Week 7: Musculoskeletal or Articular Dysfunction
Chapter 33: The Child with Musculoskeletal or Articular Dysfunction
Copyright © 2019, Elsevier Inc. All rights reserved.
Trauma in Children
Leading Cause of Death in Children Over 1 Year
Trauma is the leading cause of death in children older than 1 year of age.
Developmental stage affects aspects of injury in children.
Unintentional injuries rank as the leading cause of death in children aged 1 to 19 years.
Epidemiology of Trauma
Types of Injuries
Unintentional (accidental) injury
Child abuse (nonaccidental) injury
Childhood Characteristics Affecting Susceptibility to Injuries
Factors that may increase children's vulnerability to injury due to their developmental stage.
Prevention of Injury
Recommended practices include:
Careful History: Taking a detailed injury history from caregivers.
Discharge Planning: Ensuring safety at home post-injury treatment.
Routine Well-Child Exams: Regular assessments to catch concerns early.
School and Community Education Programs: Raising awareness and skills to prevent injuries.
Emergency Management of Trauma
ABCs & Level of Consciousness: Evaluation of airways, breathing, and circulation along with consciousness level.
Spinal Cord Injury Immobilization: Prioritizing immobilization if spinal injuries are suspected.
Emergency Medical Services (EMS), Basic Life Support (BLS), Advanced Life Support (ALS): Importance of emergency care interventions.
Control of Bleeding: Immediate first aid measures to control hemorrhage.
Systematic Assessment:
Conduct a Primary Survey: Initial assessment to address life-threatening issues.
Conduct a Secondary Survey: Comprehensive evaluation for injuries.
The Immobilized Child
Old Perspectives vs. Current Understanding of Immobilization
It was once thought to facilitate recovery but is now known to have serious consequences, including:
Physical: Weakness, muscle atrophy.
Social: Potential isolation from peers.
Psychological: Anxiety, depression.
Emotional: Stress related to changes in mobility and social interactions.
Etiology of Immobilization
Causes include congenital defects, neuromuscular conditions, and infections/injuries.
Physiological Effects of Immobilization (1/3)
Muscular System
Decreased muscle strength and endurance.
Muscle atrophy: Reduction in muscle mass over time.
Loss of joint mobility due to inactivity.
Skeletal System
Bone demineralization occurs, leading to weakened bones.
Negative calcium balance can result in osteoporosis.
Cardiovascular System
Orthostatic intolerance (dizziness upon standing).
Increased workload on the heart.
Thrombus formation risk increases due to venous stasis.
Physiological Effects of Immobilization (2/3)
Respiratory System
Decreased respiratory effort.
Reduced normal movement of secretions leading to risk of pneumonia.
Gastrointestinal System
Decreased mobility of the bowel, leading to constipation.
Increased risk for aspiration due to difficulty swallowing.
Renal System
Renal stasis (urinary retention due to bed rest).
Hypercalcemia can lead to renal calculi formation.
Metabolism
Decreased metabolic rate.
Reduced production of stress hormones.
Physiological Effects of Immobilization (3/3)
Integumentary System
Decreased circulation results in poor healing capacity of skin.
Risk of ischemia (decreased blood flow) increases.
Urinary System
Changes in gravitational force make voiding difficult in supine position.
Urinary retention leads to discomfort and risk of infections.
Impaired ureteral peristalsis can affect urine flow.
Neurosensory System
Loss of innervation may occur if nerve tissue is compressed.
Sensory deprivation can lead to cognitive and perceptual issues.
Psychological Effects
Exposure to diminished environmental stimuli may lead to developmental regression.
Increased frustration, helplessness, anxiety, depression, and aggressive behavior.
Effect on Families
Extended Periods of Immobilization
Presents logistical challenges in managing a sick child.
Families may need increased support and home care assistance, including:
Coping skills development.
Crisis management strategies; dealing with financial strains.
Adjusting to the child’s altered behavior or physical condition.
Addressing sleep deprivation often seen in families with immobilized children.
Nursing Care Management
Physical Assessment:
Continuous monitoring to prevent injury and complications.
