Musculoskeletal or Articular Dysfunction

Chapter 48


Musculoskeletal or Articular Dysfunction


David Wilson



Learning Objectives


On completion of this chapter, the reader will be able to:


• Outline a care plan for a child immobilized with an injury or a debilitating condition.


• Formulate a teaching plan for the parents of a child in a cast.


• Explain the functions of the various types of traction.


• Differentiate among the various congenital skeletal defects.


• Design a teaching plan for the parents of a child with a congenital skeletal deformity.


• Describe the therapies and nursing care of a child with scoliosis.


• Outline a plan of care for a child with osteomyelitis.


• Differentiate between osteosarcoma and Ewing sarcoma.


• Describe the nursing care of a child with juvenile arthritis.


• Demonstrate an understanding of the management of systemic lupus erythematosus.



The Immobilized Child


One of the most difficult aspects of illness in children is the immobility it imposes. Children by nature are usually active; and immobility, however temporary, may have lasting effects on the child’s developmental progress. The most frequent reasons for immobility are congenital defects (e.g., spina bifida); degenerative disorders (e.g., muscular dystrophy); and infections or injuries that impair the integumentary system (severe burns), the musculoskeletal system (e.g., multiple fractures, osteomyelitis), or the neurologic system (e.g., spinal cord injury, Guillain-Barré syndrome, traumatic brain injury). At times therapies such as traction and spinal fusion are responsible for prolonged immobilization, although the increasing trends in health care are early mobilization and discharge and outpatient treatment.



Physiologic Effects of Immobilization


Many clinical studies, including space program research, have documented predictable consequences that occur after immobilization and the absence of gravitational force. Functional and metabolic responses to restricted movement can be noted in most of the body systems. Each has a direct influence on the child’s growth and development because homeostatic mechanisms thrive on normal use and need feedback to maintain dynamic equilibrium. Inactivity leads to a decrease in the functional capabilities of the whole body as dramatically as the lack of physical exercise leads to muscle weakness.


Disuse from illness, injury, or a sedentary lifestyle can limit function and potentially delay age-appropriate milestones. Most of the pathologic changes that occur during immobilization arise from decreased muscle strength and mass, decreased metabolism, and bone demineralization, which are closely interrelated, with one change leading to or affecting the other. Some results of immobilization are primary and produce a direct effect; other pathophysiologic consequences occur frequently but seem to be more indirect and therefore are secondary effects. Many pathophysiologic changes affect more than one body system, with the primary or secondary effect being demonstrated in both systems.


The major effects of immobilization are outlined briefly in Table 48-1 and are related directly or indirectly to decreased muscle activity, which produces numerous primary changes in the musculoskeletal system with secondary alterations in the cardiovascular, respiratory, metabolic, and renal systems. The musculoskeletal changes that occur during disuse are a result of alterations in gravity and stress on the muscles, joints, and bones. Muscle disuse leads to tissue breakdown and loss of muscle mass (atrophy). Muscle atrophy causes decreased strength and endurance, which may take weeks or months to restore.



