The Child With a Musculoskeletal Alteration - Chapter 50

Casts, Traction, and Other Immobilizing Devices

Immobilizing a bone or joint helps achieve and maintain a more functional position or rests and protects an affected area during bone healing. Because many musculoskeletal problems require the application of an immobilizing device, the nurse should understand the general principles of care.

Limb Differences

Limb differences are common in children. Most alterations of arms and legs are mild variations of normal posture. Education and reassurance are the primary nursing interventions for patients with limb differences.

Fractures Incidence

Pediatric trauma is the leading cause of death and disability in children and one of the largest challenges to their health The United States has the highest incidence of pediatric trauma among developing nations; musculoskeletal trauma makes up the largest portion of pediatric injuries, with 25% of children sustaining an injury annually and 8.5% to 25% of those injuries being fractures

Splints

Splints are used to stabilize and protect or rest an affected area, increase range of motion and function, and decrease pain Splints are fabricated of fiberglass, plaster of Paris, metal, or thermoplastic polymers. Splint materials are chosen for drapability, durability, softness, setup time, thickness, capacity for remolding, and color. Splinting is a safe, effective, and cost-saving alternative to casting for some conditions

Osteomyelitis Manifestations

The manifestations of osteomyelitis in infants can be vague and nonspecific, such as fever, irritability, lethargy, and feeding difficulties. Some infants demonstrate signs of sepsis. In the older child, the major signs and symptoms include pain, warmth, erythema, and tenderness localized over the site of infection; favoring of the affected extremity; limited range of motion; and systemic manifestations such as fever and lethargy. Pain, usually localized, can radiate to adjacent areas of the body; radiating pain to an adjacent joint necessitates an assessment for possible septic arthritis

Casts

A cast provides support and maintains anatomic position for bone healing or aids in correction of a deformity. Casts are also used to ensure adherence to treatment protocols or to protect a wound. The type and size of the cast are dictated by the child's age and size, type of fracture or injury, type of surgery, and amount of weight the extremity can bear. Casts are made of synthetic materials, such as fiberglass, semirigid nonfiberglass (soft cast), or plaster of Paris Casting material comes in varied colors and patterns; casts can be wrapped and decorated to appeal to young children. The following equipment is needed for cast application: • Tubular gauze/stockinette (optional) • Waterproof lining (optional) • Cotton under-cast padding material (e.g., Webril) • Casting material, fiberglass and/or plaster of Paris (rolls and/or strips/splints) • Water (clarify water temperature with professional applying cast) • Moleskin • Waterproof tape • Scissors • Cast remover (if needed to trim edges or split cast) The cast is usually applied by the physician and another trained person, one to hold the extremity in correct alignment and one to apply the cast. It is very important not to move the affected area to be casted while applying the cast. A waterproof liner or stockinette is applied if desired. Waterproof linings for casts have been shown to be as effective as cotton lining for immobilization A thin layer of Webril is then applied over the initial lining. The material is rolled in a spiral fashion around the affected area, overlapping each layer by approximately 50%. Additional padding can be placed over bony prominences, making sure there are no wrinkles in any layer. Any wrinkles in the cast padding or cast material become "set" into the cast and can cause skin breakdown. Next, the casting material is dipped in water and applied over the cotton padding, making sure to leave a cotton edge at the top and bottom of the cast for patient comfort and to maintain skin integrity. A chemical reaction between casting material and water makes it feel warm and causes it to harden. The cast should not be covered while warm to prevent a burn. Rough edges of casts must be trimmed to prevent injury. Petaling of cast edges with moleskin or latex-free tape decreases irritation and breakdown of adjacent skin and protects the edges of the cast from excessive wear. Fiberglass casts dry quickly, usually set within 30 minutes of application. Fiberglass should be rolled onto the affected body part without stretching the fiberglass. Fiberglass is less forgiving in the presence of swelling; if the fiberglass is pulled "tight" or stretched during application, the neurovasculature can be compromised Fiberglass casts are lighter weight and more durable than plaster casts. Fiberglass casts are water-resistant, so the hard outer shell will not break down in water; however, the padding underneath the cast material is likely cotton and will absorb and hold water. Therefore, if a fiberglass cast becomes wet, inadequate airflow under the cast will prevent thorough drying of the padding and skin. Damp skin is more susceptible to skin breakdown and infection. Plaster casts can be used when the physician wants to "mold" the cast to apply corrective forces to a body part, as in the treatment of a clubfoot or early onset scoliosis. Plaster casts will set within 10 to 15 minutes, but will not fully dry for 24 to 48 hours. Plaster is not water resistant and will break down if it gets wet.

Adolescent Idiopathic Scoliosis Prevalence and Etiology

Adolescent idiopathic scoliosis (AIS) is the most common type of scoliosis. Radiographic evidence of curves of at least 10 degrees has established a prevalence of 2% to 3% in the general population The ratio of affected females to affected males increases with increasing curvature. Progressive curvature is more prevalent in females than males To date, there is no defined causative factor for idiopathic scoliosis. The most common proposed etiologies involve central neurologic dysfunction, connective tissue abnormalities, and genetic factors Evidence indicates a strong genetic tendency toward idiopathic scoliosis in some families, as well as apparent autosomal dominant inheritance of adolescent idiopathic scoliosis and linkage between several chromosomes

Neurovascular Status

After the device is applied, perform a neurovascular assessment (CSM—circulation, sensation, and motion) at least every 2 hours during the first 48 hours. Assess the strength of the pulse distal to the site, and compare it with the pulse in the uninvolved extremity. A sluggish capillary refill time suggests neurovascular impairment. Signs of circulatory impairment include coldness, pallor, blueness of the extremity, swelling, loss of motion, and numbness and tingling of the extremity. Touch the child's skin proximal and distal to the device to assess temperature; ask the child to move the fingers or toes. Paresthesia, or numbness, burning, and tingling, can be assessed by touching the fingers or toes and noting any decrease or loss of feeling. Paresthesia is of serious concern because paralysis can result if the problem is not corrected. Report a child's complaints of a pins-and-needles sensation or of the extremity "feeling asleep." Young children are not always able to describe a feeling or sensation, so avoid questions such as "Do you feel this?" Instead, ask a child to wiggle the fingers or toes to appropriately determine motor impairment.

Juvenile Idiopathic Arthritis Family education.

As part of the multidisciplinary approach, the nurse must take an active part in helping the child and parents learn how to cope with and adapt to the limitations of the disease. This support includes referring them at onset to sources of accurate information about the condition and its associated care. Information should be of a variety of types and appropriate for the child's developmental level. Parents also want to ensure that others in the community have an understanding of JIA. Increased understanding by others in the child's environment will increase his or her ability to maintain a normal, developmentally appropriate lifestyle. Because most of the child's care takes place in the home, the success of the therapeutic plan will be determined by the parents. Planning begins as soon as possible in the course of the illness. The parents should be involved in as many nursing activities as possible to reduce their anxiety and increase their sense of control over difficult situations. Provide verbal and written instructions and use return demonstration to ensure parental understanding of procedures. Coordinate referrals and physical therapy with the child's and parents' routines and schedules. Encourage the parents to provide a diet high in fiber, protein, and calcium and an adequate fluid intake. If the child has anorexia or pain while eating, consider smaller, more frequent high-calorie foods. Emphasize regular visits to the ophthalmologist to evaluate the eyes for inflammation. Children with JIA should be referred to an ophthalmologist at diagnosis and for recommended periodic follow-ups

Developmental Dysplasia of the Hip Interventions Preventing injury.

Assume a proactive role, and advise parents of the potential for injury and the importance of taking safety precautions. Most infant-carrying devices are not suitable or safe for infants in spica casts. Assist parents in identifying strategies for transporting their infant in a safe and comfortable manner, including the use of a car seat that can accommodate the wide leg spread caused by the spica cast or a car vest restraint for older children During waking hours, teach parents to vary the child's position at least every 2 hours throughout the day. Remind parents that the child must never be left unattended; infants and young children often develop a surprising ability to move despite the restrictions imposed by a cast.