Encouragement of Activity:
Support use of aids such as orthotics, prosthetics, crutches, canes, and wheelchairs.
Position Changes:
Importance of pressure reduction mattresses and regular position changes.
Range of Motion (ROM) Exercises:
Braden Q scale to assess risk for pressure ulcers.
Involvement of Child Life Specialists:
Engage with family and involve child in self-care.
Child in a Cast
Purpose of Casting: Used to immobilize fractures to promote healing and ensure proper alignment.
Nursing Care Management:
Monitoring for progress of healing through regular assessments.
Supporting skin integrity and circulation.
Educating and providing discharge planning support to family.
Child in Traction
Indications for Traction: Used in severe or complex injuries to maintain alignment.
Types of Traction:
Skin traction and skeletal traction.
Nursing Care Management:
Actions must be done under direct supervision of a provider.
Ensuring skin care at pin sites.
Managing pain and providing ongoing support to the patient and family.
Amputation
Factors Leading to Amputation:
May result from congenital absence, trauma, or surgical necessity due to conditions such as cancer.
Nursing Care Management:
Ensure ongoing assessment post-surgery, including monitoring for complications.
Use elastic bandaging for compression and proper positioning.
Provide pain management and support to the child and family.
Planning for rehabilitation and follow-up care.
Fractures
Epiphyseal Injuries:
The weakest point of long bones is the cartilage growth plate (epiphyseal plate).
Such injuries are frequent and can affect future bone growth.
Treatment may necessitate open reduction and internal fixation to avoid growth disturbances.
Common Fracture Types in Childhood:
Specific patterns of fractures (e.g., clavicle fractures prevalent in younger children) vary significantly from adults.
Types of Fractures (1 of 2)
Categorization of Fractures:
Complete vs. Incomplete: Total break vs. partial break in the bone.
Simple vs. Compound: Closed (skin intact) vs. open (bone protruding through skin).
Complicated Fractures: Involves damage to nearby organs or tissues.
Types of Fractures (2 of 2)
Various fracture mechanisms include:
Transverse Fracture: Horizontal fracture line.
Oblique Fracture: Diagonal fracture line.
Spiral Fracture: Twisted fracture line usually due to a rotational force.
Comminuted Fracture: Bone shatters into multiple fragments.
Greenstick Fracture: Incomplete fracture typically seen in pediatric patients, bone bends but does not break completely.
Bone Healing and Remodeling
Healing Timeline: Children typically exhibit rapid healing:
Neonates: 2 to 3 weeks
Early Childhood: 4 weeks
Later Childhood: 6 to 8 weeks
Adolescence: 8 to 12 weeks
Clinical Manifestations of Fracture
Common indicators of fracture include:
Generalized Swelling: Typically present at the injury site.
Pain or Tenderness: Directly associated with the injury.
Diminished Functional Use: Limited ability to use the affected limb.
Bruising: Often accompanies fractures.
Severe Muscular Rigidity: Increased tension or spasms in the muscles around the injury.
Crepitus: A grating sound felt during movement.
X-ray: Most useful diagnostic tool for confirming fractures.
Assessment of Fractures—The Five Ps
Essential assessments are encapsulated in the Five Ps:
Pain: Point of tenderness at the affected area.
Pulse: Check pulse distal to the fracture site.
Pallor: Skin color changes indicating potential complications.
Paresthesia: Sensation checks distal to the fracture (numbness or tingling).
Paralysis: Assess movement capability distal to the fracture site.
Nursing Care Management—Fractures
Goals: Facilitate healing and prevent injuries/complications.
Monitor pulses, capillary refill time (CRT), skin color, and temperature.
Palpate cast for “hot spots” indicating potential pressure sores or complications.
Alleviate pressure on nerves, addressing pain management.
Promote nutrition and hydration to support recovery.
Support growth and development along with family involvement in the care process.
Sports Participation Considerations
Preparation for Sports:
The American Academy of Pediatrics (AAP) provides classification and guidelines for children’s participation in sports based on the likelihood of injury and intensity of the activity.
Injury Types in Sports:
Traumatic Injuries: Often seen in soft tissue damage like muscles, ligaments, and tendons during play.
