Chapter 53 - Muscular PDF

UNIT 12 Health Conditions of Children 53 Musculoskeletal or Articular Conditions Natasha Bath Originating US Chapter by Marilyn J. Hockenberry http://evolve.elsevier.com/Canada/Perry/maternal OBJECTIVES On completion of this chapter the reader will be able to: 1. Outline a care plan for a child im...

UNIT 12 Health Conditions of Children 53 Musculoskeletal or Articular Conditions Natasha Bath Originating US Chapter by Marilyn J. Hockenberry http://evolve.elsevier.com/Canada/Perry/maternal OBJECTIVES On completion of this chapter the reader will be able to: 1. Outline a care plan for a child immobilized with an injury or a physically limiting condition. 2. Formulate a teaching plan for the parents of a child in a cast. 3. Explain the functions of the various types of traction. 4. Differentiate among the various congenital skeletal defects. 5. Design a teaching plan for the parents of a child with a congenital skeletal deformity. 6. 7. 8. 9. 10. THE IMMOBILIZED CHILD Disuse from illness, injury, or a sedentary lifestyle can limit function and potentially delay age-appropriate milestones. Most of the pathological 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 pathophysiological consequences occur frequently but seem to be more indirect and are thus secondary effects. Many pathophysiological 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 53.1 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. 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, more calcium leaves the bone, causing osteopenia (demineralization One of the most difficult aspects of illness in otherwise healthy 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 (e.g., severe burns) (Chapter 52), the musculoskeletal system (e.g., multiple fractures, osteomyelitis), or the neurological system (e.g., spinal cord injury, Guillain-Barr
e syndrome, traumatic brain injury, and coma) (Chapter 54). At times therapeutic interventions such as traction and spinal fusion are responsible for prolonged immobilization, although the increasing trends in health care are early mobilization, rehabilitation, discharge, and outpatient treatment. Physiological Effects of Immobilization Many clinical studies have documented predictable consequences that occur after immobilization. Functional and metabolic responses to restricted movement can be noted in most of the body’s 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. Describe the therapies and nursing care of a child with scoliosis. Outline a care plan 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. 1443 1444 UNIT 12 TABLE 53.1 Health Conditions of Children Summary of Physical Effects of Immobilization∗ Primary Effects Secondary Effects Nursing Considerations 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 position as often as possible. Bone demineralization Perform passive range-of-motion exercises. Disuse atrophy and loss of muscle mass Catabolism Loss of strength Have patient perform active and passive range-of-motion, 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. Muscular System Decreased muscle strength, tone, and endurance Skeletal System Bone demineralization— Osteoporosis, hypercalcemia Negative calcium balance With paralysis, use upright posture on tilt table. Pathological fractures Handle extremities carefully when turning and positioning. Calcium deposits Administer calcium-mobilizing medications (diphosphonates) and normal saline infusions as directed. Extraosseous bone formation, especially at hip, knee, elbow, and shoulder Negative calcium balance Metabolism Decreased metabolic rate Renal calculi Ensure adequate fluid intake; monitor output. Acidify urine. Promptly treat urinary infections. Life-threatening electrolyte imbalance Monitor serum calcium levels. Provide electrolyte replacement as indicated. Slowing of all systems Mobilize as soon as possible. Have patient perform active and passive resistance and deep breathing exercises. Decreased food intake Ensure adequate food intake. Provide a high-protein diet. Decline in nutritional state Encourage small frequent feedings with protein and preferred foods. Negative nitrogen balance Impaired healing Monitor for and prevent pressure sores. Hypercalcemia Electrolyte imbalance See nursing considerations 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 Inability to adapt readily to upright position (orthostatic orthostatic intolerance) neurovascular reflexes 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 hypotension (intolerance) with syncope—Hypotension, decreased cerebral blood flow, tachycardia Provide abdominal support. In severe cases, use antigravitational pants. Position horizontally. Altered distribution of blood volume Increased cardiac workload Monitor hydration, blood pressure, and urinary output. Decreased exercise tolerance Continued CHAPTER 53 TABLE 53.1 Musculoskeletal or Articular Conditions 1445 Summary of Physical Effects of Immobilization—cont’d Primary Effects Venous stasis Secondary Effects Systemic embolus or thrombus development, pulmonary emboli Nursing Considerations Encourage and assist with frequent position changes. Elevate extremities without knee flexion. Ensure adequate fluid intake. Have patient perform active or passive exercise 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 medications as prescribed. Dependent edema Tissue breakdown and susceptibility to infection Administer skin care. Turn every 2 hours. Monitor skin colour, temperature, and integrity. Use pressure-reduction surface as necessary to prevent skin breakdown. 