1. Musculoskeletal

5. Fractures Common in childhood Developmental aspects are useful in addressing fractures in childhood Fractures are rare in infants Children 5 to 9 related to MVA’s

6. Fractures Remember Waddell’s triad Femur from the car bumper Thorax from the hood of the car Head from fall to the ground

7. Fractures Usual site for fractures in children The ulna The clavicle The tibia The femur Radius Point to remember a child with an uncomplicated fx should not present with signs of shock

8. Fractures Most common type of fractures Point to remember: the most serious type of fracture is an epiphyseal fracture because it occurs in the area of the growth plate

10. Fractures Clinical Manifestations Pain or tenderness at the site Immobility or decreased range of motion Deformity of the extremity Crepitus Ecchymosis Edema Muscle spasm Inability to bear weight

11. Fractures Goal of therapy: Realign bone fragments and provide support during the healing process

12. Fractures Diagnosis is made with x-ray Therapeutic Mangement Reduction Closed Open Retention Casts Traction

13. Fractures Close reduction is the manual alignment followed by immobilization Open reduction is a surgery in which alignment is attained by the use of internal fixation devices.

14. Fractures Retention Devices Casts Plaster of paris Synthetic Each type of cast has it’s advantage and disadvantages

15. Fractures Traction Defined as a pull or force exerted on one part of the body May be applied to the spine, pelvis or long bones Use to reduce and immobilize fractures Requires hospitalization and prolonged immobility

16. Fractures Traction Can be either intermittent or continuous The nurse should always assume the traction is continuous unless otherwise ordered May be applied to the skin or skeletal Bryant traction specific to pediatrics

17. Fractures Skin traction exerts force directly on the body surface Non invasive Best suited for children < 30lbs or younger than 2 and 3 years old Preferred in conditions where invasive procedures are contraindicated Nurses are responsible for neurovascular assessments and monitoring for skin breakdown

18. Fractures Skeletal traction exerts a greater force and is tolerated physiologically for longer periods of time Most serious complication associated with skeletal traction is osteomyelitis Skeletal traction is always continuous

19. Fractures Nursing Care If fracture is caused by trauma begin by assessing ABC’s Obtain a history on how the fracture occur Is story consistent with injury? Generally the child will favor the injured extremity

20. Fractures Nursing care Begin assessment by asking the child to point where it hurts Assess for swelling, skin lacerations and bruising Assess for complications Nerve compression Circulation impairment Compartment syndrome

21. Fractures Is swelling within the compartment surrounded by the inelastic fascia Noted by severe pain which is not relieved with analgesics

22. Fractures Neurovascular assessment Important nursing responsibility Should be done every 1 -2 hours the first 48 hours following injury Assess quality of pulses distal to the injury and compare to the other side Check capillary refill

23. Fractures Neurovascular assessment Assess site for skin temperature, color (pallor or blueness), feeling (swelling or numbness), loss of motion Assess for uncontrolled pain (early sign) Numbness or tingling may be described as pins or needles or the extremity “falling asleep” by children With pain looks for other signs such as restlessness and crying in children

25. Fractures Cast Care Remember when plaster of paris casts are applied they feel hot Assess for hot spots– sign of infection Circle drainage, date and time Use palms only to move extremity with a cast

27. Fractures Nursing Care Monitor for the type of toys Provide colored markers to the child and his friends For school aged children provide for ways to keep up with school work

28. Fractures Remember cast removal may be very frightening to a child Child may fear body mutilation Let the child see the cast cutter Demonstrate cast removal on a doll Have the parents stay with the child

29. Fractures Casts and traction can impact a child’s mobility Mobility is a form of interaction for a child Cast or traction may be viewed as a form of punishment In younger children there is a struggle for dependence vs independence May impact a child’s cognition

30. Fractures Nursing interventions for immobility Change the environment Provide activities for fine motor development Anticipate regressive behavior Encourage age appropriate self care activities

