Child Health (Ch.29: Child with musculoskeletal or Articular dysfunction)

Clubfoot may be further divided into three categories:

(1) positional clubfoot (also called transitional, mild, or postural clubfoot), which is believed to occur primarily from intrauterine crowding and responds to simple stretching and casting; (2) congenital clubfoot, also referred to as idiopathic,which may occur in an otherwise normal child and has a wide range of rigidity and prognosis; and (3) syndromic (or teratologic) clubfoot, which is associated with other congenital anomalies (such as myelomeningocele or arthrogryposis) and is a more severe form of clubfoot that is often resistant to typical treatment.

Osteogenesis Imperfecta (OI)

- A group of heterogeneous inherited disorders of connective tissue - Characterized by excessive fragility and bone defects - Defective periosteal bone formation and reduced cortical thickness of bones - Hyperextensibility of ligaments - 12 described types Bone can be very fragile. Growth retardation, hyperextensibility.

Metatarsus Adductus

- AKA metatarsus varus - Most common congenital foot deformity - Often results from abnormal position in uterus; usually evident at birth - Angulation at tarsometatarsal joint "Pigeon toed" gait - Treatment: physical therapy, orthotics, casting - Nursing care management: identify the defect, teach parents how to stretch forefoot, instruct parents in cast care and observation of corrective device if required Closely monitor for the hip. Stretching might help. Not treated pigeon toed gait!!!teach parent that stretching can help with the symptoms.

Nursing Care Management: Congenital Clubfoot

- Care of child with a cast - Reinforce and clarify orthopedist's explanations and instructions - Encourage normal development Flexing their ankle problem. Deformity in ankle and heel. Cast 6-10 weeks. And tenotomy and cast 3 weeks. Nursing care of the child with clubfoot is the same as for any child who has a cast (see earlier in this chapter). Because the child will spend considerable time in a corrective device, nursing care plans include both long- and short-term goals. Careful observation of the skin and circulation is particularly important in young infants because of their rapid growth rate

Fractures

- Common injury in children Methods of treatment are different in pediatrics than in older adult population - Rare in infants, except with motor vehicle crashes - Clavicle is the most frequently broken bone in childhood, especially in those <10 years old - School age: bike, sports injuries Fractures Bone fractures occur when the resistance of bone against the stress being exerted yields to the stress force. Fractures are a common injury at any age but are more likely to occur in children and older adults. Because childhood is a time of rapid bone growth, the pattern of fractures, problems of diagnosis, and methods of treatment differ in children compared with adults. In children, fractures heal much faster than in adults. Consequently, children may not require as long a period of immobilization of the affected extremity as an adult with a fracture. Fracture injuries in children are most often a result of traumatic incidents at home, at school, in a motor vehicle, or in association with recreational activities. Children's everyday activities include vigorous play that predisposes them to injury, including climbing, falling down, running into immovable objects, skateboarding, trampolines, skiing, playground activities, and receiving blows to any part of their bodies by a solid, immovable object. Aside from automobile accidents or falls from heights, true injuries that cause fractures rarely occur in infancy. Bone injury in children of this age group warrants further investigation. In any small child, radiographic evidence of fractures at various stages of healing is, with few exceptions, a result of nonaccidental trauma (child abuse). Any 949investigation of fractures in infants, particularly multiple fractures, should include consideration of osteogenesis imperfecta (OI) after nonaccidental trauma has been ruled out. Fractures in school-age children are often a result of playground falls or bicycle/automobile or skateboard injuries. Adolescents are vulnerable to multiple and severe trauma because they are mobile on bicycles, all-terrain vehicles, skateboards, skis, snowboards, trampolines, and motorcycles and are active in sports. A distal forearm (radius, ulna, or both) fracture is the most common fracture in children. The clavicle is also a common fracture sustained in childhood, with approximately half of clavicle fractures occurring in children younger than 10 years old. Common mechanisms of injury include a fall with an outstretched hand or direct trauma to the bone. In neonates, a fractured clavicle may occur with a large newborn and a small maternal pelvis. This may be noted in the first few days after birth by a unilateral Moro reflex or at the 2-week well-child check, when a fracture callus is palpated on the infant's healing clavicle.

Nursing Care Management: Scoliosis

- Concerns of body image - Concerns of - prolonged treatment of condition - Preoperative care - Postoperative care - Family issues Pre-op : lab works, long surgery lose a lot of blood. Intentionally lower the blood pressure using medications before surgery closely monitor for stability. Teach about autologous blood donation and give during the procedure where they lose a lot of blood during surgery. Postop: need a lot of pain medication. Pain medication is challenge. Change position every 2hour and logroll them. Educate them in advance what logroll is and how to do it. They might have chest tube, foley, and educate. Hospitalized for a while and get something to be active.

Congenital Clubfoot

- Deformity of the ankle and foot, described according to the position of the ankle and foot - 5 common positions, most cases are a combination Incidence is 1-2 per 1000 births, boys twice as often as girls Cause unknown Clubfoot is associated with an increased incidence of hip dysplasia

Nursing Care Management: OI

- May rule out OI if multiple fractures occur - Caution with handling to prevent fractures - Family education - Occupational planning and genetic counseling Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. However, nurses should not be afraid to touch or handle the infant or child with OI. Such children need compassionate handling and care as much as any other patient. Both parents and the affected child need education regarding the child's limitations and guidelines in planning suitable activities that promote optimal development and protect the child from harm. Realistic occupational planning and genetic counseling are part of the long-term goals of care. Educational materials and information can be obtained from the Osteogenesis Imperfecta Foundation,* which also has a network that places families in contact with other families with a similar condition. Children with current fractures or healing fractures should be screened for OI; the assumption that abuse or neglect is the cause of fractures in children must be carefully evaluated by a multidisciplinary team. A detailed history, no evidence of associated soft-tissue injury, and the presence of other symptoms related to OI help to determine the diagnosis.