Osteomyelitis Etiology/Incidence

Bacteria infiltrate the bone through endogenous routes (e.g., skin or respiratory infections, abscessed teeth, acute otitis media) or exogenous routes (e.g., injury, surgical procedures). The infection is usually the result of vascular spread of the bacteria. Osteomyelitis also can occur as a result of direct entry (open fracture), injury to surrounding soft tissues (cellulitis), external fixation devices, and skeletal traction. The most common causative organism for osteomyelitis and septic arthritis in all age-groups is Staphylococcus aureus Cases of community-acquired methicillin-resistant S. aureus osteomyelitis have been reported (Sarkissian et al., 2015). Streptococcus pyogenes, Haemophilus influenzae (in unimmunized infants), Kingella kingae, Escherichia coli, and group B streptococci (in neonates) also can cause osteomyelitis. When the cause is trauma, the possible organisms include Pseudomonas aeruginosa and other organisms found in the soil. Salmonella is the most common causative organism for osteomyelitis in children with sickle cell anemia. Osteomyelitis typically affects preschoolers and young school-age children, with a mean age of 6 years. Boys are affected more often than girls, possibly because of more risk-taking behavior leading to minor trauma

Types of Skin Traction

Buck • Purpose: Used to treat some fractures, hip disorders, contractures, and muscle spasms. • Description: Continuous or intermittent boot or circular wrap is applied to the skin. Traction is applied to boot or wrap. Rolled towels are placed on the external surface of the knee to prevent external rotation of the affected leg. Unless otherwise ordered, the mattress should be flexed at the knee (20 to 30 degrees). Bryant • Purpose: Used to treat very young children (younger than 2 years of age) with femur fractures or developmental dysplasia of the hip. • Description: The child's affected lower extremity or extremities are wrapped. The child lies in bed (or crib) with hips flexed 90 degrees and the knees extended. Traction is applied overhead with just enough weight to elevate the buttock off the surface of the mattress. • Is continuous for femur fractures, but can be intermittent for children with developmental dysplasia of the hip. Traction is used for 2 to 4 weeks to loosen muscles before a child goes to the operating room for closed or open reduction of the displaced hip. Skin traction is not appropriate if the child has a skin infection, an open wound, or extensive tissue damage. Skin breakdown can develop as a result of skin traction. Applying tincture of benzoin to the intact skin before the traction is applied helps to protect against skin irritation. If the traction has not been set up correctly, neurovascular impairment can result. Therefore, skin traction is not appropriate for patients with abnormal sensation in the lower extremities Hyperextension of the knee and elastic bandages that have been wrapped too tightly are the most common causes of traction-related neurovascular impairment. A thorough assessment of the traction apparatus and the extremity should be conducted at least once each shift.

Clubfoot Ponseti Casting Method

By far, the standard of care for clubfoot treatment is the Ponseti casting method developed in the 1940s and essentially unchanged to this day. This method requires weekly, gentle stretching and manipulation of the misaligned bones followed by application of a well-molded, long-leg plaster cast The cast maintains the correction obtained by the orthopedist and allows for further relaxation and softening of the tissues with atraumatic remodeling of the abnormal joint surfaces. Unlike other forms of nonoperative treatment, the Ponseti method corrects all the components of the deformity simultaneously, with the exception of the equinus, which is corrected last. Correction of the deformity is usually obtained within 6 to 8 weeks of casting, with a percutaneous tendoachillis lengthening (TAL) being frequently performed before the final cast application to correct the equinus contracture The TAL is generally performed in the clinic setting using a topical anesthetic cream (eutectic mixture of local anesthetic [EMLA]) or needleless injectable lidocaine A final cast is applied and maintained for 3 weeks. On completion of casting, the foot will appear overcorrected. Correction is maintained through the use of an abduction orthosis full-time for 3 months followed by 12-hour nightly use until at least 2 years of age in an effort to prevent recurrence of the deformity.

Developmental Dysplasia of the Hip Interventions Teaching about spica cast care.

Caring for a child in a spica cast is similar to caring for a child in any other type of cast (as previously discussed), with some additional adaptations. Because the cast covers the entire lower half of the child's body with only a limited perineal opening, managing the child's elimination is a challenge. Excess urine can trickle under the cast, irritating and macerating the skin, resisting drying, and becoming malodorous. Advise the family to tuck a disposable diaper underneath the cast edges at the circular perineal opening; advise parents not to use sheet plastic under the cast, which can cause pooling of urine beneath the cast and subsequent skin breakdown. Place a sanitary napkin within the diaper that is tucked under the cast edges. Elevating the head of the bed helps urine and feces drain downward and away from the cast. Monitor the child's neurovascular status frequently, and teach the family the signs of neurovascular compromise. Fever, wound drainage, and discomfort are signs of infection and should be reported promptly. Teach the family ways to provide environmental and developmental stimulation (e.g., by moving the child to different areas during the day, placing appropriate toys within reach, and providing age-appropriate activities). Teach the family to ensure that the extremities within the cast are always supported with pillows, rolled-up towels, or "bean bag" chairs. Explain the importance of feeding the child a diet high in fluids, calories, calcium, protein, and fiber, and instruct parents to keep the child in an upright position for a minimum of 30 minutes after feeding. Explain ways to dress the child to accommodate climate, style, and other needs (e.g., by fitting socks over the toes of the cast, using Velcro closures on pants and shorts, or using clothing made of stretch fabrics). Give the parents the name and telephone number of an easily accessible healthcare provider in case questions arise at home.

Parents Want to Know Home Care for the Child in a Cast

Check the Edges of the Cast as Follows: • If they appear rough or are irritating the skin, "petal" the cast by overlapping moleskin or adhesive tape (1 to 2 inches in width; 3 to 4 inches in length with one rounded edge) around the cast edges. • Waterproof tape should be used in the perineal area. To Assist with Drying the Cast, Do the Following: • Place the child on a firm mattress. • Support the cast and adjacent joints with pillows. • For a plaster cast, reposition every 2 to 4 hours to ensure thorough drying. • Lift the cast with the palms of your hands. • A fan directed toward the cast facilitates drying. • Once dry, the cast should sound hollow and be cool to the touch. Swelling Generally Peaks within 24 to 48 Hours. To Prevent Problems, Do the Following: • Apply bagged ice to the casted area (be sure to keep melting ice from touching the cast or leaking underneath). • Elevate the extremity at the level of the heart with pillows. • Apply pressure to the nail bed of the child's casted extremity and count how long it takes for the color to return (it should take no longer than 2 seconds). Repeat every 2 hours for the first 24 to 48 hours. • The casted extremity should be the same color and temperature as the other extremity. • Check each finger or toe for sensation and movement several times each day for 2 days. Protect the Cast as Follows: • If the child is permitted to bathe or shower, be sure to cover the cast with plastic and waterproof tape to keep the cast dry. • Do not put anything inside the cast. Keep small toys and sharp objects away from the cast. Supervise your child during mealtimes so the child does not get food underneath the cast. Contact the Physician If Any of the Following Occurs: • The cast feels warm or hot or has an unusual smell. • Any drainage or blood suddenly appears on the cast. • Your child reports pain, burning, numbness, or tingling. • The extremity changes color or temperature, or any swelling persists. • Any fever above 101.5° F (40° C) taken by mouth. • Slipping of cast, inability to visualize toes or fingers. When Preparing to Remove the Cast, Do the Following: • Explain the cast removal to your child. The cast remover works by vibration that creates a warm, tickling feeling on the skin and sounds like a vacuum cleaner. • Allow time for the child to adjust to the cast remover. Ask the technician or physician if your child can examine the cast remover and see how it works ahead of time. • Once the cast is removed, the skin will be dry and flaky. Wash the area with warm water and soap. Discourage the child from scratching. • The extremity will be stiff for a while and will look smaller because the muscles have not been used. It might need to be supported with a sling. Normal movement will correct the stiffness.