Overuse Syndromes: Result from repetitive microtrauma, leading to inflammation, pain, and function loss (e.g., Osgood-Schlatter disease).
Types of Injuries
Contusions:
Damage to soft tissue and muscle, leading to pain and swelling.
Ecchymosis caused by subcutaneous bleeding (black-and-blue marks).
Dislocations
Definition:
Occurs when force disrupts the normal positions of bone ends at a joint.
Pain worsens with movement of the affected limb; common in dislocations like hip or shoulder.
Common pediatric dislocation: “nursemaid’s elbow.”
Sprains and Strains
Sprains:
Trauma to a joint with partial or complete tears in ligaments that may also affect adjacent structures (blood vessels, muscles).
Indicators of sprains include rapid swelling and disability of the joint.
Therapeutic Management of Sports Injuries (1 of 2)
RICE Protocol:
Rest the injured area.
Ice application (maximum 30 minutes at a time).
Compression with wet elastic bandage.
Elevation of the affected limb to reduce swelling.
ICES: Likewise focuses on Ice, Compression, Elevation, and Support.
Management: Casts or splints may be necessary depending on injury severity.
Therapeutic Management of Sports Injuries (2 of 2)
Rest is Primary Therapy:
Reduces activity and substitutes alternative exercises rather than complete bed rest.
P(R)ICE therapy: Explore rehabilitation options to support recovery.
Use of NSAID medication with caution for pain management.
Ensure appropriate nutrition to support recovery and development.
Stress Fractures
Definition:
Occur due to repeated muscle contractions, often observed in weight-bearing sports like running or gymnastics.
The tibial fracture is one of the most common types among children.
Exercise-Induced Heat Stress
Forms of Heat Stress:
Heat cramps, heat exhaustion, and heat stroke; symptoms vary significantly.
Associated Health Concerns (1 of 2)
Nutrition Needs:
Importance of balanced diet, including supplements and adequate vitamin intake.
Recommended diet composition: 50% carbohydrates, 25%-30% fats, and 1.2 to 1.5 g/kg/day protein intake to support activity.
Emphasize intake of iron and calcium for overall health.
Associated Health Concerns (2 of 2)
Weight Considerations:
Importance of maintaining optimal weight for performance in sports.
High risks in specific sports like wrestling, gymnastics, swimming, cheerleading, and dance.
Considerations for the Female Athlete
Female Athlete Triad:
Consequences including amenorrhea, osteoporosis, and eating disorders.
Substance Use by Athletes
Examples of Ergogenic Aids:
Amfetamine and stimulants, including bronchodilators and decongestants.
Risks associated with the use of anabolic steroids for performance enhancement.
Sudden Death in Sports
Definition:
Death occurring within minutes or within 24 hours following a sports-related event.
Risk associated with sports having high inherent fatality.
Possible Causes:
Unrecognized medical issues like idiopathic hypertrophic subaortic stenosis.
Symptoms include chest pain, dizziness, and notable cardiac signs.
Nurse's Role in Sports for Children and Adolescents
Essential Functions:
Prepare for success in sports participation and evaluation for activities.
Counsel for injury prevention and education on care management.
Active role in rehabilitation processes post-injury.
Torticollis
Definition:
Congenital or acquired condition resulting in limited neck motion, typically with neck flexed to one side.
Therapeutic Management:
Physical therapy to improve head position and neck motion.
Kyphosis
Definition:
Abnormally increased thoracic spine curvature.
Most common type is postural kyphosis.
Can arise from conditions such as TB, arthritis, osteodystrophy, and compression fractures.
Lordosis
Definition:
Accentuation of cervical or lumbar curvature beyond normal limits, which may accompany trauma or congenital dislocations.
In obese children, additional abdominal fat alters the center of gravity, promoting lordosis.
Scoliosis (1 of 3)
Common Spinal Deformity:
Characterized by lateral curvature of the spine, spinal rotation, and thoracic hypokyphosis.
Can be congenital or develop during childhood.
Scoliosis (2 of 3)
Causes of Scoliosis:
Most commonly idiopathic and often becomes noticeable post growth spurt.