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’s position may assist in lung expansion if the patient can tolerate it. 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 mechanisms. Poor abdominal tone and distension 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 deep breathing and coughing. 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 an infected person. Provide adequate hydration. Administer immunizations as necessary (pneumococcal, meningococcal). Gastrointestinal System Distension caused by Interference with respiratory movements poor abdominal muscle tone No specific primary effect Urinary System Alteration of gravitational force Monitor bowel sounds. Encourage small, frequent meals. Difficulty in feeding in prone position Possible constipation caused by gravitational effect on feces through ascending colon and smooth muscle tone Have patient sit upright in bedside chair, if possible Carry out bowel training program with hydration, stool softeners, increased fibre intake, and mild laxatives if necessary. Anorexia Stimulate appetite with favoured foods. Difficulty in voiding in prone or supine position Position as upright as possible to void. Continued 1446 UNIT 12 TABLE 53.1 Primary Effects Impaired ureteral peristalsis Health Conditions of Children Summary of Physical Effects of Immobilization—cont’d Secondary Effects Urinary retention in calyces and bladder Infection Renal calculi Nursing Considerations 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 Decreased circulation and pressure leading to tissue injury No specific primary and decreased healing capacity effect Difficulty with personal hygiene ∗ Turn and reposition at least every 2 hours. Frequently inspect total skin surface. Eliminate mechanical factors causing pressure, friction, moisture, or irritation. Place on pressure-relief mattress. 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. Individualize care according to a child’s needs; interventions may vary in different institutions. of the bones), which may predispose bone to pathological fractures. 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 major musculoskeletal consequences of immobilization are as follows: • Significant decrease in muscle size, strength, and endurance • Bone demineralization leading to osteoporosis • Contractures and decreased joint mobility 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 thrombus and emboli may obstruct vessels in organs such as the lungs, kidneys, or brain. Pulmonary embolus is a lifethreatening complication of immobilization. The larger the portion of the body immobilized and the longer the immobilization, the greater the hazards of immobility. Psychological Effects of Immobilization Throughout childhood, physical activity is an integral part of daily life and is essential for physical growth and development. Physical activity helps children learn and explore the environment around them, helps them regulate a variety of feelings and impulses, and provides a mechanism by which they can exert control over inner tensions. Some children respond to anxiety with increased activity; they process environmental stimuli and their emotions through activity and behaviour. Limiting or restricting physical activity because of illness or injury disrupts their ability to do this. When children are immobilized by illness or as part of a treatment regimen, they experience diminished environmental stimuli because of the 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 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. The quest for mastery at every stage of development is influenced by mobility. Even speech and language skills require sensorimotor activity and experience. For the toddler, exploration and imitative behaviours 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. The adolescent relies on mobility to achieve independence. 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 their loss of ability to function or any marked changes in body image. They may seek the attention of others by reverting to earlier developmental behaviours, such as wanting to be fed or bed-wetting and baby talk. Limbs in casts or traction transmit less than normal sensory data. Children who have limited ability to feel others touching them not only experience less tactile stimuli in a physical sense but also are deprived of warm, loving feelings that arise from being touched. The loss of feeling derived from touch can further add to their sense of being isolated and unwanted. Children may react to immobility by active protest, anger, and aggressive behaviour; or they may become quiet, passive, and submissive. They may believe the immobilization is a justified punishment for misbehaviour. Children should be allowed to express their feelings, but it should be within the limits of safety to their self-esteem and not damaging to the integrity of others (see Providing Opportunities for Play and Expressive Activities, Chapter 43). For example, providing an inanimate object to attack rather than a person or a valued possession is safe and therapeutic. When children are unable to express anger and frustration, aggression is often displayed inappropriately through regressive behaviour 