31. Notify Healthcare provider if Unusual odor beneath the cast Burning, tingling, or numbness in the casted arm or leg Drainage through the cast Swelling or inability to move the fingers or toes Slippage of the cast Cast cracked, soft, or loose Sudden, unexplained fever Unusual fussiness or irritability in an infant or child Fingers or toes that blue or white Pain that is not relieved by any comfort measures (repositioning or pain medication)

32. Soft Tissue Injuries Common in children Sprains are trauma to a joint in which ligaments are stretched or torn Strains are pulls, tears or rupture from excessive stretch of the muscles Dislocations articulating surfaces are no longer in contact

33. Soft Tissue Injury Clinical signs Pain Swelling Localize tenderness Limited Range of motion Poor weight bearing Pop or snapping sound

34. Soft Tissue Injuries Therapeutic Management R rest I ice C compression E elevation I Ice C compression E elevation S support

35. Soft tissue Injury Wrap for support Ice to reduce swelling Remember ice is not to be applied continuously….. 30 minutes on every 4 to 6 hours for 24 to 48 hours

36. Soft Tissue Injury Nursing Care Assess for severity of injury as well as for the presence of a fracture Assess for neurovascular impairment Pain management – Ibuprofen or Acetaminophen Elevate the extremity above the level of the heart Return to sports activities

37. Osteomyelitis Bacterial infection of the cone involving the cortex and or marrow Classified as acute or chronic Chronic is defined as an infection > one month or does not respond to initial antibiotic treatment Children are affected more than adults Boys more than girls Preschooler and adolescents

39. Osteomyelitis Clinical signs and symptoms Pain Favoring affected extremity Tenderness Warmth Erythema Limited range of motion Systemic manifestations

40. Osteomyelitis Diagnosis Physical examination Elevated ESR rate Blood cultures Bone changes on x-ray– not evident until 7-14 days

41. Osteomyelitis Therapeutic Management Antibiotics 4 to 6 week course of high dose parental therapy Complete bed rest With antibiotic therapy Peaks and troughs are required with certain antibiotic antibiotics Renal, hepatic and bone marrow function need to be evaluated Aminoglycosides can be ototoxic and nephrotoxic

42. Osteomyelitis Nursing Care Assess for a history of falls or trauma Assess for cat scratch fever or recent small cuts Assess for sign and symptoms: pain tenderness, erythema and swelling Assess and document child’s condition every shift Keep extremity immobilized

43. Osteomyelitis Nursing Care Frequent assessment of Intravenous site Be familiar with antibiotic therapy---dosage side effects and compatibility with other antibiotics Review lab values for liver and kidney function Always use sterile technique with dressing changes

44. Osteomyelitis Nursing Care Document appearance of wound – drainage, odor Neurovascular assessment every shift Maintain bed rest or non weight bearing activity Monitor nutritional status– needs high calories and protein

45. Osteogensis Imperfecta An inherited disorder characterized by connective tissue and bone defects Prone to fractures Parents often accused of abuse- need to carry medical info with them to show proof of diagnosis in case of injury away from primary medical doctor/hospital See handout for care instructions

46. Osteogensis Imperfecta Clinical Manifestations Blue sclera Soft transparent skin Weak muscles Short stature Frequent fractures Hearing problems early adult life Bone deformities

47. Osteogensis Imperfecta Therapeutic management Maintain integrity of MS system Prevention of fractures

48. Osteogensis Imperfecta Nursing care Assess for a history of multiple fractures Assess for delayed growth Assess for bone deformities (thoracic cage) Identify mobility issues that might impact child’s functioning 1 st priority should always be to prevent fractures and maintain muscle and joint integrity Maintain optimal weight

49. Juvenile Arthritis Previously referred to as Juvenile Rheumatic Arthritis An autoimmune inflammatory disease with no known cause A systemic multisystem disorder that affects the body’s connective tissue Characterized by joint swelling, limited ROM with pain, tenderness and inflammation in one or more joints

50. Juvenile Arthritis Occurs before the age of 16 Greatest number of cases occur between ages 1-3 and 8-12.

51. Juvenile Arthritis Clinical Manifestations Intermittent joint pain with a duration of > 6 weeks Joints are painful, stiff, swollen, warm to touch and have limited range of motion Morning stiffness Child may protect affected joint