Symptoms may include ill-fitting clothes, which can be a sign of curvature.
School screening practices are sometimes controversial and debated.
Scoliosis (3 of 3)
Diagnostic Evaluation:
Standing radiographs determine the degree of curvature.
Indicators include asymmetry in shoulder height, scapular, or flank shape and hip height.
Therapeutic Management:
Multidisciplinary approach:
Bracing, exercise, and surgical interventions if curvature severity mandates.
Various surgical systems such as Harrington, Dwyer, and Cotrel-Dubousset utilized for correction.
Nursing Considerations—Scoliosis
Concerns:
Body image and prolonged treatment can affect adolescents.
Importance of preoperative and postoperative care to support growth and family integration.
Skeletal Limb Deficiency
Definition:
Underdevelopment of extremities can range from minor to serious abnormalities.
Therapeutic Management:
Multi-faceted, addressing education and support mechanisms for families.
Developmental Dysplasia of Hip (DDH)
Etiology: Hip instability occurring post-birth notably associated with breech deliveries.
Diagnostic Evaluation:
Use of Ortolani and Barlow tests as standard screening until the child begins walking.
Galeazzi sign for hip dysplasia observation; may require radiographic exams.
Therapeutic Management:
Options include Pavlik Harness vs. casting, influencing nursing care accordingly.
Ongoing assessment of skin integrity, education, and family support necessary for normal development.
Legg-Calvé-Perthes Disease (1 of 3)
Overview:
Self-limited idiopathic condition commonly occurring in children aged 3 to 12, with higher incidence in males aged 4 to 8.
Avascular necrosis of the femoral head, often resulting in delayed bone age.
Legg-Calvé-Perthes Disease (2 of 3)
Pathophysiology:
Uncertain origin, possibly involves disrupted circulation leading to ischemic necrosis of the femoral head, which may resolve with or without alterations.
Diagnostic Evaluation:
Necessary to monitor changes and evaluate progression of the disease.
Legg-Calvé-Perthes Disease (3 of 3)
Prognosis:
Self-limiting, with variable outcomes based on multiple influencing factors.
Nursing Care Management:
Focus on identifying affected children, teaching care and management, and handling compliance issues with families.
Slipped Capital Femoral Epiphysis (SCFE)
Definition:
Spontaneous displacement of the proximal femoral epiphysis occurring commonly just before or during puberty.
Etiology:
Generally considered idiopathic and multifactorial with contributions from obesity and hormonal changes.
Clinical Manifestations:
Symptoms may include episodes of acute trauma, gradual displacement, or intermittent shifts of the femoral head.
Therapeutic Management—SCFE
Goal:
Maintain the head of the femur within the acetabulum.
Care Strategies:
Containment with supportive devices, restricted weight bearing at the onset, and potential surgical interventions in severe or persistent cases.
Osteomyelitis
Definition:
Inflammation and infection of bony tissue caused by bacteria, can result from direct infection or hematogenous spread.
Signs and Symptoms:
Abrupt onset with severity mirroring symptoms of joint diseases, marked leukocytosis in laboratory results, and potential need for diagnostic imaging (bone scans/x-rays).
Types of Osteomyelitis
Exogenous Sources:
Bone infection due to direct entry from wounds, fractures, or surgical procedures.
Hematogenous Sources:
Infections spreading to bone from pre-existing conditions such as skin infections or abscessed teeth.
Therapeutic Management of Osteomyelitis
Treatment:
Typically involves prompt initiation of vigorous intravenous antibiotics for 3 to 4 weeks, monitoring for renal and hepatic response to therapy.
Septic Arthritis
Definition:
Also known as suppurative or pyogenic arthritis, resulting from infection, usually involving a single joint such as the hip or knee.
Signs and Symptoms:
Key indicators include joint warmth, tenderness, swelling, fever, and leukocytosis.
Diagnostics and Therapeutic Management of Septic Arthritis
Diagnosis:
Confirm through blood cultures, joint fluid aspirate, and imaging studies.
Goals of Treatment:
Prevent cartilage destruction, decompress the joint, eradicate the infection, and keep the infection from spreading to bone or elsewhere.