Clubfoot

Clubfoot (talipes equinovarus) is characterized by rigid midfoot Cavus, forefoot Adduction, heel Varus, and ankle Equinus (CAVE). Clubfoot represents a congenital dysplasia of all tissue (bone, muscle, ligaments, nerves, and blood vessels) below the knee. The incidence of clubfoot is 1 in 1000 live births. Both feet are affected in nearly 50% of 1234patients, and it is seen more commonly in males by more than a 2 : 1 ratio Although the means of transmission remains unknown, heredity and race, not environment (i.e., intrauterine packing), seem to play a factor in the occurrence of clubfoot. Clubfoot is seen least frequently in the Japanese population (0.87 : 1000) and most frequently in the Hawaiian population (6.8 : 1000). Many etiologic theories have been proposed, but none can fully explain this complex deformity. The cause is likely multifactorial

Clubfoot Manifestations and Diagnostic Evaluation

Clubfoot can be diagnosed prenatally by ultrasound. Radiographic imaging is rarely used or necessary for assessment of a clubfoot. The deformity is easily recognized on clinical examination

Nursing Care Plan The Adolescent Undergoing a Spinal Fusion

Focused Assessment Preoperative Assessment • Assess anxiety related to surgery, hospitalization, and postsurgical issues (e.g., pain, appearance of the operative site, activity limitations, and altered appearance). Postoperative Assessment • Meticulously assess the neurologic status of the lower extremities. • Assess pain, fluid balance, bleeding, and return of bowel function. • Assess and document wound healing, ease of mobility, and nutritional status. • Focus on respiratory assessment if the anterior/thoracic approach has been used and the adolescent has a chest tube. • Determine discharge teaching needs and parent or adolescent understanding of follow-up care.

Soft-Tissue Injuries: Sprains, Strains, and Contusions Manifestations and Diagnostic Evaluation

Manifestations of soft-tissue injuries include pain, swelling, localized tenderness, limited range of motion, poor weight bearing, and a pop or snapping sound (sprain). The diagnosis is made based on the 1220clinical picture. However, a radiographic examination might be ordered to rule out a fracture. Magnetic resonance imaging (MRI) or arthroscopy is sometimes necessary to diagnose knee-ligament tears.

Limb Differences Diagnostic Evaluation/Therapeutic Management

Most congenital defects are readily apparent at birth. Mild defects and deformities that develop over time are usually identified by parents or school nurses and are evaluated by specialized clinicians. Radiographs may be necessary to evaluate limb defects fully and assist with developing a treatment plan. The management of children with limb differences is related to the type of difference the child is manifesting

Muscular Dystrophies

Muscular dystrophies include more than 30 genetic diseases These are progressively degenerative, inherited diseases that affect the muscle cells of specific muscle groups, causing weakness and atrophy. Muscular dystrophies vary in their patterns of inheritance and age at onset, but most are identified in early childhood

Adolescent Idiopathic Scoliosis Treatment

Nonsurgical interventions. Curves less than 25 degrees require observation for progression, regardless of skeletal maturity Patients closer to 25 degrees and who are skeletally immature will require more frequent radiographic observation than a patient with a smaller curvature who is skeletally mature. Progression is defined as a 7 to 10 degree increase in the Cobb angle. Brace treatment is recommended for patients who present or progress in curve magnitude to 25 degrees or more and are still skeletally immature. The goal of treatment is to prevent further progression, which is accomplished by pads in the brace that push on the curve. Each brace is custom made for the individual patient curve(s) by an orthotist Patients with a lumbar curve typically wear a nighttime-only brace. Other curve patterns require that a brace be worn 22 to 23 hours a day. Patients are told to wear a form-fitting T-shirt underneath the brace to reduce skin breakdown and irritation. Wearing the brace is effective in preventing progression of the curve Adolescent with scoliosis brace. Radiographs are typically obtained every 4 months during rapid growth and then every 6 months as the patient reaches maturity. The patient is told not to wear the brace the night before the visit to see how the curve is responding. As the patient is growing, adjustments to the brace may be necessary, or a new brace may be required. For girls, brace wear is discontinued once she is 18 to 24 months postmenarchal, has a Risser grade suggesting she is near skeletal maturity, and has had no further increase in standing height. For boys, discontinuation is recommended after achieving a Risser grade of 5, which is typically in the later teenage years. Surgical intervention. Surgery is considered for curvatures that reach 40 to 50 degrees. The primary goal is to reduce the size of the curve(s) and obtain a solid fusion of the treated part of the spine. A successful surgery might not completely correct the curvature but will provide the patient with a well-balanced spine that centers the patient's head, shoulders, and trunk over the pelvis Typically, the surgical approach is posterior down the length of the spine to be fused. An anterior approach is sometimes considered for a large, stiff curve; young age; or a curvature limited to the lumbar spine. In a posterior approach, implants (either hooks or screws) are placed on or in the vertebral body. These implants are then attached to two rods that are used to correct the deformity. To achieve a solid fusion of the corrected curvature, additional bone is needed to graft the fixed portion of the spine. Bone can be grafted from the patient (autograft). Common graft donor sites include parts of the vertebral body removed during surgery, the iliac crest, and ribs. Allograft in the form of frozen, bank-stored bone is becoming increasingly popular as it has proven safe, efficacious, and cost-effective Bone morphogenetic protein (BMP) is an additive that can be used to speed up and further solidify the fusion.

Osteomyelitis

Osteomyelitis is a bacterial infection of the bone that involves the cortex or marrow cavity. This serious problem can be difficult to diagnose and treat. Osteomyelitis has high morbidity and mortality rates. It is classified as acute, subacute, chronic, or chronic recurrent multifocal This condition is considered chronic if the infection persists longer than 1 month or does not respond to the initial antibiotic protocol.

Developmental Dysplasia of the Hip

Developmental dysplasia of the hip (DDH) describes a variety of disorders that present in different forms at different ages. Dysplasia varies in severity from quite mild to severe dislocation. DDH can be present at birth (congenital), but in some children, it develops after birth—hence the term developmental.

Developmental Dysplasia of the Hip Diagnostic Evaluation

DDH can be difficult to diagnose in the neonate because the signs and symptoms are often quite subtle. A well-trained nurse or physician screens for DDH at birth and during each routine infant well-child visit by carefully performing the Barlow and Ortolani maneuvers. An ultrasound of the hip is used to confirm DDH in infants Ultrasonography reveals the anatomy of the hip and the relationship of the femoral head and acetabulum. Current research indicates that ultrasonography is a more sensitive indicator of abnormalities of the infant hip than radiography. However, some authors argue that ultrasonography is too sensitive and results in overtreatment of hips that would otherwise develop normally. Plain radiography of the pelvis usually reveals a frankly dislocated hip in individuals of any age, but because ossification is not complete in infancy, radiographs may only be diagnostic after 1 year of age. Some parents are concerned about radiation exposure in the course of treating their child's DDH. Reassure them that the increase in cancer risk from the cumulative radiographs taken to manage an average patient with DDH is less than 1%. CT and MRI are sometimes used in complex cases.

Developmental Dysplasia of the Hip Interventions Teaching about the pavlik harness.

Demonstrate and teach the parents the proper care and application of the Pavlik harness, including how to position and fasten the chest halter (leave room for two fingers to rotate under this strap), fasten the shoulder straps (crossed in back) over each shoulder (leave room under the top of each shoulder strap for one finger), place the child's leg and foot into the stirrup and straps, and connect the straps to the chest halter. The requirements for harness use can change during therapy, so teaching, demonstration, and return demonstration are essential at every visit. Leg straps should be secure enough to keep the child's hips flexed without being tight. The harness should be worn 23 hr/day and should be removed only according to the physician's recommendation. Encourage the parents to hold and cuddle the infant as much as possible. An infant in a Pavlik harness can be fed in the usual positions. Teach the parents to protect the child's skin and legs under the harness. A long T-shirt ("onesie") under the halter reduces harness rubbing. The diaper should go under the harness. Teach the parents to inspect the child's skin frequently for reddened or irritated areas and to reposition the child often.