52. Juvenile Arthritis Clinical Manifestation Systemic manifestations include: malaise, fatigue, lethargy, anorexia, weight loss and growth problems History of late afternoon fevers with temperature spikes of 105 0 F

53. Juvenile Arthritis Therapeutic Management Goal preserving joint function and controlling inflammatory process, minimizing deformities and reducing impact on child’s development Drug therapy Physical and occupation therapy Family education Anticipatory guidance on child developement

54. Juvenile Arthritis Medications NSAID’s used to suppress inflammation and control pain SAARD’s slower acting or disease modifying antirheumatic drugs Corticocosteriods has limited use except in life threatening complications Immune suppressive agents only used in a child who does not response to conventional treatment

55. Juvenile Arthritis Physical and Occupational Therapy Preserving muscle integrity and joint mobility Done by muscle strengthening activities Joint support Swimming excellent way to do exercise

56. Juvenile Arthritis Treatment during exacerbations of JA Hot or cold packs Splinting Neutral positioning Pain management Simple isometric exercise

57. Juvenile Arthritis Nursing Care Assess status of joints ie warmth, tenderness, range of motion Assess pain Assess for stiffness – in the morning Assess for temperature elevations

58. Juvenile Arthritis Nursing care Application of splints, hot and cold treatments and proper positioning Monitor child taking ASA therapy if the child is suspected of having a viral disease stop ASA Manage pain – remember preverbal child expresses pain in a different way Over protection is a common parental reaction

59. Muscular Dsytrophy A group of progressive degeneration of the muscles leading to weakness and atrophy An inherited disorder Most are identified in early childhood Symptoms first appear after walking is achieve (3 to7)

60. Muscular Dsytrophy Clinical manifestations Muscular Dsytrophy Progressive symmetrical muscle wasting and weakness without loss of sensation Uses Gower maneuver to rise from the floor Gait is waddling and wide base Calf muscle are weak and large Increasing disability and deformities

61. Gower maneuver

62. Muscular Dsytrophy Clinical manifestations Walking ability is lost by age 9 to 12 Moderate obesity is common IQ below 90 is common Life span is shortened Cardiopulmonary complications most common cause of death

64. Muscular Dsytrophy Therapeutic management Goal is to maintain ambulation and independence for as long as possible Surgery Bracing Physical therapy Prevention of obesity Prompt recognition of respiratory tract infections

65. Muscular Dsytrophy Nursing Care Assess infants and children with a family history Asses family’s ability to cope with diagnosis Over time assess child’s mobility and self care abilities Assess weight gain Assess respiratory system

66. Muscular Dsytrophy Nursing Care Maintain independence and self care activities for as long as possible In late stages Reposition to prevent skin breakdown Monitor fluid intake to prevent urinary stasis Bowel regime may be necessary

67. Muscular Dsytrophy Nursing Care Diet modifications for weight control Protection for other children with respiratory or other contagious disease May eventually be placed on CPAP or ventilator

68. Scoliosis Clinical Manifestations Visible curve of the spine Rib hump when child is bending forward Asymmetric rib cage Uneven shoulder and/or pelvic heights Apparent leg length discrepancy In severe cases reduced vital capacity

71. Scoliosis Diagnosis Routine scoliosis screenings X-rays confirm the diagnosis Therapeutic Management Depends on the severity, age and anticipate growth

72. Scoliosis Treatment varies from monitoring the child to surgical intervention. Regular and periodic evaluations with x- ray Bracing Spinal fusion

73. Scoliosis Complications associated with bracing Skin integrity is compromised Neurological damage may be caused from surgery Superior mesenteric syndrome Pseudoarthosis

74. Scoliosis Nursing Care Routine school screenings Evaluate body image concerns Assess compliance with treatment modalities