Classification of Clubfoot

- Mild or positional > May correct spontaneously or require passive exercise or serial casting (weekly to get the correction done) - Teratologic or syndromic > Associated with other congenital anomalies > Usually requires surgical correction with high incidence of recurrence - Idiopathic or congenital ("true clubfoot") > Bony abnormality almost always requiring surgical intervention (idiopathic, don't know what is causing it that is called true club foot, may have bone abnormality) The mild, or postural, clubfoot may correct spontaneously or may require passive exercise or serial casting. There is no bony abnormality, but there may be tightness and shortening of the soft tissues medially and posteriorly. The teratologic clubfoot usually requires surgical correction and has a high incidence of recurrence. The congenital idiopathic clubfoot, or "true clubfoot," almost always requires surgical intervention because there is bony abnormality.

Therapeutic Management: JIA

- No specific cure - Goals of therapy: preserve function, prevent deformities, and relieve symptoms - Iridocyclitis, uveitis: > Inflammation of iris and ciliary body > Unique to JIA > Requires treatment by ophthalmologist A slit lamp eye examination is necessary to diagnosis uveitis, inflammation in the anterior chamber of the eye, which is most common in antinuclear antibody-positive young girls with oligoarthritis. Whatever function its gone, its gone, so preserve any function they have. slit lamp eye examination identify uveitis. Uveitis=JIA

Therapeutic Management: OI

- Primarily supportive care - Drugs of limited benefit > Bisphosphate therapy > IV Pamidronate - Braces and splints - Physical therapy - Surgery: intramedullary rods into the long bones can provide stability to bone Bones are very fragile and symptomatic. Don't use heavy splint, light weight splint helps. Disuse osteoporosis: use it or lose it. So they do physical therapy.

Nursing management

- Relieve Pain > The pain of JIA is related to several aspects of the disease, including disease severity, functional status, individual pain threshold, family variables, and psychological adjustment. The aim is to provide as much relief as possible with medication and other therapies to help children tolerate the pain and cope as effectively as possible. Nonpharmacologic modalities, such as behavioral therapy and relaxation techniques, have proved effective in modifying pain perception (see Pain Management, Chapter 5) and activities that aggravate pain. Opioid analgesics are typically avoided in juvenile arthritis; however, for children immobilized with refractory pain, short-term opioid analgesics can be part of a comprehensive plan that uses multiple pain relief techniques (Connelly and Schanberg, 2006). - Promote General Health > The child's general health must be considered. A well-balanced diet with sufficient calories to maintain growth is essential. If the child is relatively inactive, caloric intake needs to match energy needs to avoid excessive weight gain, which places additional stress on affected joints. Sleep and rest are essential for children with JIA. Some children require rest during the day; however, daytime napping that interferes with nighttime sleepiness should be avoided. A bedtime routine that involves comfort measures can help induce sleep. A firm mattress, electric blanket, or sleeping bag helps provide warmth, comfort, and rest. Nighttime splints needed to maintain range of motion might initially be a source of bedtime conflict. The family needs to be instructed on how to use the splint appropriately; the splint should not be painful or impede sleep. Behavior modification programs that reward splint and exercise compliance may be helpful in reducing adherence barriers. Well-child care to assess growth, development, and immunization requirements needs to be coordinated between the primary care provider and the rheumatologist. Common childhood illnesses, such as upper respiratory tract infections, may cause arthritis to worsen; consequently, medical attention must be sought quickly for relatively minor illness to prevent arthritis flares. Effective communication among the family, the primary care provider, and the rheumatology team is essential for care coordination. Children are encouraged to attend school even on days when they have some pain or discomfort. The school nurse's assistance is enlisted so that a child is permitted to take the prescribed medication at school and to arrange for rest in the nurse's office during the day. Split days or half days may help a child remain involved in school. Permitting the child to come to school late allows time to gain joint movement and reduces the time at school to avoid exhaustion. It is important that the child attend school to learn skills and engage in social interaction, especially if the JIA continues to limit physical skills. Arranging for two sets of textbooks—one for home and one for school—eliminates heavy backpacks, or rolling backpacks may be used. Additionally, extra time to take tests, allowing to stand and stretch, participating in PE as tolerated or in a modified PE program, an elevator pass, and extra time changing class can all reduce barriers and maximize the students attendance and participation in school. A formal school hearing may be necessary to obtain an individualized education program (IEP), ensured by public law, which includes intensive school modifications. - Facilitate Adherence > The child and family need to be actively involved in the treatment plan to commit to it. They need to know the purpose and correct use of any splints, exercise programs, and medications prescribed. Pill boxes can help foster adherence, although parents should continue to monitor adherence of the older child who is able to safely take medications independently. Nurses can facilitate adherence by demonstrating and providing written instructions on proper techniques for pill crushing or pill swallowing skills. Teaching parents and patients how to give subcutaneous injections lays the groundwork for future adherence by identifying and addressing potential barriers. Shots are never a pleasant activity; but if available, enlist a child life specialist as a resource in providing the child skills to cope and better understand and accept unpleasant but necessary medical treatments. 975 - Comfort Measures and Exercise > Heat has been shown to be beneficial to children with arthritis. Moist heat is best for relieving pain and stiffness, and the most efficient and practical method is in the bathtub with warm water. In some cases, a daily whirlpool bath, paraffin bath, or hot packs may be used as needed for temporary relief of acute swelling and pain. Hot packs are easily applied using a damp hand towel wrung out after being immersed in hot water or heated in a microwave oven; after testing for heat, hot packs are applied to the area, and covered with plastic to retain heat. Commercial pads that warm in only a few seconds in the microwave are also available. Painful hands or feet can be immersed in a pan of warm water or a paraffin unit. Pool therapy is the easiest method for exercising a large number of joints. Swimming activities strengthen muscles and maintain mobility in larger joints. Very small children who are frightened of the water can carry out their exercises in the bathtub. Small children love to splash, kick, and throw things in the water. Remember, adult supervision is necessary for all water activities. Activities of daily living provide satisfactory exercise for older children to maintain maximal mobility with minimal pain. These children are encouraged in their efforts to be independent and patiently allowed to dress and groom themselves, to assume daily tasks, and to care for their belongings. It is often difficult for children to manipulate buttons, comb or brush their hair, and turn faucets, but unless there is an acute flare with significant loss of motion and pain, parents and other caregivers should not offer assistance but extra time and encouragement to proceed independently. In turn, children should learn and understand why others do not help them. Many helpful devices, such as self-adhering fasteners, tongs for manipulating difficult items, and grab bars installed in bathrooms for safety, can be used to facilitate tasks. A raised (higher) toilet seat often makes the difference between dependent and independent toileting because weak quadriceps muscles and sore knees inhibit the ability to raise the body from a low sitting position. A child's natural affinity for play offers many opportunities for incorporating therapeutic exercises. Throwing or kicking a ball and riding a tricycle (with the seat raised to achieve maximum leg extension) are excellent moving and stretching exercises for a young child whose daily living activities are physically limited. An effective approach to beginning the day's activities is to awaken children early to give them their medication and then to allow them to sleep for an hour. On arising, children take a hot bath (or shower) and perform a simple ritual of limbering-up exercises, after which they commence the activities of the day, such as going to school. Exercise, heat, and rest are spaced throughout the remainder of the day according to the child's individual needs and schedules. Parents are instructed in exercises that meet the child's needs. The Arthritis Foundation and the American Juvenile Arthritis Alliance (an organization within the Arthritis Foundation) provide information and services for both parents and professionals, and nurses can refer families to these agencies as an added resource. - Support Child and Family > JIA affects every aspect of life for the child and family. Physical limitations may interfere with self-care, school participation, and recreational activities. The intensive treatment plan, including multiple medications, physical therapy, comfort measures, and medical appointments, is intrusive and disruptive to the parents' work schedule and the family routine. To prevent isolation and foster independence, the family is encouraged to pursue their normal activities. Unfortunately, the adaptations necessary to make that occur take resourcefulness and commitment from all family members. At diagnosis and throughout the span of JIA, it is essential to recognize signs of stress and counterproductive coping and provide the necessary support to maximize adaptation. The problems and needs of these families are discussed in Chapter 17 and readers are directed to that chapter for guidance in planning care.