TABLE 48-1


SUMMARY OF PHYSICAL EFFECTS OF IMMOBILIZATION WITH NURSING INTERVENTIONS*

























































































































































PRIMARY EFFECTS SECONDARY EFFECTS NURSING CONSIDERATIONS
Muscular System
Decreased muscle strength, tone, and endurance Decreased venous return and decreased cardiac output Use antiembolism stockings or intermittent compression devices to promote venous return (monitor circulatory and neurovascular status of extremities when such devices are used).
Decreased metabolism and need for oxygen Plan play activities to use uninvolved extremities.
Decreased exercise tolerance Place in upright posture when possible.
Bone demineralization Perform passive range-of-motion exercises.
Disuse atrophy and loss of muscle mass Catabolism
Loss of strength		 Have patient perform range-of-motion, active, passive, and stretching exercises.
Loss of joint mobility Contractures, ankylosis of joints Maintain correct body alignment.
Use joint splints as indicated to prevent further deformity.
Maintain range of motion.
Weak back muscles Secondary spinal deformities Maintain body alignment.
Weak abdominal muscles Impaired respiration See nursing considerations for respiratory system.
Skeletal System
Bone demineralization—osteoporosis, hypercalcemia Negative bone calcium uptake
Pathologic fractures
Calcium deposits
Extraosseous bone formation, especially at hip, knee, elbow, and shoulder
Renal calculi		 With paralysis use upright posture on tilt table.
Handle extremities carefully when turning and positioning.
Administer calcium-mobilizing drugs (diphosphonates) and normal saline infusions as ordered.
Ensure adequate intake of fluid; monitor output.
Acidify urine.
Promptly treat urinary tract infections.
Negative bone calcium uptake Life-threatening electrolyte imbalance Monitor serum calcium levels.
Provide electrolyte replacement as indicated.
Metabolism
Decreased metabolic rate Slowing of all systems
Decreased food intake		 Mobilize as soon as possible.
Have patient perform active and passive resistance and deep-breathing exercises.
Ensure adequate food intake.
Provide a high-protein diet.
Negative nitrogen balance Decline in nutritional state Encourage small, frequent feedings with protein and preferred foods.
Impaired healing Monitor for and prevent pressure areas.
Hypercalcemia Electrolyte imbalance See nursing consideration for skeletal system.
Decreased production of stress hormones Decreased physical and emotional coping capacity Identify causes of stress.
Implement appropriate interventions to lower physical and psychosocial stresses.
Cardiovascular System
Decreased efficiency of orthostatic neurovascular reflexes Inability to adapt readily to upright position (orthostatic intolerance)
Pooling of blood in extremities in upright posture		 Monitor peripheral pulses and skin temperature changes.
Use antiembolism stockings or intermittent compression devices to decrease pooling when upright.
Diminished vasopressor mechanism Orthostatic intolerance with syncope, hypertension, deceased cerebral blood flow, tachycardia Provide abdominal support.
In severe cases use antigravitational pants.
Position horizontally.
Altered distribution of blood volume Increased cardiac workload
Decreased exercise tolerance		 Monitor hydration, blood pressure, and urinary output.
Venous stasis Pulmonary emboli or thrombi Encourage and assist with frequent position changes.
Elevate extremities without knee flexion.
Ensure adequate fluid intake.
Have patient perform active or passive exercises or movement as needed.
Prescribe routine wearing of antiembolism stockings or intermittent compression devices.
Monitor for signs of pulmonary embolism—sudden dyspnea, chest pain, respiratory arrest.
Promptly intervene to maintain adequate oxygenation if signs and symptoms of pulmonary emboli are noted.
Measure circumference of extremities periodically.
Give anticoagulant drugs as prescribed.
Dependent edema Tissue breakdown and susceptibility to infection Administer skin care.
Turn every 2-4 hr.
Monitor skin color, temperature, and integrity.
Use pressure-reduction surface as necessary to prevent skin breakdown. (See Chapter 47.)
Respiratory System
Decreased need for oxygen Altered oxygen–carbon dioxide exchange and metabolism Promote exercise as tolerated.
Encourage deep-breathing exercises.
Decreased chest expansion and diminished vital capacity Diminished oxygen intake
Dyspnea and inadequate arterial oxygen saturation; acidosis		 Position for optimum chest expansion. Semi-Fowler position may assist in lung expansion if patient can tolerate.
Use prone positioning without pressure on abdomen to allow gravity to aid in diaphragmatic excursion.
Ensure that patient maintains proper alignment when sitting to prevent pressure on respiratory mechanism.
Poor abdominal tone and distention Interference with diaphragmatic excursion Avoid restriction of chest and abdominal musculature.
Supply torso support to promote chest expansion.
Mechanical or biochemical secretion retention Hypostatic pneumonia
Bacterial and viral pneumonia
Atelectasis		 Change position frequently.
Carry out percussion, vibration, and drainage (or suctioning) as necessary.
Use incentive spirometer.
Monitor breath sounds.
Loss of respiratory muscle strength Poor cough Encourage coughing and deep breathing.
Support chest wall by splinting with pillow when patient coughs.
Use incentive spirometer.
Observe for signs of respiratory distress with pulse oximetry or blood gas measurement as necessary.
Upper respiratory tract infection Prevent contact with infected persons.
Provide adequate hydration.
Administer immunizations as necessary (pneumococcal, meningococcal).
Gastrointestinal System
Distention caused by poor abdominal muscle tone Interference with respiratory movements Monitor bowel sounds.
Encourage small, frequent feedings.
Difficulty in feeding in prone position Have patient sit in upright position in bedside chair if possible.
No specific primary effect Possible constipation caused by gravitational effect on feces through ascending colon or weakened smooth muscle tone Carry out bowel training program with hydration, stool softeners, increased fiber intake, and mild laxatives if necessary.
Anorexia Stimulate appetite with favored foods.
Urinary System
Alteration of gravitational force Difficulty in voiding in prone or supine position Position as upright as possible to void.
Impaired ureteral peristalsis Urinary retention in calyces and bladder
Infection
Renal calculi		 Hydrate to ensure adequate urinary output for age.
Stimulate bladder emptying with warm running water as necessary.
Catheterize only for severe urinary retention.
Administer antibiotics as indicated.
Integumentary System
Altered tissue integrity Decreased circulation and pressure leading to tissue injury Turn and reposition at least every 2-4 hr.
Frequently inspect total skin surface.
Eliminate mechanical factors causing pressure, friction, moisture, or irritation.
Place on pressure-relief mattress.
Difficulty with personal hygiene Assess ability to perform self-care and assist with bathing, grooming, and toileting as needed.
Encourage self-care to potential ability.
Ensure adequate intake of protein, vitamins, and minerals.