75. Scoliosis Braces adolescent girls may find them cosmetically offensive Teach the child the brace must be worn according to the prescribed schedule full time bracing is 18 to 23 hours/day Inspect the skin for signs or irritation and or breakdown Instruct on proper hygiene: bathe daily, inspect skin frequently and avoid lotions and powders

76. Scoliosis Surgical Treatment Nursing Care Monitor neurological status of the lower extremities for color, circulation and capillary refill, warmth, sensation and motion every 2 hours first 24 hours Check pedal pulses every 4 hours for first 48 hours

77. Scoliosis Surgical Treatment Nursing Care Assess urinary output Assess bowel sounds Monitor fluid and electrolytes Monitor for blood loss Assess for pain Maintain strict flat bedrest Prevent respiratory infection

78. Developmental Dysplasia of the Hip DDH a condition in which the head of the femur is improperly seated in the acetabulum

79. Developmental Dysplasia of the Hip Clinical Manifestations In neonates Laxity of the ligaments around the hip, which allows the femoral head to be displaced from the acetabulum upon manipulation

80. Developmental Dysplasia of the Hip Infants Beyond the newborn period Asymmetry of the gluteal skin folds Limited range of motion in the affected hip Apparent short femur on the affected side The walking child Minimal to pronounced variations in gait with lurching toward the affected side

83. Developmental Dysplasia of the Hip Diagnosis Usually diagnosed during routine screening either at time of birth or routine well child screens.

84. Developmental Dysplasia of the Hip Therapeutic Management Early diagnosis and treatment essential to maximize outcomes Treatment depended on age at diagnosis Treatment is aimed at maintaining flexion, abduction and external rotation of the affected hip

85. Developmental Dysplasia of the Hip Treatment devices Pavlik Harness Traction Surgery and hip spica cast

86. Nursing Care With the pavlik harness teach the parents proper application and care of the harness Have the parents do a return demonstration Harness is to be worn 23 hours a day Promote bonding behaviors in the parents Developmental Dysplasia of the Hip

89. Legg-Calve-Perthes Disease Self limiting condition Avascular necrosis of the femoral head Occurs between ages 2 – 12 years Occurs 4 to 5 X more often in boys than girls Cause –Necrosis results from interruption of the blood supply to the femoral epiphysis (What is the significance of epiphysis??)

91. Legg-Calve-Perthes Disease Clinical Manifestations StageClinical Manifestations Prenecrosis An insult or coagulation disorder causes loss of blood supply to the femoral head I –Necrosis Avascular sage (3-6 Months); the child is asymptomatic, bone radiographs are normal and the head of the femur is structurally intact but avascular II Revascularization Period of 1-4 years characterized by pain and limitation of movement. Bone radiographs show new bone deposition and dead bone resorption. Fracture and deformity of the head of the femur can occur III Bone healingReossification takes place, pain decreases IV RemodelingThe disease process is over, pain is absent, and improvement in joint function occurs

92. Legg-Calve-Perthes Disease DX –Aneroposterior and frog-leg radiographs –MRI –Bone Scan –WBC –Protein C –Protein S –APC-R

93. Legg-Calve-Perthes Disease Therapy –Depend on degree of femoral involvement Early detection important for success of therapy –Desired outcome Pain free hip that functions properly Prevention of deformity –Femoral head must be contained within the acetabulum to maintain its sphericity Healing

94. Legg-Calve-Perthes Disease Observation Examination Physical rehabilitation Occasionally traction Casting Bracing Anti-inflammatory medication Tx pain and discomfort Severe –Surgery to release adductor muscles, treat the acetabulum or femur, restore rage of motion

96. Slipped Capital Femoral Epiphysis Femoral head is displaced from the femoral neck Common during adolescent growth spurt –Between ages 12 to 15 in boys Girls 10-13 –Affected Boys more often girls Black children Overweight children Sport injuries or other trauma Hx radiation therapy Endocrine disease

97. Slipped Capital Femoral Epiphysis (scfe) Slippage of femoral head occurs –Proximal epiphyseal plate –Femur displaces from epiphysis –Usually gradual but can be caused from trauma –Synovial membrane becomes inflamed Edematous painful

99. Figure 35-13 In slipped capital femoral epiphysis, the femoral head is displaced from the femoral neck at the proximal epiphyseal plate.