Slipped Capital Femoral Epiphysis

- Spontaneous displacement of the proximal femoral epiphysis - Most often develops shortly before or during accelerated growth and the onset of puberty - Males and obese children - Emergency: early diagnosis and treatment Head of the femur stays but neck and shaft displace and slip. Can't beat weight, in their leg. Time of puberty period. Growing fast. Once have diagnosis, emergency treated right away to prevent further slip.

Diagnostic Evaluation: Scoliosis

- Standing radiographs to determine degree of curvature - Asymmetry of shoulder height, scapular or flank shape, or hip height - Often have primary curve and compensatory curve to align head with gluteal cleft

Classification of OI

- Type I > Most common > mild to no bone fragility > Autosomal dominant inheritance > Blue sclerae - Type II > Lethal; stillborn or die in early infancy > Severe bone fragility with multiple fractures at birth > Autosomal recessive - Type III > Severe bone fragility leads to severe progressive deformities > Normal sclera, marked growth failure > Most are autosomal recessive, but some are autosomal dominant inheritance - Type IV > Similar to type I with white sclerae Type II: growth failure, autosomal recessive. Not be able to ambulate, still born while giving birth and fracture while passing by the moms

Epiphyseal Injuries

- Weakest point of long bones is the cartilage growth plate (epiphyseal plate) - Frequent site of damage during trauma - May affect future bone growth - Treatment may include open reduction and internal fixation to prevent growth disturbances Growth plate, soft, porous. Kids hurting there epiphyseal may effect future bone growth. Do internal fixation to prevent growth effects. Growth Plate (Physeal) Injuries The weakest point of long bones is the cartilage growth plate, or the physis. Consequently, this is a frequent site of damage of childhood trauma. Growth plate fractures are classified with the Salter-Harris classification system (Fig. 29-3). Detection of physeal injuries is sometimes difficult but critical. Close monitoring and early treatment, if indicated, is essential to prevent longitudinal or angular growth deformities (or both). Treatment of these fractures may include surgical open reduction and internal fixation to prevent or reduce growth disturbances. FIG 29-3 Salter-Harris fracture classification. Types of epiphyseal injury in order of increasing risk. The injuries are classified as follows: Type I, separation or slip of growth plate without fracture of the bone; type II, separation of growth plate and breaking off of section of metaphysis; type III, fracture of epiphysis extending through joint surface; type IV, fracture of growth plate, epiphysis, and metaphysis; and type V, crushing injury of epiphysis (can be diagnosed only in retrospect). This classification of epiphyseal injuries was developed by orthopedists RB Salter and WR Harris. (First published in Salter RB, Harris WR: Injuries involving the physeal plate, J Bone Joint Surg Am 45[3]:587-622, 1963.) Immediately after a fracture occurs, the muscles contract and physiologically splint the injured area. This phenomenon accounts for the muscle tightness observed over a fracture site and the deformity that is produced as the muscles pull the bone ends out of alignment. This muscle response must be overcome by traction or complete muscle relaxation (e.g., anesthesia) to realign the distal bone fragment to the proximal bone fragment.