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*Individualize care according to child’s needs; interventions may vary in different institutions.


During immobilization a joint contracture begins when the arrangement of collagen, the main structural protein of connective tissues, is altered, resulting in a denser tissue that does not glide as easily. Eventually muscles, tendons, and ligaments can shorten and reduce joint movement, ultimately producing contractures that restrict function. The daily stresses on bone created by motion and weight bearing maintain the balance between bone formation (osteoblastic activity) and bone resorption (osteoclastic activity). During immobilization increased calcium leaves the bone, causing osteopenia (demineralization of the bones), which may predispose bone to pathologic fractures.


The major musculoskeletal consequences of immobilization are as follows:



Circulatory stasis combined with hypercoagulability of the blood, which results from factors such as damage to the endothelium of blood vessels (Virchow triad), can lead to thrombus and embolus formation. Deep vein thrombosis (DVT) involves the formation of a thrombus in a deep vein such as the iliac and femoral veins and can cause significant morbidity if it remains undetected and untreated. The larger the portion of the body immobilized and the longer the immobilization, the greater the risks of consequences of immobility.



Psychologic Effects of Immobilization


For children one of the most difficult aspects of illness is immobilization. Throughout childhood physical activity is an integral part of daily life and is essential for physical growth and development. The activity helps children deal with a variety of feelings and impulses and provides a mechanism by which they can exert control over inner tensions. Children respond to anxiety with increased activity. Removal of this power deprives them of necessary input and a natural outlet for their feelings and fantasies.


When children are immobilized by disease or as part of a treatment regimen, they experience diminished environmental stimuli with a loss of tactile input and an altered perception of themselves and their environment. Sudden or gradual immobilization narrows the amount and variety of environmental stimuli that children receive by means of all of their senses: touch; sight; hearing; taste; smell; and proprioception, or the feeling of where they are in their environment. This sensory deprivation commonly leads to feelings of isolation and boredom and of being forgotten, especially by peers.