Juvenile Idiopathic Arthritis Etiology/Incidence

Despite extensive research, the cause of JIA remains unknown. The cause is most likely multifactorial, including genetic predisposition, abnormal immune response, and environmental triggering factors such as infection or trauma. JIA affects approximately 100,000 children in the United States. The most common age of onset is between 2 and 4 years of age; for the most common subtype of JIA (pauciarticular), girls are three times more likely to experience the condition than boys

Developmental Dysplasia of the Hip Therapeutic Management

Early diagnosis and treatment of DDH are important for maximizing the likelihood of a successful outcome. Treatment depends on the age of the child at the time of diagnosis and on the severity of the dysplasia. The primary goal of treatment in DDH, regardless of age, is to facilitate normal development of the hip socket. This is accomplished through approaches that provide anatomic reduction of the hip and maintenance of the reduction. In newborns and infants younger than 6 months, a Pavlik harness is the treatment of choice for a hip that is dislocated and can be reduced by the examiner. The Pavlik harness maintains the hips in flexion, abduction, and external rotation. This device consists of chest and shoulder straps and foot stirrups Initially, the harness is worn continuously. This bracing method can be the only treatment necessary to allow the hip to mold and grow normally, promoting development of a functional hip socket and a well-formed femoral head. Hips that remain unstable become progressively deformed as the skeleton matures, resulting in functional disability. Parents must be taught the proper use of the harness because improper positioning of the infant's hip can cause interruption of the blood supply to the head of the femur, resulting in avascular necrosis (tissue damage caused by an inadequate blood supply) or femoral palsy. Teach parents to observe for equal leg extension in and out of the harness. In addition, skin care; techniques for holding, feeding, and diapering; and the importance of vigilant follow-up must be emphasized.

Traction

Effective immobilization can also be achieved with traction. Traction is a pull or force exerted on one part of the body. Traction can be applied to the skin or the bone. For treatment, traction can be applied to the spine, pelvis, or long bones of the upper and lower extremities. The angle formed by the placement of the pulley and the angle of the involved joint determines the direction of the pull or force. Once the direction of the pull or force has been determined, the traction is directed along the long axis of the bone. An opposing pull or force (counter-traction) must be provided at the same time if the traction is to be effective. Counter-traction results in a two-way pull that maintains alignment of the affected extremity. The child's weight is usually sufficient to provide the counter-traction. If body weight is not sufficient, additional weights are used. Depending on the age of the child, restraining devices might be needed to maintain counter-traction. Some forms of traction, such as halo traction used for cervical spine injury, exert a force without the use of weights. If traction is being applied while the child is in bed, the part of the bed that holds the traction apparatus is tilted or elevated, thereby assisting with counter-traction. For example, if the leg were being placed in traction, the foot of the bed would be elevated. Otherwise, the child would slide in the direction of the traction, disrupting the alignment of the extremity and reducing the effectiveness of treatment. In addition, the mattress should be firm, and a foot board or foot plate may be necessary to keep the extremity in the correct position. Traction is either continuous or intermittent. Continuous traction exerts a constant pull and is used for fractures and dislocations. Intermittent traction provides a periodic pull or force and is used for contractures, low back pain, or muscle spasm. The nurse should always assume that traction is continuous unless the physician states otherwise. The removal of traction intended to be continuous could prove harmful to the child. If the force of the traction is altered, the muscles contract, and fracture alignment could be disrupted. The tissues around the fracture could also be injured, resulting in poor healing. The nursing care plan should always reflect the frequency and amount of time intermittent traction may be removed. When removing the traction apparatus, the nurse must maintain manual traction and pull on the body part. The disadvantages of traction include prolonged immobility and the potential need for hospitalization. Currently, early casting and percutaneous pinning are replacing the use of traction for some musculoskeletal conditions

Fractures

Fractures in children are common and can vary in severity from benign to life threatening. A fracture is a break or disruption in a bone's continuity. Most fractures occur when excessive or traumatic force exceeds the strength of the bone. First, children's bones are less brittle, with a higher collagen-to-bone ratio. This difference is protective, making incomplete fractures more likely. Secondly, children have a stronger periosteum. This also makes complete fractures less likely or at least limits fracture displacement. The third essential pediatric bone difference is the epiphyseal plate or growth plate. The epiphyseal plate is the weakest part of the growing bone but often bears the brunt of children's bone injuries. An understanding of growth and development is helpful when assessing trauma in specific age-groups. For example, fractures in infancy are generally rare because of the cartilaginous quality of the skeleton. Fractures in infants are usually the result of trauma during birth or nonaccidental trauma. Therefore, fractures that occur after the birthing process warrant further investigation to rule out the possibility of child abuse.

Pathophysiology Fractures and Physeal Growth Plate Injuries

Fractures result in bone fragmentation and injury to the surrounding tissues. Torn blood vessels cause bleeding from the bone and tissues around the bone fragments. As blood clots at the site, fibrin strands provide a network for healing. Osteoblasts begin forming in immense numbers almost immediately after the injury. This increased osteoblastic activity results in the formation of new bone matrix between the bone fragments. Calcium salts are deposited in the new bone matrix, forming a callus. The callus provides stability and support of the fracture while healing occurs. Gradually, the callus is formed into new bone. Remodeling (the correction of an injury at the fracture site through the buildup of callus) occurs more rapidly in growing children. Fractures are categorized as simple or compound. A simple (closed) fracture is one with the skin intact. A simple fracture still requires a thorough nursing assessment because of potential problems associated with this injury. Possible complications include internal hemorrhage, compartment syndrome, and neurovascular compromise. When the skin, subcutaneous tissue, or muscle has been disrupted, the fracture is classified as compound (open). Infection is a risk with this type of fracture because organisms can enter the fracture site through the wound. Children with compound fractures are at risk for blood loss as a result of external hemorrhage. Systemic risks associated with fractures, especially multiple fractures or femur fractures, are emboli and shock. Emboli can result from postinjury bleeding with clotting or from fat droplets released from the fractured bone marrow (fat embolism). The emboli enter the circulatory system and can travel to the lungs, heart, or brain. Hypovolemic shock is a possibility with both closed and open fractures. A break or fracture between the shaft of the bone and epiphyseal plate is referred to as a growth plate injury. In a growing bone, the region of least resistance to stress is the area between the metaphysis and the cartilaginous epiphyseal plate. The amount of growth arrest associated with an epiphyseal injury is determined by the extent of the damage to the epiphyseal plate If the germinal cells remain with the epiphysis and appear uninjured, healing is rapid and growth is seldom affected. However, if the germinal layer is destroyed, growth disturbances will occur. The Salter-Harris classification system classifies epiphyseal growth plate injuries and their associated risk of growth disturbance.