Developmental Dysplasia of the Hip

1. Acetabular dysplasia: This is the mildest form of DDH, in which there is a delay in acetabular development evidenced by osseous hypoplasia of the acetabular roof that is oblique and shallow, although the cartilaginous roof is comparatively intact. The femoral head remains in the acetabulum. 2. Subluxation: The largest percentage of DDH, subluxation, implies incomplete dislocation of the hip. The femoral head remains in contact with the acetabulum, but a stretched capsule and ligamentum teres cause the head of the femur to be partially displaced. Pressure on the cartilaginous roof inhibits ossification and produces a flattening of the socket. 3. Dislocation: The femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim. The ligamentum teres is elongated and taut.

Juvenile Idiopathic Arthritis (JIA)

AKA juvenile rheumatoid arthritis, juvenile chronic arthritis, or idiopathic arthritis of childhood Chronic inflammation of synovium with joint effusion, destruction of cartilage, and ankylosis of joints as disease progresses Possible causes—immunogenic susceptibility, environmental or external trigger Rub against each other in severe form. The cause of JIA is unknown. JIA starts before 16 years old with a peak onset between 1 and 3 years old. Twice as many girls as boys are affected. The reported incidence of chronic childhood arthritis varies from 1 to 20 cases per 100,000 children with a prevalence of 10 to 400 per 100,000 (Cassidy and Petty, 2011). Genetic factors and environmental triggers (e.g., rubella, Epstein-Barr virus, parvovirus B19) have been associated with the onset of JIA, but the etiology remains unclear. Pathophysiology The disease process is characterized by chronic inflammation of the synovium with joint effusion and eventual erosion, destruction, and fibrosis of the articular cartilage. Adhesions between joint surfaces and ankylosis of joints may occur if the inflammatory process persists.

American College of Rheumatology Diagnostic Criteria for JIA

Age of onset <16 years 1 or more affected joints Duration of arthritis >6 weeks Exclusion of other forms of arthritis

Nursing Management: DDH

Assessment Care of child in a cast or splinting device - Teach parents to apply and maintain reduction device Early detection is beneficial because they can just put spica or harness and not surgery. Don't adjust the harness and take to the hospital every week to make any modification. Cast children grow fast so children in cast extended period so take the growth in consideration. Look for compartment syndrome. Take them to hospital every week. And ask if they can remove when shower if not need to take shower with them.

Diagnostic Evaluation: Congenital Clubfoot

Can be detected prenatally The deformity is readily apparent at birth if it has not been detected prenatally through ultrasonography. However, it must be differentiated from some positional deformities that can be passively corrected. Once it is detected, a careful yet comprehensive physical assessment of the affected foot (or feet) should be completed to allow for appropriate decision making regarding treatment plans and prognosis. The affected foot (or feet) is usually smaller and shorter with an empty heel pad midfoot medial crease. When the deformity is unilateral, the affected limb may be shorter and calf atrophy is present. Radiographs of the feet are generally not necessary. A thorough hip examination should be performed for all infants with clubfoot; an increased risk of hip dysplasia is associated with clubfoot deformities.

The Child in a Cast

Cast application techniques Explain procedure Use distraction methods (distraction while putting the cast on and tell them it will be a little warm) Assess extremities Nursing considerations Hip spica cast can take 24-48 hours to dry Check for hot spots Assess circulation status Assess for 6 P's. to see any compartment syndrome and inflammation.

The Child in a Cast

Cast care at home Signs and symptoms that cast is too tight Specially designed car seats and restraints are available Cast care Cast removal Explain procedure Skin care The corner can get rubbed off and have ruff edges so watch for that to prevent skin breakdown or rashes. Might have tingling sensation. When cast comes off the skin looks bad, so educate them not to use scrubber to scrub it and inform them to use really washclothes and take a bath, shave the leg wait until all the cracked skin is resolved).

Diagnostic Evaluation: Slipped Capital Femoral Epiphysis

Child displays clinical signs: - Often obese (BMI >95%) - Possible inability to bear weight because of severe pain - Limp on affected side - Pain in groin, thigh, or knee - Affected leg is externally rotated - Loss of abduction and internal rotation as severity increases - Shortening of lower extremity Confirmed by anteroposterior and frog-leg radiographic examination

Clinical Manifestation: :DDH

Clinical Manifestations of Developmental Dysplasia of the Hip Infants Shortening of limb on affected side (Galeazzi sign) Restricted abduction of hip on affected side Unequal gluteal folds (best visualized with infant prone) Positive Ortolani test (hip is reduced by abduction) Positive Barlow test (hip is dislocated by adduction) Older Infants and Children Affected leg appears shorter than the other Telescoping or piston mobility of joint: Head of femur felt to move up and down in buttock when extended thigh is pushed first toward child's head and then pulled distally Trendelenburg sign: When child stands first on one foot and then on the other (holding onto a chair, rail, or someone's hands) bearing weight on affected hip, pelvis tilts downward on normal side instead of upward, as it would with normal stability Greater trochanter prominent and appearing above a line from anterosuperior iliac spine to tuberosity of ischium Marked lordosis and waddling gait (bilateral hip dislocation)

Clinical Manifestations of Fracture

Clinical Manifestations of a Fracture Signs of injury: • Generalized swelling • Pain or tenderness • Deformity • Diminished functional use of affected limb or digit May also demonstrate: • Bruising • Severe muscular rigidity • Crepitus (grating sensation at fracture site)