Physical interference with the activity of young children makes them feel frustrated and helpless. Even speech and language skills require sensorimotor activity and experience. For the toddler exploration and imitative behaviors are essential to developing a sense of autonomy; the preschooler’s expression of initiative is evidenced by the need for vigorous physical activity; the school-age child’s development is strongly influenced by physical achievement and competition; and the adolescent relies on mobility to achieve independence and self-identity. The quest for mastery at every stage of development is related to mobility.


The monotony of immobilization may lead to sluggish intellectual and psychomotor responses, decreased communication skills, increased fantasizing, and rarely hallucinations and disorientation. Children are likely to become depressed over loss of ability to function or the marked changes in body image. They may regress to earlier developmental behaviors such as wanting to be fed, bed-wetting, and baby talk.


Children may react to immobility by active protest, anger, and aggressive behavior; or they may become quiet, passive, and submissive. They may believe that the immobilization is a justified punishment for misbehavior. Children should be allowed to display their anger, but it should be within the limits of safety to their self-esteem and not damaging to the integrity of others. When children are unable to express anger, aggression is often displayed inappropriately through regressive behavior and outbursts of crying or temper tantrums.



Effect on Families


Even brief periods of immobilization may disrupt family function, and sudden catastrophic illness or chronic disability may severely tax their resources and coping abilities.


The family’s needs often must be met by the services of a multidisciplinary team, and nurses play a key role in anticipating the services they will need and coordinating conferences to plan care. In preparation for discharge home visits are advisable, and home management is commonly planned weeks in advance of the actual discharge. Such planning includes special considerations for cultural, economic, physical, and psychologic needs. A child with a severe disability is very dependent, and caregivers need rest periods to revitalize themselves (respite). Individual and group counseling is beneficial for solving problems in advance and provides an emotional support system. Parent groups may also be helpful and often allow nonthreatening social contact. The families of children with permanent disabilities need long-term resources because some of the most difficult problems arise as they try to sustain high-quality care for many years (see Chapter 36).



Care Management


Physical assessment of the child who is immobilized for any number of reasons (e.g., injury or illness) includes a focus not only on the injured part (e.g., fracture) but also on the functioning of other systems that may be affected secondarily (i.e., the circulatory, renal, respiratory, muscular, and gastrointestinal systems). With long-term immobilization there may also be neurologic impairment and changes in electrolytes (especially calcium), nitrogen balance, and the general metabolic rate. The psychologic impact of immobilization should also be assessed.


Children who require prolonged total immobility and are unable to move themselves in bed should be placed on a pressure-reduction mattress to prevent skin breakdown. Frequent position changes also help prevent dependent edema and stimulate circulation, respiratory function, gastrointestinal motility, and neurologic sensation. Children at greater risk for skin breakdown include those with prolonged immobilization; mechanical ventilation; orthotic and prosthetic devices, including wheelchairs; and casts. Additional risk factors include poor nutrition, friction (from bed linen with traction), and moist skin (from urine or perspiration). Nursing care of children at risk includes strategies for preventing skin breakdown when such conditions are present. The Braden Q Scale is a reliable, objective tool that may be used in the assessment for pressure ulcer development in children who are acutely ill or at risk for skin breakdown from neurologic conditions and immobilization (Noonan, Quigley, and Curley, 2011) (see also Maintaining Healthy Skin, Chapter 39).


The use of antiembolism stockings or intermittent compression devices prevents circulatory stasis and dependent edema in the lower extremities and the development of DVT. Anticoagulant therapy may also be implemented with low-molecular-weight heparin, vitamin K antagonists, or unfractionated heparin. The child should be allowed as much activity as possible within the limitations of the illness or treatment. Any functional mobility, however minimal, is preferred to total immobility. High-protein, high-calorie foods are encouraged to prevent negative nitrogen balance, which may be difficult to correct by diet, especially if there is anorexia as a result of immobility and decreased gastrointestinal function (decreased motility and possibly constipation). Stimulating the appetite with small servings of attractively arranged, preferred foods may be sufficient. Sometimes supplementary nasogastric or gastrostomy feedings or intravenous (IV) fluids may be needed, but these are reserved for serious disability in which oral intake is impossible.