Types of Skeletal Traction

Halo • Purpose: To stabilize fractures or displaced vertebrae in cervical and thoracic areas. Also used to prepare the spine (muscles, vertebrae, and spinal cord) before spinal fusion, casting, or bracing in younger patients. • Description: The halo is fitted with pins drilled directly into the skull. The halo is then attached by a rope to weights or a pulley above the head or to a special vest connected to the halo with rods. When the halo is attached to weights, the center of the curved metal bar over the halo must extend along the same planes as the spinal cord. Traction pull is always along the axis of the spine. The child must maintain straight body alignment. 90/90 Femoral • Purpose: Most commonly used traction for complicated fractures of the femur; most effective in children older than 6 years. Within 2 to 3 weeks, callus formation is sufficient to allow application of a spica cast. • Description: A pin or wire is inserted through the distal femur. The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used for traction. Clinical manifestations include localized pain, swelling, warmth, tenderness, unusual odor, fever, and irritability or lethargy in young children. To decrease the risk of infection, pin site care is required at least once per day. Pin care protocols involve inspecting each site for signs of infection (e.g., tenting or pulling around the pin, redness at the site, purulent drainage) and cleaning the skin around pin sites with one of various cleansing solutions (e.g., chlorhexidine gluconate, plain normal saline, soap and water), Upon practice review of pin-site-care protocols, there is no one method that is best for preventing infection at pin sites

Osteomyelitis Diagnostic Evaluation

Imaging studies such as radiography, ultrasonography, radionuclide bone scans, MRI, and computed tomography (CT) scans diagnose and monitor the progress of osteomyelitis Laboratory evidence of an infectious process (elevated ESR, elevated CRP level, and elevated white blood cell count) is usually found. Blood culture can positively identify the infecting organism. The physician can aspirate the affected area to obtain fluid for culture and sensitivity.

Pathophysiology Developmental Dysplasia of the Hip

In the normal infant hip, the head of the femur is well seated in the acetabulum (hip socket) and is stable. Developmental dysplasia of the hip occurs in varying degrees, ranging from instability of the hip joint to frank dislocation, defined as follows: • Instability of the hip is the appropriate term when the head of the femur is located in the acetabulum but is subluxated (partially dislocated) or even dislocated with manual manipulation. • Dislocation of the hip occurs when the head of the femur lies outside the acetabulum. It can occur as a late stage of developmental dysplasia of the hip or in children with certain neuromuscular disorders. • Subluxation of the hip occurs when the head of the femur is positioned under the edge of the acetabulum. It is not well seated in the acetabulum, yet neither is it completely dislocated. Interestingly, many unstable hips spontaneously resolve. If untreated, only approximately 20% will settle into a dislocated position.

Osteomyelitis Therapeutic Management

Intravenous (IV) antibiotics are usually started based on the probable organism and changed as needed according to culture results. This protocol makes obtaining the child's history a key component of case management. Controversy exists regarding the length of time required for antibiotic therapy, the need for IV versus oral antibiotics, and the role of bactericidal antibiotics and therapeutic blood levels. Nevertheless, therapy for osteomyelitis generally requires high-dose parenteral therapy, preferably through a peripherally inserted central catheter (PICC). The organism involved dictates the type of antibiotic and the length of treatment. Assessment of the child's response to the antibiotics is an integral part of the treatment protocol. Peak and trough serum antibiotic levels are closely monitored. Children receiving aminoglycosides should be periodically assessed for side effects such as ototoxicity and nephrotoxicity. Renal and hepatic function should be monitored and blood cell counts measured frequently to determine bone marrow activity. Physical activities depend on the child's clinical condition and pain control. Surgical intervention may be necessary if an abscess is present or if the infection does not respond to antibiotics. Invasive procedures include draining the abscess, débriding necrotic tissue, and performing a sequestrectomy (removal of the sequestrum). Osteomyelitis of the proximal femur generally requires some type of surgical decompression because septic arthritis of the hip can accompany this infection.

Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA), formerly known as juvenile rheumatoid arthritis, is an autoimmune inflammatory disease with no known cause. The term juvenile rheumatoid arthritis is misleading because it implies a positive RF test. However, only approximately 5% of children with JIA test positive for RF. Arthritis in children appears in a number of different forms, each with a different treatment protocol and prognosis. The term arthritis refers to swelling in a joint. There are many causes of joint swelling, including trauma and infection. To diagnose JIA, the child must be younger than 16 years of age and have swelling in at least one joint for at least 6 weeks with two or more signs of decreased range of motion, discomfort on movement, or increased warmth JIA is one of the more common chronic diseases in children and the leading cause of childhood disability. With ongoing research and advances in treatment, the prognosis has improved over the past decade.

Kyphosis

Kyphosis is the natural curvature of the thoracic spine in the sagittal plane although it also can occur in other areas of the spine. Normally, kyphosis ranges between 20 and 45 degrees by Cobb angle measurement. Hyperkyphosis is any angle greater than 45 degrees. Postural kyphosis is benign and can be corrected by proper posture techniques (actively contracting the erector spinae muscles and tightening the abdominal muscles) Typically, this condition resolves if the patient follows a core-muscle-strengthening program.

Limb Differences Etiology and Incidence

Limb differences can be physiologic, congenital birth anomalies, or the result of trauma, infection, or radiation. These differences take many forms, including webbing (syndactyly), extra digits (fingers or toes; polydactyly), genu valgum ("knock-knees"), genu varum (bowlegs), 1227limb-length differences, and congenital absence of all or part of an extremity.

Osteomyelitis Pathophysiology

Osteomyelitis occurs most frequently in the metaphyseal region of the long bones, especially the femur or tibia. Bacteria enter the metaphysis through small capillaries, and the inflammatory process begins. A preceding trauma can cause rupture of these capillaries, providing a medium for bacterial growth. Pus forms, and because it cannot move from the metaphyseal area into a joint, it spreads toward the medullary canal as well as the cortex of the bone. Pus accumulates under the periosteum and displaces it, causing it to separate and form an abscess. The underlying blood supply is interrupted, which causes necrotic tissue to form (sequestrum). New bone (involucrum) develops around the sequestrum, and the inflammatory process continues, causing further damage to surrounding bone tissue. Large sections of sequestrum may eventually become honeycombed with cavities or sinuses that contain infective material. These cavities are so effectively walled off that antibiotic therapy might not be successful. Thus, osteomyelitis can become chronic. Septic arthritis has the same basic pathophysiology, with the bacteria entering the joint.

Juvenile Idiopathic Arthritis Manifestations

Persistent joint swelling in one or more joints that lasts 6 weeks or longer suggests JIA. The joints may be stiff, swollen, warm to the touch, erythematous, and have a limited range of motion. Stiffness is worse in the morning or after a prolonged period of rest. This feature is referred to as the "gel phenomenon," because the joints seem to gel into place. Identification of the subtype will guide management and prognosis. If untreated, uveitis, an associated inflammation of the eye structures in the uveal tract, can lead to vision loss.

Juvenile Idiopathic Arthritis Drug Therapy

Pharmacologic treatment is dependent on the severity of the disease and the number of joints involved. Although NSAIDs such as ibuprofen, naproxen sodium (Naprosyn), sulindac (Clinoril), and celecoxib (Celebrex) are the first line of treatment, other medications are often needed. If the child's condition does not improve after 4 to 6 weeks, methotrexate, a disease-modifying antirheumatic drug (DMARD) is added to the medication regimen. However, methotrexate is being used more often as a first line of treatment because it provides longer periods of disease control and clinical remission Additional medications, commonly referred to as biologics, are sometimes needed to completely control the child's arthritis. These drugs include etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade). Anakinra (Kineret) is a newer medication used in children with systemic-onset juvenile arthritis. Local corticosteroid injections are often used to reduce inflammation in selected joints.