Osteogenesis Imperfecta (OI)
Definition:
A group of inherited disorders characterized by bone fragility and connective tissue anomalies.
Key features include excessive fragility, a tendency for fractures, and hyperextensibility of ligaments.
Classifications of OI (1 of 2)
Type I:
Variants include:
Type I-A: Mild bone fragility, blue sclera, normal teeth.
Type I-B: Similar but with abnormal dental health.
Type I-C: No fragility with other characteristics.
Represents the majority of OI cases.
Type II:
Lethal form, typically results in death at birth or early infancy due to severe fragility.
Classifications of OI (2 of 2)
Type III:
Severe forms lead to significant progressive deformities, typically with normal sclera and marked stunted growth.
Type IV:
Variants such as type IV-A indicating mild to moderate fragility and type IV-B associated with abnormal dentition.
Therapeutic Management of OI
Approach:
Primarily supportive with consideration for medications such as bisphosphonates for bone density improvements.
Emphasis on precautionary measures during handling to avert fractures and family education for management and support.
Juvenile Idiopathic Arthritis (JIA) (1 of 2)
Definition:
Formerly known as juvenile rheumatoid arthritis; it represents a heterogeneous group of diseases.
Onset Peaks:
Occurs mainly between ages 1 to 3 and 8 to 10.
Commonly overlooked; characterized by chronic inflammation of the synovium, joint effusion, cartilage destruction, and potential ankylosis.
Juvenile Idiopathic Arthritis (JIA) (2 of 2)
Clinical Presentation:
Symptoms include stiffness, swelling, loss of mobility in joints, warmth, and tenderness—often exacerbated by physical stress.
No definitive diagnostic tests exist, yet leukocytosis during flares and positive antinuclear antibodies are noteworthy findings.
Diagnostic Evaluation of JIA
Criteria for Diagnosis (American College of Rheumatology):
Age of onset younger than 16 years, one or more affected joints, duration exceeding 6 weeks, and exclusivity from other arthritis forms.
JIA—Therapeutic Management (1 of 2)
Goals:
Maintaining function, preventing deformities, and relieving symptoms, with a specific emphasis on related uveitis management.
Medications:
Includes NSAIDs, SAARDs (slow-acting anti-rheumatic drugs), corticosteroids, cytotoxic agents, and DMARDs.
JIA—Therapeutic Management (2 of 2)
Additional Management:
Individualized approach considering physical therapy, nutrition, splinting devices, and emotional support strategies for children and families.
Systemic Lupus Erythematosus (SLE)
Overview:
A chronic multisystem autoimmune disease characterized by variable inflammation affecting connective tissues.
Demographics:
More prevalent in females aged 10 to 19 from various ethnic backgrounds, including a familial tendency.
Causes are multifactorial, with hormonal, immunological, and environmental contributors.
SLE—Clinical Manifestations
Key Symptoms:
May include cutaneous lesions, lymphadenopathy, GI symptoms, general weakness, and joint pain.
Severe cases can feature neurological symptoms, including forgetfulness and paralysis, as well as renal involvement such as proteinuria.
SLE—Criteria for Diagnosis
Diagnostic Criteria: Must meet at least four of the following symptoms:
Butterfly rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal disorder, neurologic disorder, hematologic disorder, and positive ANA (antinuclear antibodies).
SLE—Therapeutic Management
Treatment Goals:
Provide supportive care, effective pharmacological management including anti-inflammatory and immunosuppressive agents, and promote compliant care among patients.
Emphasize lifestyle factors such as diet and exercise to aid normal growth and development.
Chapter 33 Questions
Question 1: Which of the following would be the most appropriate play activity for a 3-year-old child in a spica cast, considering both safety and development?
Options:
Marbles
Game of checkers
Coloring with crayons
Playing with a toy telephone
Question 2: What would be most concerning assessment finding in a child with a newly placed femur cast?
Options:
The skin under the cast itches.
Toes of the affected limb are warm and mobile.
The toes feel like they are asleep.
The cast edges are warm to touch.
Answers to Questions
Answer to Question 1: D
Answer to Question 2: C
Copyright © 2019, Elsevier Inc. All rights reserved.