Adequate hydration and, when possible, an upright position and remobilization promote bowel and kidney function and help prevent complications in these systems. Children are encouraged to be as active as their condition and restrictive devices allow. This poses few problems for children, whose innate ingenuity and natural inclination toward mobility provide them with the impetus for physical activity. They need the opportunity, the materials or objects to stimulate activity, and the encouragement and participation of others. Those who are unable to move benefit from passive exercise and movement in consultation with a physical therapist.


Whenever possible, transporting the child outside the confines of the room increases environmental stimuli and allows social contact with others. Specially designed wheelchairs for increased mobility and independence are available. While hospitalized, children benefit from same-age visitors, computers, books, interactive video games, and other items brought from their own room at home, all of which help them to function in a more normal way. They also benefit from frequent visitors, accessibility of clocks and calendars, and a program of diversional therapy to help them function more normally. A child life specialist should be consulted for recreational planning. An activity center or slanting tray can be helpful for the child with limited mobility to use for drawing, coloring, writing, and playing with small toys such as trucks and cars. Children are able to express frustration, displeasure, and anger through play activities (see Chapter 38), which are helpful in the child’s recovery. Hospitalized children should be allowed to wear their own clothes (street clothes, especially for preadolescent and adolescent girls) and resume school and preinjury activities. A parent or siblings should be allowed to stay overnight and room in with the hospitalized child to prevent the effects of family disruption caused by hospitalization. All efforts should be made to minimize this disruption. Although most of the suggestions discussed relate to hospital care, the same consultations (physical therapist, occupational therapist, child life specialist, speech therapist) and environment may also be considered in the home to help the child and family achieve independence and normalization.


Using dolls, stuffed animals, or puppets to illustrate and explain the immobilization method (e.g., traction, cast) is a valuable tool for small children. Placing a cast, tubing, or other restraining equipment on the doll offers the child a nonthreatening opportunity to express, through the doll, feelings about the restrictions, the nurse, and other health care providers. The doll or puppet may also be used for teaching the child and family procedures such as IV therapy, procedural sedation, and general anesthesia.


One of the most useful interventions to help children cope with immobility is participation in their own care. Self-care to the maximum extent is usually well received by children. They can help plan their daily routine; select their diet; and choose “street clothes,” including innovative adornment such as a baseball cap or brightly colored socks to express their autonomy and individuality. They are encouraged to do as much for themselves as they are able to keep their muscles active and their interest alive.


Visits from significant people such as family members and friends offer occasions for emotional support and also provide opportunities for learning how to care for the child. Privacy is necessary, especially for adolescents.


For a child with greatly restricted movement (e.g., child with a large bilateral hip spica cast), nursing care is often a challenge. These situations require long-term care either in the hospital or at home; but, wherever the care occurs, consistent planning and coordination of activities with other health care workers and significant others are vital nursing functions.


With the increased trend toward early mobilization, early discharge, and home health care, many children are discharged home within a few days of hospitalization. Follow-up treatment may take place in the home setting or an outpatient ambulatory facility.




Family Support and Home Care


The needs of a child with severe disabilities can be complex, and family members require time to assimilate the teachings and demonstrations needed to understand the child’s situation and care. Even a child who is confined on a short-term basis can be a challenge for the family, who are usually unprepared for the problems imposed by the child’s special needs. Home modification is usually needed for facilitating care, especially when it involves traction, a large cast, or extended confinement. Suitable child care may be needed for times when all family members work.