Adolescent Idiopathic Scoliosis Postoperative management/follow-up care

Postoperative pain is typically treated with analgesics and regional anesthesia (e.g., epidural) These methods of pain management are usually used up to postoperative day 2 or 3, at which time the patient is switched to an oral method of pain control. Patients are able to sit up in a chair on postoperative day 2 and typically go home by day 4 or 5. Patients return to the clinic within 1 to 6 weeks, depending on surgeon preference, and are usually followed for 2 or more years postoperatively or until reaching 18 years of age. Most patients return to school after 2 weeks. Patients are released to full activity by 6 months to 1 year postoperatively. Every patient is instructed to avoid tattoos and piercings. Although controversial, some surgeons will also require their patients to have prophylactic antibiotics before dental procedures to reduce the chance of infection

Muscular Dystrophies Duchenne Manifestations

Progressive generalized weakness and muscle wasting affecting limb and trunk muscles first; calves often enlarged; waddling gait; lordosis; cardiomyopathy; Gower maneuver; cognitive disability common

Scheuermann's Kyphosis

Scheuermann's disease is the most common cause of hyperkyphosis in adolescents This condition involves a fixed angular kyphosis with a characteristic wedging of the anterior vertebra at the apex of the curve (middle). The incidence of Scheuermann's disease is reported as 0.4% to 10% of adolescents between 10 and 14 years of age. The etiology of this disease is unknown. Patients can experience pain at the apex of the deformity and at the base of the neck. The kyphotic apex becomes apparent on an Adams forward bend. Most patients are given a core-strengthening program and need no further intervention, as the natural history of this disease is relatively benign. Follow-up includes clinical and radiographic observation on an annual basis. For patients who have progressive kyphosis with the apex located in the thoracic area, bracing might be advised. However, correction gains made during bracing disappear when bracing is discontinued Surgical treatment of Scheuermann's disease is reserved for patients with documented pain in a rigid curve of more than 70 degrees and a poor sagittal contour clinically The goal of surgery is to provide a well-balanced spine in the sagittal plane. Typically, a posterior spinal fusion is performed in a manner similar to that for an AIS patient. Intraoperative neuromonitoring is key, as the hyperkyphosis presents a more stretched spinal cord than in scoliosis and can increase the risk for spinal cord injury. Potential complications, postoperative care, and follow-up are the same as those described for surgical treatment of AIS

Adolescent Idiopathic Scoliosis Diagnostic Evaluation

School screening. They recommend that girls be screened twice, at 10 and 12 years of age (grades 5 and 7), and boys once, at age 13 or 14 (grades 8 or 9). Screening should always include the forward bending test, also known as an Adams forward bend test A scoliometer, a small level-type device, can be used during the forward bend test to provide an angle of any vertebral rotation. Referral to an orthopedic surgeon is recommended for scoliometer readings of 7 or greater, indicating a 7-degree angle of trunk rotation. Because no single test is completely reliable for screening, a screening protocol should also assess for shoulder asymmetry, unequal scapular prominence, hip prominence or asymmetry, and the head not centered over the pelvis If asymmetry is detected, the parents should be informed, and orthopedic referral is recommended. Physical examination. The orthopedist will view the entire back as well as the shoulders and iliac crests The examination includes observing the shoulders and iliac crests for asymmetry, flank creases, rib hump, waist asymmetry, limb length discrepancy, and whether the head and/or trunk are centered over the middle of the pelvis. The patient is also assessed from the side to appreciate any decrease or increase in the natural curvature of the sagittal plane of the spine. A basic neurologic examination of strength and reflexes of the extremities will be performed. The patient's abdominal reflexes are assessed to rule out a neurologic cause of the scoliosis (idiopathic patients respond the same on both sides of the abdomen). Spinal deformity progression is driven by growth; therefore, indicators of skeletal maturity are important factors in analyzing a patient with AIS. For girls, menarche is a crucial indicator; a premenarchal girl is still actively growing, whereas a postmenarchal girl is in the decelerated process of growth, and thus, has a lower chance of curvature progression. The sexual maturity of the patient is assessed using the Tanner system, which classifies breast and pubic hair development Radiographs. Plain radiographs will be obtained with a coronal and sagittal view, from the head down to the mid-thigh Possible findings include a single curvature or a main curvature with secondary or even tertiary curvatures surrounding it. These secondary curves can be structural or compensatory (meaning not a true manifestation of the disease but the body's response in trying to get the head level over the pelvis)

Scoliosis

Scoliosis is a lateral deviation, or curvature, of the spine that is greater than 10 degrees The extent of lateral curvature is determined using a Cobb angle measurement. In addition to lateral curvature, scoliosis involves actual rotation of the vertebral bodies in the spine; therefore, this deformity is considered to be three-dimensional As a spinal curvature worsens, rotational structural deformities are seen in the vertebra and rib cage; severe rotational deformities can result in compromised respiratory function. Distortion of the intrathoracic and abdominal organs can also occur with severe deformity; however, this condition usually does not affect the function of these organs. Classifications of scoliosis etiologies include congenital, syndromic, neuromuscular, and neural axis abnormalities; spinal tumors; thoracogenic (caused by a thoracotomy approach for surgical repair of an unrelated condition) (Table 50.4); and idiopathic. Idiopathic scoliosis can present at any point during a child's growth and is classified by the age at presentation: infantile (birth to 3 years of age), juvenile (3 to 10 years of age), and adolescent (10 years or older). Early onset scoliosis (EOS), regardless of cause, occurs in infants and children up to 8 years of age. Children with EOS are at particular risk for thoracic insufficiency syndrome, which occurs when progressive rotation of the ribs or lack of thoracic growth (associated with congenital scoliosis) impairs growth of one or both lungs and 1223interferes with respiration Children with EOS must be examined frequently to assess for respiratory compromise. Both nonoperative and operative management are options for these children, with the goals being to halt the progression of the curve, facilitate thoracic growth, and improve pulmonary function.

Assessing and managing compartment syndrome

Serious complications, such as nerve compression, circulatory impairment, and compartment syndrome, can result from swelling caused by trauma or an immobilizing device. The muscles and nerves of the upper and lower extremities are enclosed in compartments surrounded by tough, inelastic fascia (comparable to sausage casing). Compartment syndrome occurs when swelling causes pressure to rise within these closed fascial compartments, compromising vascular perfusion to the muscles and nerves Compartment syndrome is a true surgical emergency that requires prompt diagnosis and intervention to prevent paralysis and tissue necrosis Signs of compartment syndrome include severe pain, often unrelieved by analgesics, and signs of neurovascular impairment If extending the fingers or wiggling the toes produces pain, and/or the quality of the radial or pedal pulse is poor to absent, notify the physician. In addition, assess for pallor, paresthesia, and pulselessness as previously described. Paresis and paresthesias are late findings, typically a sign of permanent damage The diagnosis of compartment syndrome is made primarily on physical findings, but if physical findings provoke any question, diagnosis can be aided by measurement of the pressure within the affected compartment. The intracompartmental pressure at which compartment syndrome ensues is unknown, and the pressure can vary with the measurement technique If compartment syndrome is suspected, the nurse should immediately elevate the extremity only to the level of the child's heart, loosen any restrictive bandages or dressings (if able), split the cast (if able), notify the physician immediately, and administer pain medication as ordered. The child will be kept on nothing-by-mouth (NPO) status for possible emergent surgical management.

Adolescent Idiopathic Scoliosis Surgical complications

Significant blood loss is common with spinal fusion surgery because of the vascular nature of the vertebrae and spinal canal. Several methods are used to reduce the need for donor blood transfusion intraoperatively; these include preoperative autologous blood donation (children donate their own blood before surgery), controlled hypotensive anesthesia, hemodilution, cell salvage of lost blood, and the use of antifibrinolytic agents (aprotinin or aminocaproic acid [Amicar]). Clinical indicators, not just hemoglobin values, inform the decision to transfuse A potential complication of surgical correction is insult or injury to the spinal cord. Intraoperative neuromonitoring (IONM) of motor and sensory function, with immediate corrective actions by the surgeon or the anesthetist should the changes be severe can reduce the chance of neurologic injury during surgery. Other complications include lack of solid bone fusion (pseudoarthrosis), implant failure (rod breakage or pullout of a hook or screw), continued progression of the deformity, and infection Some infections require only a round of oral antibiotics, while others are extensive and require irrigation, débridement, and total implant removal.

Skin Traction

Skin traction is noninvasive and well tolerated, and application does not require anesthesia Skin traction is most effective for children who weigh less than 15 kg (33 lb) or are younger than 2 to 3 years. It can be applied to the pelvis, spine, or extremities (usually the long bones). Skin traction is preferred for conditions in which invasive procedures are contraindicated, such as hemarthrosis (collection of blood in the joint) as a result of hemophilia. Foam rubber straps, adhesive moleskin, elastic bandages, or cloth belts are applied to the skin and then attached to the weights and pulleys. If skin traction to the lower leg is needed, a foam rubber or fabric boot can be used; the fit should be secure.