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 CHAPTER 53 the services of an interprofessional team. Nurses play a key role in anticipating the services they will need and in coordinating conferences to plan care. Nursing Care. Physical assessment of the child who is immobilized as a result of an injury or illness focuses not only on the injured part (e.g., fracture or damaged joint) but also on the functioning of other systems that may be affected secondarily (e.g., the circulatory, renal, respiratory, muscular, and gastrointestinal systems). With long-term immobilization, there may also be neurological impairment and changes in electrolytes (especially calcium), nitrogen balance, and the general metabolic rate. The psychological 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 special surface to prevent skin breakdown. Frequent position changes also help prevent dependent edema and stimulate circulation, respiratory function, gastrointestinal motility, and neurological sensation. Children at greater risk for skin breakdown include those with prolonged immobilization; 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). In critically ill children, mechanical ventilation may increase the risk for skin breakdown. In newborns and infants, skin breakdown is more likely to occur on the occiput and on the nasal septum when nasal continuous positive airway pressure devices are used (Murray et al., 2013). 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 injury development in children who are acutely ill or at risk for skin breakdown from neurological conditions and immobilization (Noonan et al., 2011) (see Additional Resources at the end of the chapter). The use of antiembolic stockings and intermittent compression devices helps prevent circulatory stasis and dependent edema in the lower extremities and the development of DVT. Some children require anticoagulant therapy with low-molecular-weight heparin, vitamin K antagonists, or unfractionated heparin. Close monitoring of the signs and symptoms for possible DVT and pulmonary emboli is crucial to early detection and intervention for all immobilized children (SickKids, 2017). 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 difficult. 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 issues 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 children who are unable to move need passive exercise and movement, often in consultation with a physiotherapist. Musculoskeletal or Articular Conditions 1447 Using dolls, stuffed animals, or puppets to illustrate and explain the immobilization method (e.g., traction, cast) is a valuable tool for educating 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 concerning the restrictions and feelings toward 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 anaesthesia. 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 visits by family and friends, use of computers and personal tablets, books, interactive video games, and other items brought from their own room at home. An activity centre or slanting tray can be useful for the child with limited mobility for drawing, colouring, writing, and playing with small toys, such as trucks and cars. Accessibility to clocks, calendars, and a program of diversional therapy are also beneficial. All these interventions help children to function in a more typical way while hospitalized. A child life specialist should be consulted for recreational planning. Children are able to express their frustration, displeasure, and anger through play activities (see Chapter 44), which is helpful in their recovery. All efforts should be made to minimize family disruption resulting from the hospitalization. Hospitalized children should be allowed to wear their own clothes (street clothes, especially for preadolescent and adolescent children) and resume school and preinjury activities if able. A parent or siblings should be allowed to stay overnight and room in with the hospitalized child to prevent the effects of family disruption. Visits from significant persons, 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. One of the most useful interventions to help children cope with immobility is participation in their own self-care. Self-care to the maximum extent possible is usually well received by children. They can help plan their daily routine, select their diet (when possible), and choose clothes, including innovative adornments such as baseball caps, brightly decorated sunglasses, or brightly coloured stockings, to express their autonomy and individuality. They should be encouraged to do as much as they are able to for themselves to keep muscles active and their interest alive. Although most of the suggestions discussed here relate to hospital care, the same consultations (physiotherapist, 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. 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. Family Support and Home Care. The needs of a child with complex or chronic conditions that cause immobility can be complex. Although the optimal situation is for family members to have time to assimilate the teachings and demonstrations needed to understand the child’s situation and care, this is often shortened considerably by moving the child to a rehabilitation facility or even to the home within a matter of days. Even the child who is confined on a short-term basis can be 1448 UNIT 12 Health Conditions of Children a challenge for the family, which is usually unprepared for the adjustments imposed by the child’s special needs. Home modification is usually needed for facilitating care, especially when it involves traction, large casts, 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 should be encouraged to be as independent as possible and to follow a schedule that approximates their usual 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; areas of injuries are shown in Figure 53.1. 