100. Clubfoot A congenital malformation of the lower extremity Clinical manifestations Foot is plantar flex with heel inverted and foot adducted Defect may be unilateral or bilateral Defects are rigid and can not be manipulated into a neutral position

101. Clubfoot Therapeutic Management Treatment is started soon after birth Serial manipulation and casting are perform at least weekly If deformity does not respond to serial casting, surgery is required

102. Clubfoot Nursing Care Pain management post operatively important. Use medication, elevation of extremity and ice useful Neurovascular checks every 2 hours If the child has a cast teach the parent cast care Stress the importance of long term care

106. Genu Valgum Knock-Knees Genu Varum Bowlegs

107. Bowlegs or Knock-Knees Causes for genu varum (bowlegs) –Blount disease Abnormal growth on the medial side of the proximal tibia –Increasing compression forces across the medial knee More common in overweight Black Female children –Rickets Inadequate bone mineralization usually caused by deficiency of calcium & or vitamin D May be X-lined autosomal dominant or recessive gene –DX Measurements Radiographic studies Arthography MRI CT

108. Bowlegs or Knock-Knees TX –Braces to correct mild varus and valgus –Varus : worn at night –Valgus: Worn at day and night –Worse cases surgical repair Osteotomy (cutting of the bone ) Child wears cast for 6 to 10 weeks –Rickets Dietary rickets –Supplementation with calcium and vitamin D Familial hypophosphatemic rickets (FHR) –Calcium and phosphorus 5 to 6 daily doses

109. Osteosarcoma Most common bone malignancy in children Aggressive tumor Symptoms can be attributed an injury or “growing pains” Most common site is the distal femur Site of metastasis is the lungs Associated with teen age years- a period of rapid bone growth

110. Osteosarcoma Clinical Manifestations Progressive, insidious, intermittent pain at the tumor site Palpable mass Limping Progressive limited range of motion Eventually a pathological fx at the tumor site

111. Osteosarcoma Diagnosis x-rays of the site x-rays of the chest (metastasis to lung) CT scan MRI Bone scan

112. Osteosarcoma Medical Management Goal: to remove tumor and prevent spread of the cancer Amputation may be necessary (used to be only option) Limb salvage procedures (use of cadaver bone, can be done ONLY if not expecting growth in that bone area as cadaver bone won’t grow with child) Surgery is followed by chemotherapy

113. Osteosarcoma Nursing Assessment Hx of injury and hx of discomfort Assessment of activity and involvement in sports– import psychosocial assessment Body image assessment Site of tumor may appear red with shiny skin Child c/o tenderness and pain Warm to touch

114. Osteosarcoma Nursing Interventions Initial care revolves around pain management Pre operative care Central line is inserted Base line assessment of VS Chemotherapy

115. Osteosarcoma Post operative management Post operative pneumonia may be greater in children with pulmonary metastasis Monitor tissue perfusion and for nerve damage every 15-30 minutes for first 4 hours then decrease to Q 2hours, Q4 hours. Phantom limb pain may be present Wound care Prepare for prosthesis Chemotherapy required

116. Ewing’s scarcoma Common bone tumor (rare in African Americans) Has no defining characteristics– therefore may be difficult to diagnosis Found in mid shaft of long bones, such as femur, vertebrae, ribs and pelvis Highly malignant

117. Ewing’s scarcoma Clinical manifestations Pain Soft tissue swelling around the bone With metastasis anorexia, fever, malaise, fatigue and weight loss With a vertebral tumor may be neurological symptoms With rib tumor may be respiratory symptoms

118. Ewing’s scarcoma Diagnosis same as osteosacroma Biopsy necessary to differentiate Medical management Begins with chemotherapy followed by surgery to remove cancer and surrounding bone and possible radiation Long-term follow up for possible second neoplasm from radiation therapy Nursing care similar to osteosacroma