Just as in the hospital, the child at home is encouraged to be as independent as possible and follow a schedule that approximates his or her normal lifestyle as nearly as possible such as continuing school lessons, regular bedtime, and suitable recreational activities.



Traumatic Injury


Soft-Tissue Injury


Injuries to the muscles, ligaments, and tendons are common in children (Fig. 48-1). In young children soft-tissue injury usually results from mishaps during play. In older children and adolescents, participation in sports is the more common cause.


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FIG 48-1 Sites of injuries to bones, joints, and soft tissues.


Contusions


A contusion is damage to the soft tissue, subcutaneous structures, and muscle. The tearing of these tissues and small blood vessels and the inflammatory response lead to hemorrhage, edema, and associated pain when the child attempts to move the injured part. The escape of blood into the tissues is observed as ecchymosis, a black-and-blue discoloration.


Large contusions cause gross swelling, pain, and disability; those sustained while the child is participating in sports usually receive immediate attention from health personnel. The less spectacular, smaller injuries may go unnoticed, allowing continued participation; however, they can become disabling after rest because of pain and muscle spasm. The young athlete is commonly instructed to “walk it off” or disregard the pain. Instead of this approach, first a qualified health care worker or certified athletic trainer should carry out an assessment of the affected area because further damage to the site may result if the area is severely traumatized. Immediate treatment consists of cold application, as described in the section on sprains. Return to participation is allowed when the strength and range of motion of the affected extremity are equal to those of the opposite extremity. Myositis ossificans may occur from deep contusions to the biceps or quadriceps muscles; this condition may result in a restriction of flexibility of the affected limb.


Contusions are crush injuries that occur in children when they slam their fingers (in doors, folding chairs, or equipment) or hit them (as when hammering a nail). A severe crush injury involves the bone, with swelling and bleeding beneath the nail (subungual) and sometimes laceration of the pulp of the distal phalanx. The subungual hematoma can be released by creating a hole at the proximal end of the nail with a battery-operated microcautery device or a heated sterile 18-gauge needle.



Dislocations


Long bones are held in approximation to one another at the joint by ligaments. A dislocation occurs when the force of stress on the ligament is so great as to displace the normal position of the opposing bone ends or the bone end from its socket. The predominant symptom is pain that increases with attempted passive or active movement of the extremity. In dislocations there may be an obvious deformity and inability to move the joint. Dislocation of the phalanges is the most common type seen in children, followed by elbow dislocation. One of the most common injuries in young children is subluxation of the annular ligament, also called pulled elbow or nursemaid elbow. With this injury the annular ligament slips proximally off the radial head into the joint between the radial head and ulna, causing immediate pain and limited supination (Carrigan, 2011). In the majority of cases the injury occurs in a child younger than 5 years who receives a sudden longitudinal pull or traction at the wrist while the arm is fully extended and the forearm pronated. It usually occurs when an adult or older sibling who is holding the child by the hand or wrist gives a sudden pull or jerk to prevent a fall or attempts to lift the child by pulling the wrist or when the child pulls away by dropping to the floor or ground. The child often cries, appears anxious, and refuses to use the affected limb; there is an absence of swelling. The practitioner manipulates the arm by applying firm finger pressure to the head of the radius, then supinates and flexes the forearm to return the ligament to its place. A click or clunk may be heard or felt, and functional use of the arm returns within minutes. However, the longer the subluxation is present, the longer it takes for the child to recover mobility after treatment. Usually no anesthetic is required, but a mild pain reliever such as acetaminophen may be given. In an older child severe elbow injury or dislocation should be carefully evaluated by a practitioner immediately; likewise a traumatic elbow injury in the younger child that is not a subluxation should be evaluated carefully.


In children younger than 5 years of age the hip can be dislocated by a fall. The greatest risk after this injury is the potential loss of blood supply to the head of the femur. Relocation of the hip within 60 minutes after the injury provides the best chance for preventing damage to the femoral head.