Types of Fractures

Compound or open: fractured bone protrudes through the skin Complicated: bone fragments have damaged other organs or tissues (puncture through your organ) Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue Greenstick: compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture (bending fracture and newborns bones are flexible) A fractured bone consists of fragments—the fragment closer to the midline, or the proximal fragment, and the fragment farther from the midline, or the distal fragment. When fracture fragments are separated, the fracture is complete; when fragments remain attached, the fracture is incomplete. The fracture line can be any of the following: Transverse: Crosswise at right angles to the long axis of the bone Oblique: Slanting but straight between a horizontal and a perpendicular direction Spiral: Slanting and circular, twisting around the bone shaft The twisting of an extremity while the bone is breaking results in a spiral break. If the fracture does not produce a break in the skin, it is a simple, or closed, fracture. Open, or compound, fractures are those with an open wound through which the bone protrudes. If the bone fragments cause damage to other organs or tissues (e.g., lung, liver), the injury is said to be a complicated fracture. When small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue, the injury is a comminuted fracture. This type of fracture is rare in children. The types of fractures that are seen most often in children are described

Congenital Defects

Developmental dysplasia of the hip (DDH) Congenital clubfoot Metatarsus adductus (varus) - Osteogenesis Imperfecta - Slipped Capital Femoral Epiphysis - Idiopathic Scoliosis

CAST CARE

Family-Centered Care Cast Care Keep the casted extremity elevated on pillows or similar support for the first day or as directed by the health professional. Avoid denting the plaster cast with fingertips (use palms of hand to handle) while it is still wet to avoid creating pressure points. Expose the plaster cast to air until dry. Observe the extremities (fingers or toes) for any evidence of swelling or discoloration (darker or lighter than a comparable extremity) and contact the health professional if noted. Check movement and sensation of the visible extremities frequently. Follow health professional's orders regarding any restriction of activities. Restrict strenuous activities for the first few days: • Engage in quiet activities but encourage use of muscles. • Move the joints above and below the cast on the affected extremity. Encourage frequent rest for a few days, keeping the injured extremity elevated while resting. Avoid allowing the affected limb to hang in a dependent position for any length of time: • Keep an injured upper extremity elevated (e.g., in a sling) while upright. • Elevate a lower limb when sitting and avoid standing for too long. Do not allow the child to put anything inside the cast. Keep small items that might be placed inside the cast away from small children. Keep a clear path for ambulation. Remove toys, hazardous floor rugs, pets, and other items over which the child might stumble. Use crutches appropriately if lower limb fracture requires non-weight bearing on affected extremity. The crutches should fit properly, have a soft rubber tip to prevent slipping, and be well padded at the axilla. With crutch walking, the child's body weight is supported on the hand grips, not the axilla. Nurses can help families adapt the child's home environment to meet the temporary encumbrance of a large cast or one that restricts the child's mobility (e.g., a long-leg or spica cast [Fig. 29-6]). Commonplace situations become problematic (e.g., transporting a child safely and comfortably in a car). Standard seat belts and car seats may not be readily adapted for use by children in some casts. Specially designed car seats and restraints are available that meet safety requirements.* Alterations to standard car seats to accommodate the cast are not recommended because the structure may be adversely altered and fail to properly restrain the child. A bedside commode or rental wheelchair maybe be necessary equipment for a child who is nonambulatory. Parents are taught the proper care of the cast or brace and are helped to devise means for maintaining cleanliness. A superabsorbent disposable diaper is tucked beneath the entire perineal opening of the cast. A larger diaper can be applied and fastened over the small diaper and cast to hold the smaller diaper in place. In the event that the larger diaper becomes wet or soiled, it is likely the cast is as well. For tightly fitting casts, transparent film dressings can be cut into strips as for petaling with one edge applied to the cast edge and the other directly to the perineum; this forms a continuous, waterproof bridge between the perineum and the cast to prevent leakage. An additional advantage to the use of this transparent dressing is that it keeps both the skin and the cast dry while allowing for observation of skin beneath the dressing. Older infants and small children may stuff bits of food, small toys, or other items under the cast; parents should be alerted to this possibility so they can initiate suitable preventive measures. Feeding an infant in a hip spica cast offers problems in positioning. Very young infants can be fed in the supine position with the head elevated. With the infant's hips and legs supported on a pillow at the side, the parent can cuddle the infant in his or her arms during feeding. A somewhat similar position can be used for breastfeeding (i.e., with the infant supported on pillows or held in a "football" hold facing the mother with the legs behind her). An alternate position is to hold the infant upright on the caregiver's lap with the legs of the infant astride the adult's leg. Children in spica casts usually find the prone position easier for self-feeding from a small table placed next to the dining table; alternatively, they may manage a semi-sitting position in bed or in a wheelchair (Fig. 29-7). The use of a conventional toilet is almost impossible. A bedside toilet can be adapted for use. Small bedpans or other containers offer alternatives for elimination. The nurse may suggest waterproofing methods by devising plastic wraps for elimination and showers. Baths are possible only if the plaster cast is kept out of the water and covered to prevent it from becoming wet. FIG 29-7 Single spica cast. Note diaper to maintain dryness. (Courtesy of Texas Children's Hospital, Houston, TX.) Cast Removal Cutting the cast to remove it or to relieve tightness is frequently a frightening experience for children. They fear the sound of the cast cutter and are terrified that their flesh, as well as the cast, will be cut. The oscillating blade vibrates rapidly back and forth and will not cut when placed lightly on the skin. Children have described it as producing a "tickly" sensation. The vibration also generates heat that may be felt by the child. Both of these feelings should be explained. Preparation for the procedure will help reduce anxiety, especially if a trusting relationship has been established between the child and the nurse. Many young children come to regard the cast as part of themselves, which intensifies their fear of removal (Fig. 29-8). They need continual reassurance that all is going well and that their behavior is accepted. After the cast is removed, the parents and child should be given the option of keeping the cast. If the cast has been in place for a 954lengthy period, decreased muscle mass will be noted. The child should be reassured that resuming exercise and routine activities will return function and appearance (provided there was no significant trauma beforehand).