Soft-Tissue Injuries: Sprains, Strains, and Contusions

Sprains occur as a result of trauma to a joint in which ligaments are stretched or are partially or completely torn. Strains, also known as pulls, tears, or ruptures, result from an excessive stretch of muscle. Contusionsoccur when soft tissue, muscle, or subcutaneous tissue is damaged. Sprains and contusions frequently accompany each other. Dislocation occurs when a joint is disrupted in such a way that articulating surfaces are no longer in contact. Sprains are not seen frequently in young children because of their poorly developed epiphyseal plates. A twisting or turning injury will more likely result in a fracture at the weak epiphyseal location than a sprain. Sprains and strains are more common in adolescents and are frequently the result of athletic injuries. Anterior cruciate ligament (ACL) tears are one of the most common types of knee injury, especially in adolescent athletes.

Adolescent Idiopathic Scoliosis Manifestations

The clinical manifestations of scoliosis include a visible curvature of the spine Other frequent manifestations include a rib hump that is visible when the child is bending forward, an asymmetrical rib cage, uneven shoulder or pelvic heights, prominence of the scapula, or hip, and leg-length discrepancy. A size difference in the space between the arms and the trunk is sometimes visible when the child is standing. Complaints of back pain are considered atypical and require a careful history and physical examination by the orthopedist. Impairment of respiratory function is also uncommon, as most patients are treated surgically before the curve progresses to a magnitude that would impair function.

Juvenile Idiopathic Arthritis Diagnostic Evaluation

The early diagnosis of JIA depends on a comprehensive history and physical examination. The character, frequency, and severity of the systemic and articular manifestations are critical to the diagnosis and treatment. Laboratory markers such as the RF, antinuclear antibody (ANA), human leukocyte antigen B27 (HLA-B27), and anticyclic citrullinated peptide (anti-CCP) antibody are helpful in identifying the JIA subtype. CBC, ESR, and CRP can be useful in identifying the presence of inflammation. In addition, children with JIA need routine slit-lamp eye exams to screen for uveitis, which occurs more frequently in individuals who are positive for ANA.

Developmental Dysplasia of the Hip Etiology and Incidence

The exact cause of DDH is unknown, but genetic factors may play a role Risk factors include being the first-born child, being female, breech position, and low levels of amniotic fluid in utero Estimates of the incidence of hip instability in the newborn range from 1 in 100 to 1 in 250, with an actual hip dislocation in approximately 1 to 1.5/1000 Higher incidences are reported when screening uses both clinical examination and ultrasonography. The incidence of DDH shows distinct geographic and racial variations. Children of African or Chinese descent have a low incidence of DDH, while other groups, including Native American children, have a high incidence. One or both hips can be involved.

Nursing Quality Alert The Child With a Soft Tissue Injury

The first 6 to 12 hours after soft tissue injury are the most important in controlling swelling and reducing muscle damage. Treatment of soft-tissue injuries is summarized in the acronyms RICE and ICES: Rest, ice, compression, elevation Ice, compression, elevation, support

Fractures Therapeutic Management

The goal for managing fractures in children is to maintain function without affecting growth. The key to healing is the correct reduction and retention of the fracture. Reduction is the repositioning of the bone fragments into normal alignment. Retention entails the application of a device or mechanism that maintains alignment until healing occurs. Reduction Methods Fractures are treated by either closed or open reduction. Closed reduction is accomplished by manual alignment of the fragments followed by immobilization. Simple or closed fractures are treated by closed reduction. Hospitalization is seldom necessary for closed reduction, and most of these fractures heal without complications. Open reduction entails the surgical insertion of internal or external fixation devices such as rods, wires, or pins that help maintain alignment while healing occurs. When open reduction is used, hospitalization may be required to assess the child for postoperative complications. Complications after open reduction include delayed healing, nonunion, and infection. Close assessment by the healthcare team and strict adherence to sterile technique during dressing changes decrease the risk of postoperative problems and promote healing. Retention Once the bone is aligned, the fracture site must be protected and the position of the fragments maintained. This stability is accomplished through the application of a splint, cast, external fixation device, or traction that effectively immobilizes the area while healing occurs.

Clubfoot Therapeutic Management

The goal of treatment for a child with a clubfoot is to reduce or eliminate all of the components of the deformity so the child has a functional, structural, mobile, pain-free foot Additionally, treatment goals include a satisfactory appearance, ability to wear normal shoes, and the avoidance of unnecessary or prolonged treatment. Until the mid-1990s, the preferred treatment for clubfoot in the United States was predominately surgical. Because long-term complications and recurrence were found to occur after surgical correction, nonoperative treatment modalities are now used. The Ponseti casting method and the French physiotherapy method greatly decrease the need for extensive surgery in these patients The French physiotherapy method, used by only experienced physical therapists in inpatient settings, involves daily sequential stretching, strengthening, and mobilization of the foot followed by taping and splinting to allow for gradual correction of the deformity Most of the correction is obtained by the physical therapist within the first 3 months of treatment, with full correction expected within 5 months. Committed, well-trained parents are an integral part of the technique, with parents being taught the technique early on and home therapy continuing until walking age. Splinting continues until 2 or 3 years of age in an effort to prevent recurrence of the deformity

Fractures Manifestations

The presentation of fractures varies with location, type, and cause of injury. General signs and symptoms include pain or tenderness at the site, immobility or decreased range of motion, deformity, and swelling. Other signs and symptoms include crepitus, ecchymosis, erythema, muscle spasm, and inability to bear weight. The periosteum of children's bones is thicker and stronger than that of adults; therefore, fractures are less likely to be displaced. Local signs and symptoms of a fracture are not always present, which can make diagnosis of a fracture difficult. Radiography is the most effective tool for determining the type and location of a fracture. Fractures are not always visible on radiographs until healing begins. A radiograph of the unaffected extremity might be obtained for comparison purposes, especially when trying to determine whether a line on the radiograph represents a fracture or merely an epiphyseal line. Radiographs are also obtained after fracture reduction and during the healing process to assess progress.

Soft-Tissue Injuries: Sprains, Strains, and Contusions Therapeutic Management

The primary goal in managing a soft tissue injury is to control swelling and prevent further injury. External pressure (compression) is most beneficial before edema has accumulated Swelling can inhibit healing by keeping the ligament ends separated and increasing fibrous scarring. The earlier the treatment is initiated, the less severe the swelling and immobility. The injured area should be immediately wrapped with a compression bandage to support the joint and control swelling. Ice should be applied to the injured area to reduce swelling for no longer than 20 minutes at a time. The effects of the ice can last as long as 5 to 6 hours, and ice should be used repeatedly for several days. Nonsteroidal antiinflammatory drugs (NSAIDs) help to alleviate pain and reduce inflammation. For more severe soft-tissue injuries, the child should avoid bearing weight for 3 days. Crutches are sometimes necessary to ensure that the affected limb does not bear weight. An air cast (a plastic, air-filled pressure cuff) can be used over the elastic wrap to support the joint and reduce swelling. The air cast or compression bandage should be worn for several weeks while the joint is healing. The child can begin stretching and isometric exercises to improve joint stability after the swelling and pain have diminished. Immobilization of the injured joint and cold application are generally effective in the treatment of incomplete ligament tears. A complete rupture can require surgery to prevent excessive scar formation and long-term joint stability problems. Application of a cast or splint for 4 to 5 weeks may also be necessary, especially for knee injuries.