Shoulder dislocations occur most often in older adolescents and are often sports related. Temporary restriction of the joint with a sling or bandage that secures the arm to the chest in a shoulder dislocation can provide sufficient comfort and immobilization until medical attention is received.


Simple dislocations should be reduced as soon as possible with the child under mild (procedural) sedation and often local anesthesia. Anesthetics such as IV ketamine (Ketalar), midazolam (Versed), IV propofol (Diprivan), or fentanyl (Sublimaze) can be used to produce partial or complete analgesia. Nitrous oxide in concentrations of 50% to 70% has been shown to be safe for relatively short periods (15 to 20 minutes) in children ages 1 year and above (Babl, Oakley, Seaman, et al., 2008; Zier and Liu, 2011) An unreduced dislocation is complicated by increased swelling, making reduction difficult and increasing the risk of neurovascular problems. Treatment depends on the severity of the injury.





Therapeutic Management


The first minutes to 12 hours are the most critical period for virtually all soft-tissue injuries. Basic principles of managing sprains and other soft-tissue injuries are summarized in the acronyms RICE and ICES:
















R—Rest I—Ice
I—Ice C—Compression
C—Compression E—Elevation
E—Elevation S—Support

Soft-tissue injuries should be iced immediately. This is best accomplished with crushed ice wrapped in a towel or encased in a screw-top ice bag or resealable storage bag. A wet elastic wrap, which transfers cold better than dry wrap, is applied to provide compression and keep the ice pack in place. Chemical-activated ice packs are also effective for immediate treatment but are not reusable and must be monitored closely for leakage. A cloth barrier should be used between the ice container and the skin to prevent trauma to the tissues. Ice has a rapid cooling effect on tissues and reduces the pain threshold. However, it should never be applied for more than 30 minutes at a time because of the homeostatic response of the body to cold, which may trigger a decrease in vascularization at the injury site. A plastic bag of frozen vegetables such as peas serves as a convenient ice pack for soft-tissue injuries. It is clean, watertight, and easily molded to the injured part. When available, snow placed in a plastic bag may serve as an ice bag.


Elevating the extremity uses gravity to facilitate venous return and reduce edema formation in the damaged area. The point of injury should be kept several inches above the level of the heart for therapy to be effective. Several pillows can be used for elevation. Allowing the extremity to be dependent causes excessive fluid accumulation in the area of injury, delaying healing and causing painful swelling.


Torn ligaments, especially those in the knee, are usually treated by immobilization with a knee immobilizer or range-of-motion brace until the child is able to walk without a limp. Crutches are used for mobility to rest the affected extremity. Passive leg exercises, gradually increased to active ones, are begun as soon as sufficient healing has taken place. Parents and children are cautioned against using any form of liniment or other heat-producing preparation before examination. If the injury requires casting or splinting, the heat generated in the enclosed space can cause extreme discomfort and even tissue damage. In many cases torn knee ligaments are managed with arthroscopy and ligament repair or reconstruction as necessary, depending on the extent of the tear, the ligaments involved, and the child’s age. Surgical reconstruction of the anterior cruciate ligament may be performed in young athletes who wish to continue in active sports (Sarwark, 2010).



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 the child and the adult. 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 (i.e., climbing, falling down, running into immovable objects, skateboarding, and receiving blows to any part of their bodies).


Aside from automobile accidents or falls from heights, true injuries that cause fractures rarely occur in infancy; therefore bone injury in children of that age-group warrants further investigation. In any small child, especially under the age of 12 months, radiographic evidence of fractures at various stages of healing is, with few exceptions, a result of nonaccidental trauma (child abuse). Any investigation of fractures in infants, particularly multiple fractures, should include consideration of osteogenesis imperfecta.


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) injury 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 of age. 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.



Types of Fractures


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:


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Sep 16, 2016 | Posted by in NURSING | Comments Off on Musculoskeletal or Articular Dysfunction

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