Developmental Dysplasia of the Hip (DDH)

Formerly called congenital hip dysplasia or congenital dislocation of the hip Three degrees of DDH: - Acetabular dysplasia: - Subluxation - Dislocations Capsular laxity that is causing this DDH. Subluxation: head of femur glides inside acetabulum its not coming out Dislocation: femur of the head loses contact with acetabulum. Can put it back with reduces. shortening of the leg.

Therapeutic Management: Slipped Capital Femoral Epiphysis

Goal: Prevent further slippage, prevent complication and restore function. Non-weight bearing Pre-surgery: - Bed rest and traction Post-surgery: - Non-weight bearing with crutch ambulation - Surgery done within 24 hours and not weight bearing, and use crutches. Take weeks to months to bear weight. - Check vital signs, hemorrhage, infection, and teach proper use of crutches. Avoid boredom and let them help as much as possible.

Therapeutic Management: Fractures

Goal: Regain alignment and length, restore function, prevent further injury Simple traction and immobilization Therapeutic Management The goals of fracture management are: • To regain alignment and maintain the length of the bony fragments (reduction) • To retain alignment and length (immobilization) • To restore function to the injured parts • To prevent further injury and deformity The majority of children's fractures heal well, and nonunion is rare. Fractures are splinted or casted to immobilize and protect the injured extremity. Children with displaced fractures may have immediate surgical reduction and fixation (internal or external) rather than being immobilized by traction (Fig. 29-4). This practice is more common and holds true for all types of fractures, including femur fractures, although there is variation based on provider preference and institutional practice. Some conditions require immediate medical attention, including open fractures, compartment syndrome, fractures associated with vascular or nerve injury, and joint dislocations that are unresponsive to reduction maneuvers. In children, immobilization is used until adequate callus is formed. The position of the bone fragments in relation to one another influences the rapidity of healing and residual deformity. Weight bearing and active movement for the purpose of regaining function may begin after the fracture site is determined to be stable by the medical provider. The child's natural tendency to be active is usually sufficient to restore normal mobility, and physical or occupational therapy is rarely indicated. 951 Children are most frequently hospitalized for fractures of the femur and supracondylar area of the distal humerus. If simple reduction cannot be achieved or a neurovascular problem is detected after the injury, observation in a hospital setting may be indicated. The trend is to avoid hospitalization. The major methods for immobilizing a fracture, casting and traction, are described later. Treat fast to reduce any complications like ischemia and necrosis. Traction immobilize longer, so they prefer internal and external fixation. Open fracture surgery as soon as possible. Any sign of compartment syndrome: no elevate leg, no ice

Scoliosis: Clinical Manifestations

Idiopathic scoliosis is most commonly identified during the preadolescent growth spurt. Parents frequently bring a child for follow-up on an abnormal school scoliosis screening or because of ill-fitting clothes, such as poorly fitting jeans. School screening is controversial because there are no controlled studies to demonstrated improved outcomes and a reported number of false-positive results lead to referrals. The American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics published a joint statement favoring scoliosis screening for preadolescents and adolescents in the school, provider's office, or nurses' clinic (Richards and Vitale, 2008). According to the American Academy of Orthopaedic Surgeons (Richards and Vitale, 2008), girls should be screened at 10 and 12 years old, whereas boys should be screened once either at 13 or 14 years old. The benefits of early detection, referral, and medical treatment are considered to be significant, but the persons performing the screenings must be educated in the detection of spinal deformity.

Nursing Management: Fractures

If the child is alert and has no hemorrhage, nursing interventions are directed towards calming and reassuring the child and parents Assess extent of injury—6 P's Pain and point of tenderness Pulse Pallor Paresthesia Paralysis Pressure No signs of shock, calm the child to do more detailed assessment. Management of pain so parents can calm down. Open wound put sterile dressing over it. If you see patient who has fracture use any things to use it as splint. Cold to injure area can help and elevate. (R.I.C.E)

Therapeutic Management: DDH

Importance of early intervention Longer treatment is delayed, more severe the deformity Newborn to age 6 months: Pavlik harness for abduction of hip (keeps abducted to keep it heal/ 6-12 weeks, if not more intervention) Age 6-18 months: dislocation unrecognized until child begins to stand and walk; use traction and cast immobilization (spica) (surgical reduction and do hip spica) Older child: operative reduction, tenotomy, osteotomy; difficult after 4 years (harness won't help so need to do surgical procedure and put hip spica)( at 4 or greater, prognosis will be severe)

Clinical Manifestations: DDH

Infant: - Shortened limb on affected side - Restricted abduction of hip on affected side - Unequal gluteal folds when infant prone - Positive Ortolani test - Positive Barlow test Older infant and child: - Affected leg shorter than the other - Telescoping or piston mobility of joint - Trendelenburg sign - Greater trochanter is prominent and appears above line from anterosuperior iliac spine to tuberosity of ischium - Marked lordosis - Waddling gait (when borth hip dislocated)

Scoliosis

Most common spinal deformity May be congenital or develop during childhood Multiple potential causes; most cases idiopathic Generally becomes noticeable after preadolescent growth spurt May have complaints of ill-fitting clothes School screening Complex spinal deformity in three planes: - Lateral curvature - Spinal rotation causing rib asymmetry - Thoracic hypokyphosis infantile occurs at birth up to 3 years old; juvenile occurs in children ages 3 to 10 years old; andadolescent occurs at 10 years old or older. Scoliosis can be caused by a number of conditions and may occur alone or in association with other diseases, particularly neuromuscular conditions (neuromuscular scoliosis). In most cases, however, there is no apparent cause, hence the name idiopathic scoliosis. There appears to be a genetic component to the etiology of idiopathic scoliosis; however, the exact relationship has yet to be established. The following section is limited to a discussion of adolescent idiopathic scoliosis. Ask them to bend and when they figure out they have scoliosis. Doesn't look smooth. Have lateral curvature and thoracic curvature. Head to the midline to have compensated curvature.

