap lightly on the cast. o Do not use lotions or powders. • Do not pull padding out from the inside of the cast. • Protect the cast from wetness. o Apply a plastic bag around cast and tape securely for bathing or showering. Continue to avoid placing the cast directly in water (unless it is Gore-Tex lined). o Waterproof cast covers are available through medical supply stores (still remain cautious about submerging cast with water). o Cover it when your child eats or drinks. o If a cast become soiled it can be wiped clean with a slightly damp clean cloth. o If the cast gets wet, dry it with a blow dryer on the cold setting (if warm setting is used the child could get burned). Use of a vacuum cleaner with a hose attachment to pull air through may speed drying-be careful to avoid skin. • If the child has a large cast, change position every 2 hours during the day and while sleeping change position as often as possible. • Check the skin for irritation. o Press the skin back around edges of the cast. o Use a flashlight to look for reddened or irritated areas. o Feel for blisters or sores. • Call the physician or nurse practitioner if: o The casted extremity is cool to the touch, pale, blue, or very swollen. o The child cannot move the fingers or toes. o Severe pain occurs when the child attempts to move the fingers or toes. o Persistent numbness or tingling occurs. o Drainage or a foul smell comes from under the cast. o Severe itching occurs inside the cast. o The child runs a fever greater than 101.5°F for longer than 24 hours. o Skin edges are red and swollen or exhibit breakdown. o Child complains of rubbing or burning under cast. o The cast gets wet and does not dry or is cracked, split, or softened.

nursing management for scoliosis: providing post op care

• Goal of nursing management in post op period after spinal fusion with or without instrumentation is to avoid complications. Perform neurovascular checks with each set of vital signs. When turning child, use long-roll technique to avoid flexion on back. Provide proper pain management and medicate for pain before repositioning and ambulation. Administer prophylactic IV antibiotics if ordered. Assess for drainage from operative site and for excess blood loss via Hemovac or other drainage tubes. Maintain Foley patency, as child will be confined to bed for the first couple of days. Maintain strict recording of I&O. Administer transfusions of PRBCs if ordered. Ambulation, once ordered, should be done slowly to avoid orthostatic hypotension. Assist the family with arrangements to continue the teen's schoolwork while hospitalized and/or arrange for home tutoring during the several-week recovery period

nursing management for scoliosis: providing preop care

• If the curve progresses despite bracing or causes pulmonary or cardiac compromise, surgical intervention will be warranted. In the preoperative period, teach the teen the importance of turning, coughing, and deep breathing in the postoperative period. Explain the tubes and lines that will be present immediately after the surgery. Review positioning guidelines: back flexion or extension will not be allowed. Introduce the child to the patient-controlled analgesia pump and explain pain scales. There is a high risk for significant blood loss with spinal fusion and instrumentation, so if possible arrange for preoperative autologous blood donation