Developmental Dysplasia of the Hip Manifestations

The symptoms of DDH vary according to age. In neonates, it is characterized by instability of the hip; the femoral head can be displaced partially (subluxated) or fully (dislocated) from the acetabulum by the examiner. The hip sometimes rests in a dislocated position and can be reduced on examination. This condition can be detected by performing the Ortolani and Barlow tests (see Chapter 21) or by observing significant changes in the morphology of the hip on sonograms. Infants beyond the newborn period exhibit asymmetry of the gluteal skinfolds when lying with the legs extended against the examining table (or when the infant is held upright with the legs dangling). The affected hip has a limited range of motion, and asymmetric abduction is present when the child is placed supine with the knees and hips flexed. The femur on the affected side appears to be shorter than that on the other side. The symptoms range from lax ligaments to contractures and stiffness in the affected hip joint or joints. Any abnormalities in an older child's gait should be carefully evaluated as possible signs of the condition. Walking children may exhibit limping, toe-walking, or a waddling gait. Bilateral dysplasia is always more difficult to identify than unilateral dysplasia because there is not a normal hip to use for comparison.

Juvenile Idiopathic Arthritis Pathophysiology

The synovial joints are the primary structures involved in this process. Normally, joints are movable and contain synovium, a highly vascular tissue that produces a clear, viscous synovial fluid that nourishes and lubricates articular cartilage. In juvenile idiopathic arthritis (JIA), immune complexes in blood and synovial tissue initiate the inflammatory response, producing inflammatory cytokines. Phagocytosis and accumulation of immune complexes cause chronic inflammation and joint destruction. As the synovium becomes inflamed, excessive fluid is produced. Unlike normal synovial fluid, this fluid is thin and watery. The synovium swells, and thickened villi and nodules protrude into the joint cavity. Pannus (inflamed granulating tissue) formation occurs over the articular cartilage. With further deterioration, the articular cartilage and contiguous bone become eroded and are destroyed.

Juvenile Idiopathic Arthritis Therapeutic Management

This is no known cure for JIA. Therapeutic management is directed toward preserving joint function, controlling the inflammatory process, minimizing deformity, and reducing the impact of the disease on the child's development Management includes medication, physical and occupational therapy, family education, home care, and encouragement of age-appropriate activities as tolerated.

Safety Alert The Child in a Cast or Traction

Tissue ischemia and nerve damage are serious complications that can accompany immobilization in a cast or traction. Skin color and temperature, movement and sensation of the extremity, quality of pulses, and capillary refill time are related to neurovascular status and should be carefully assessed. Problems must be handled quickly to prevent permanent disabilities. The five Ps can be used as a guide for assessing neurovascular status: Pain unrelieved by analgesia Pallor Pulselessness or lack of capillary refill Paresthesia Paralysis or progressive loss of motion Assessment that identifies any of these five Ps of neurovascular compromise indicates possible tissue ischemia. Prompt referral to a physician and intervention is crucial if neurovascular impairment is to be prevented.

Skeletal Traction

exerts greater force than skin traction and can be physiologically tolerated for longer periods. Skeletal traction helps maintain correct alignment of bony fragments and assists in proper healing. Traction is maintained by a metal device inserted into the bone. The fracture site determines the insertion site of the stainless steel wires, pins, or tongs. Common sites for skeletal traction include the skull, the proximal end of the ulna, the distal end of the femur, as well as the tibia and heel. General anesthesia is necessary for skeletal traction placement and removal.

Muscular Dystrophies Duchenne

the most common muscular dystrophy, occurring in 1 in 3600 male children This disease accounts for approximately 50% of all cases of muscular dystrophy. Despite differences in genetic transmission, age at onset, distribution of involvement, and clinical course, the changes in muscles are similar across all forms of muscular dystrophies Early in this process, muscle fibers begin to leak the protein creatine kinase and take on excess calcium, causing further harm to muscle fibers. Over time, muscle fibers degenerate and are replaced by fat and connective tissue. As muscle fibers die, progressive weakness and wasting of symmetric groups of skeletal muscles result in increasing disability and deformity. Onset: usually before 3 yr, manifests between 3-6 yr Rapidly progressive; loss of walking by 9-12 yr; death in late teens from respiratory failure, heart failure, pneumonia X-linked recessive Most common hereditary neuromuscular disease; affects all races

External Fixation Devices

used in the treatment of complex fractures, to lengthen bones, and to correct angular deformities that involve bone and soft tissue. These devices provide distraction, keeping the bone ends separated and in alignment so that healing can occur. External fixators also allow periodic changes in alignment and bone length. These devices, such as the Ilizarov external fixator, consist of pins or wires inserted through skin, soft tissue, and bone that are secured on the outer limb surface to a rigid metal frame. General anesthesia is necessary for placement and removal of external fixation devices. Because the pins or wires of the external fixator pass through the skin to anchor into the bone, meticulous assessment of entry sites for signs of inflammation, infection, or loose pins is necessary. Pin tract infection occurs in approximately 50% of cases Pin site care similar to that for children in traction is recommended. To prevent injury to the other limb or to others, sharp protrusions from the fixator should be adequately covered.

Pediatric Differences in the Musculoskeletal System

• In the fetus, bony tissue begins to develop as closely packed connective tissue. Connective tissue is replaced by cartilage, and cartilage is replaced by mineral salts, which give rise to solid bone. The infant's bones are only 65% ossified at 8 months of age and are neither as firm nor as brittle as those of the older child. • The periosteum of the child's bone is much stronger than that of adults. • New bony tissue is produced during periods of growth. The rate of growth varies at different ages. Skeletal growth is stimulated by pituitary growth hormone. Growth of the long bones occurs at the epiphyses, which are located at the ends of the bones and separated from the main portion of the bone by cartilage during the period of growth. Injury to the epiphyses can cause growth disturbances. • Growing bones produce callus and heal quickly, making internal fixation of fractures unnecessary in most children. Fractures in children younger than 1 year are unusual due to the large amount of force necessary to break an infant's bone; abuse or underlying pathophysiology is often the cause of fractures in infants. • The skull is not rigid during infancy, and the sutures of the cranium do not fuse completely until approximately 12 to 18 months of age. Increased intracranial pressure can separate the sutures, causing the infant's head to enlarge. • Muscle tissue is almost completely developed at birth. Growth occurs because of an increase in size rather than number of the muscle fibers. • Postural changes during infancy and childhood result from the development of neurologic control, bone and muscle growth, and the laying down of adipose tissue. Postural changes are a good indication of the level of development of the musculoskeletal and neurologic systems. • Soft tissues are resilient in children, so dislocations and sprains are also less common than in adults.

Key Concepts

• The neurovascular assessment of a child in traction or a cast includes assessment of skin color, capillary refill time, temperature, sensation, and movement of digits in casted hand or foot, if exposed. The quality of the pulse distal to the site should also be evaluated and compared with that of the uninvolved extremity. • When evaluating neurovascular status, remember to assess for the five Ps of ischemia—pain, pallor, pulselessness, paresthesia, and paralysis. • Consequences of immobility include alterations in the integumentary, gastrointestinal, respiratory, genitourinary, and musculoskeletal systems as well as children's growth and psychological development. • Musculoskeletal problems are frequently caused by trauma. Nonaccidental trauma or child abuse may be involved. Therefore, nursing assessment should always begin with a primary emergency survey. • Treatment of fractures involves repositioning the bone fragments (reduction) and applying a cast or traction to maintain alignment (retention) until healing occurs. • Nursing care of the child with osteomyelitis includes assessment and documentation of the child's status, pain management, and administration of antibiotics without iatrogenic injury. • Frequently seen musculoskeletal developmental disorders include scoliosis, limb differences, DDH, Legg-Calvé-Perthes disease, SCFE, and clubfoot. Splinting, traction, bracing, casting, or a combination thereof is often required. Similar approaches are used in the management of orthopedic anomalies related to various childhood syndromes. • Nursing outcomes for a child with muscular dystrophy include maintaining physical activity, promoting respiratory function, managing weight, and reducing the impact of the disease on the child's development. • Nursing outcomes for a child with JIA include keeping the child free from injury, controlling pain, enhancing physical mobility, and promoting age-appropriate developmental behaviors.