Pharmacology for JIA

NSAIDs: ibuprofen (GI disturbance, hepatic ) DMARDs: (initiation therapy or escalating therapy)(methotrexate: use contraceptive if in sexual active or don't use while pregnant/ avoid alcohol) Corticosteroids: systemic arthritis use corticosteroids. Biologic agents: methotrexate not effective use biologic agent. Subcutaneous. Every 2 weeks. No life vaccine.

Diagnostic Evaluation: JIA

No definitive diagnostic tests Elevated sedimentation rate in some cases Antinuclear antibodies common, but not specific for JIA Leukocytosis during exacerbations Radiographs (identify soft tissue swelling with synovial fluid) Diagnosis based on criteria of American College of Rheumatology

Nursing management: Slipped Capital Femoral Epiphysis

Nursing Care Management: Nursing care involves preparing the child and family for the surgical procedure and recovery. Postoperative care involves hemodynamic stabilization, pain management, and assessment for complications. The adolescent is taught the proper use of crutches and the importance of avoiding weight bearing on the affected hip. Self-care and performance of activities of daily living to capability are encour

Types of Fractures:

Plastic deformation: bone bends Buckle: compression swell Greenstick and plastic deformation.

Nursing Care Management: JIA

Relieve Pain: NSAIDs Promote General Health Facilitate Compliance Encourage Heat and Exercise: night time splint helps. If it affects there sleep remove it. Support Child and Family KNOW!!

Therapeutic Management: Congenital Clubfoot

Serial casting Browne splint Surgery Therapeutic Management The goal of treatment for clubfoot is to achieve a painless, plantigrade, and functional foot. Treatment of clubfoot involves three stages: (1) correction of the deformity, (2) maintenance of the correction until normal muscle balance is regained, and (3) follow-up observation to avert possible recurrence of the deformity. Some feet respond to treatment readily; some respond only to prolonged, vigorous, and sustained efforts; and the improvement in others remains disappointing even with maximal effort. Recommended treatment of clubfoot is with the use of the Ponseti method. Serial casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along with placement of serial long-leg casts allow for gradual improvement in the alignment of the foot (Fig. 29-18). The extremity or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. The majority of the time, a percutaneous heel-cord tenotomy is performed at the end of casting to correct the equinus deformity. After the tenotomy, a long-leg cast is applied and left in place for 3 weeks. After casting is completed, children are transitioned to utilizing Ponseti sandals with a bar set in abduction to help maintain the correction and prevent a recurrence of the foot deformity. Inability to achieve normal foot alignment after casting and tenotomy indicates the need for surgical intervention (Ponseti, 1996). Change the cast weekly. Serious of casting might have to do percutaneous tenotomy, release the tendon so the ankle can be flexed.

Symptoms of JIA

Stiffness Swelling Loss of mobility in affected joints Warm to touch, usually without erythema Tender to touch in some cases Symptoms increase with stressors Growth retardation KNOW!!

Therapeutic Management: Scoliosis

Team approach to treatment Bracing Exercise Surgical intervention for severe curvature (instrumentation and fusion): - Spinal Fusion - Luque-rods

Cast

The Cast Casts are constructed from gauze strips and bandages impregnated with plaster of Paris or, more commonly, from synthetic lighter weight and water-resistant materials (e.g., waterproof liners, fiberglass and polyurethane resin). Both types of casting produce heat from chemical reaction activated by water immediately after application. Plaster casts mold closely 952to the body part, take 10 to 72 hours to dry, have a smooth exterior, and are inexpensive. The newer synthetic casting (fibroglass) material is lightweight, dries in 5 to 20 minutes, permits earlier weight bearing, and is water resistant when applied with a waterproof liner. It is always desirable to give children choices, and synthetic casting materials come in a variety of colors. The disadvantages of synthetic casting are its inability to mold closely to body parts and its rough exterior, which may scratch surfaces. Synthetic casts are also difficult to write on; a waterproof marker or color markers may be used. ( Don't use hair dryer/ don't use heat) (warning a site: bad odor (infection). Cast Application The child's developmental age should be considered before the cast is applied. For preschoolers who fear bodily harm and fantasize about the loss of an extremity, it may be helpful to use a plastic doll or stuffed animal to explain the procedure beforehand. Toddlers and preschoolers do not have easily defined body boundaries; if an extremity is wrapped in a bandage, cast, or splint, to the young child the extremity ceases to function or exist. It is also helpful to explain that some synthetic cast material will become warm during application but will not burn. During the application of the cast, various distraction methods can be used, including discussing favorite pets or activities at school, blowing bubbles, and so forth. In this age group, explanations, such as "This will help your arm get better," are futile because the child has no concept of causality. Before the cast is applied, the extremities are checked for any abrasions, cuts, or other alterations in the skin surface and for the presence of rings or other items that might cause constriction from swelling; such objects are removed. A tube of cloth stockinette or Gore-Tex liner is stretched over the area to be casted, and bony prominences are padded with soft cotton sheeting. Dry rolls of casting material are immersed in a pail of water. The wet rolls are put on in a bandage fashion and molded to the extremity. During application of the cast, the underlying stockinette is pulled over the rough edges of the cast and secured with casting material to form a padded edge to protect the skin. Nursing Care Management The complete evaporation of the water from a hip spica cast can take 24 to 48 hours when older types of plaster materials are used. Drying occurs within minutes with fiberglass cast material. The cast must remain uncovered to allow it to dry from the inside out. Turning the child in a plaster cast at least every 2 hours will help to dry a body cast evenly and prevent complications related to immobility. A regular fan or cool-air hair dryer to circulate air may be helpful when the humidity is high. Nursing Alert Heated fans or dryers are not used because they cause the cast to dry on the outside and remain wet beneath or cause burns from heat conduction by way of the cast to the underlying tissue. A wet plaster cast should be supported by a pillow that is covered with plastic and handled by the palms of the hands to prevent indenting the cast, which can create pressure areas. A dry plaster-of-Paris cast produces a hollow sound when it is tapped with the finger. After it has dried, "hot spots" felt on the cast surface or a foul-smelling odor may indicate an infection. This should be reported for further evaluation, and if concern continues, an opening, or a "window," may be exposed over the area of concern to evaluate the site. During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications (compartment syndrome) (see Box 29-3). To reduce the likelihood of this potential problem, the body part can be elevated, thereby increasing venous return. If edema is excessive, casts are bivalved (i.e., cut to make anterior and posterior halves that are held together with an elastic bandage). The cast and the involved extremity are observed frequently for neurovascular integrity and any signs of compromise. Permanent muscle and tissue damage can occur within a few hours.

Scoliosis: therapeutic management

Therapeutic Management Current management options include observation with regular clinical and radiographic evaluation, orthotic intervention (bracing), and surgical spinal fusion. Treatment decisions are based on the magnitude, location, and type of curve; the age and skeletal maturity of the child or adolescent; and any underlying or contributing disease process. Bracing and Exercise For moderate curves (25 to 45 degrees) in the growing child and adolescent, bracing may be the treatment of choice. Historically bracing has not been shown to be curative; the goal is to slow the progression of the curvature to allow skeletal growth and maturity. The two most common types of bracing are the Boston and Wilmington braces, which are underarm orthoses customized from prefabricated plastic shells, with corrective forces using lateral pads and decreasing lumbar lordosis, and a thoracolumbosacral orthosis (TLSO), which is an underarm orthosis made of plastic that is custom molded to the body and then shaped to correct or hold the deformity (Fig. 29-20). The Milwaukee brace, which is an individually adapted brace that includes a neck ring, is rarely used in scoliosis but is sometimes used in the treatment of kyphosis. The Charleston nighttime bending brace is worn only when the child is in bed, because it prevents walking because of the severity of the trunk bend. Wearing the brace is challenging due to the child's age and preoccupation with body image and appearance. Bracing, although used as the gold standard treatment for moderate curves in a growing child, has not proved to be entirely effective in the treatment of idiopathic scoliosis. There is very limited evidence regarding the effect of exercises and chiropractic treatment in the prevention of curve progression in scoliosis. Transcutaneous electrical nerve stimulation has proved to be an ineffective treatment. Exercises are of benefit when used in conjunction with bracing to maintain and increase the strength and range of motion of the spine. Operative Management Surgical intervention may be required for treatment of severe curves, which are typically greater than 45 degrees (Mistovich and Spiegel, 2016). The child's age, location of the curvature, and curve magnitude influence the decision for surgery. Any progressive or severe curve that does not respond to conservative orthotic measures (such as bracing) requires surgical correction. Bracing and exercise have been found to be ineffective in managing curves greater than 45 degrees. Neuromuscular, dysplastic and congenital curves, which eventually progress, are best treated with surgical stabilization. Difficulties with balance or seating, respiratory compromise, or pain are also considered. There are a number of surgical techniques for severe scoliosis. A spinal fusion consists of realignment and straightening of the spine with internal fixation and instrumentation combined with bony fusion (arthrodesis). Posterior and/or anterior surgical approaches may be implemented. The goals of surgical intervention are to improve the curvatures on the sagittal and coronal planes and to provide a solid, pain-free fusion in a well-balanced torso, with maximum mobility of the remaining spinal segments. Advances in surgical technology currently being evaluated include thoracoscopic spinal fusion and placement of implants; metallic staples may also be placed into the vertebral bodies to achieve spinal fusion and to correct the deformity (Mistovich and Spiegel, 2016). The use of minimally invasive surgery techniques has gained acceptance for its small incisions, decreased blood loss, decreased recovery time, earlier mobilization, and decreased pain and need for pain medications (Sarwahi, Wollowick, Sugarman, et al, 2011). Less than 25-45 curvature mild bracing and exercsie help 45 bracing not going to cure the disease just preventing getting worse and help with skeletal growth.

Types of fracture

Types of Fractures in Children - Plastic deformation: Occurs when the bone is bent but not broken. A child's flexible bone can be bent 45 degrees or more before breaking. However, if bent, the bone will straighten slowly but not completely, producing some deformity but without the angulation seen when the bone breaks. Bends occur most commonly in the ulna and fibula, often in association with fractures of the radius and tibia. - Buckle, or torus, fracture: Produced by compression of the porous bone; appears as a raised or bulging projection at the fracture site. These fractures occur in the most porous portion of the bone near the metaphysis (the portion of the bone shaft adjacent to the epiphysis) and are more common in young children. - Greenstick fracture: Occurs when a bone is angulated beyond the limits of bending. The compressed side bends, and the tension side fails, causing an incomplete fracture similar to the break observed when a green stick is broken. - Epiphyseal InjuriesComplete fracture: Divides the bone fragments. These fragments often remain attached by a periosteal hinge, which can aid or hinder reduction. FIG 29-2 Types of fractures in children. Not common in infants, vary degree in healing child had been diagnosis not accidental injury. Not accident injury rule out might be osteogenesis. Children play outside more common in children. More exposure to sport related injury.

Diagnostic Evaluation: Fractures

X- Ray Radiographic examination is the most useful diagnostic tool for assessing skeletal trauma. The calcium deposits in bone make the entire structure radiopaque. Radiographic films are taken after fracture reduction and, in some cases, may be taken during the healing process to determine satisfactory progress.