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. Contusions. A contusion (bruise) 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. Contusions caused by crush injuries can occur in children when they slam their fingers (in doors, folding chairs, or equipment) or hit their fingers (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. Large contusions that are often sustained while the child is participating in sports cause gross swelling, pain, and disability, and usually receive immediate attention from health personnel. Smaller injuries Femur Tendon (strain) Ligament (sprain) Joint (dislocation) Epiphysis (separation) Muscle and soft tissue (contusion) Tibia may go unnoticed, allowing continued participation; however, they can become disabling after rest because of pain and muscle spasm. Initial immediate treatment has traditionally consisted of cold application. 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. 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 to displace 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. Children with naturally lax joints are more prone to dislocation of joints. Dislocation of the phalanges is the most common type seen in children, followed by elbow dislocation. In the adolescent population, shoulder dislocations are more common, and dislocation unaccompanied by fracture is rare. A common injury in young children is subluxation or partial dislocation of the radial head, also called pulled elbow or nursemaid elbow. In most cases, the injury occurs in a child less than 5 years old who receives a sudden longitudinal pull or traction at the wrist while the arm is fully extended and the forearm pronated (Carrigan, 2020). 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. To treat this, the health care provider 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 anaesthetic is required; a mild pain reliever such as acetaminophen or ibuprofen may be given. In an older child, severe elbow injury or dislocation should be carefully evaluated by a health care provider immediately. If a traumatic elbow injury in a younger child is not a subluxation or if attempts at reduction are unsuccessful, the child should be carefully evaluated, with the consideration of X-rays. 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 prevention of damage to the femoral head. Shoulder dislocations occur most often in older adolescents and are often sports related. In a shoulder dislocation, temporary restriction of the joint, with a sling or bandage that secures the arm to the chest, 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 local anaesthesia as required. An unreduced dislocation will be complicated by increased swelling, making reduction difficult and increasing the risk of neurovascular complications. Treatment depends on the severity of the injury. Sprains. A sprain occurs when trauma to a joint is so severe that a Fig. 53.1 Sites of injuries to bones, joints, and soft tissues. ligament is partially or completely torn or stretched by the force created as a joint is twisted or wrenched, often accompanied by damage to associated blood vessels, muscles, tendons, and nerves. Common sprain CHAPTER 53 sites include ankles and knees. Sprains can be graded as follows: grade 1 sprain has mild damage to a ligament or ligaments without instability of the affected joint; grade 2 sprain is a partial tear to the ligament, stretched to the point that it exhibits excessive laxity; and grade 3 has a complete tearing of the ligament with a very loose or unstable joint (Karlin et al., 2020). The presence of joint laxity is the most valid indicator of the severity of a sprain. In a severe injury the child may describe the joint as “feeling loose” or as if “something is coming apart” and may describe hearing a “snap,” “pop,” or “tearing.” Pain is seldom the principal subjective symptom. There is a rapid onset with swelling (often diffuse), accompanied by immediate disability and appreciable reluctance to use the injured joint. Strains. A strain is a microscopic tear to the musculotendinous unit and has features in common with sprains. The area is painful to touch and swollen. Most strains are incurred over time rather than suddenly, and the rapidity of the appearance provides clues regarding severity. In general, the more rapidly the strain occurs, the more severe the injury. When the strain involves the muscular portion, there is more bleeding, often palpable soon after injury and before edema obscures the hematoma. Therapeutic Management. The first minutes to 12 hours are the most critical period for virtually all soft-tissue injuries. The goal is to limit further injury, control swelling and pain, and minimize strength and flexibility losses (Karlin et al., 2020). Basic principles of managing sprains and other soft-tissue injuries are summarized in the acronym PRICE: P—Protection R—Rest I—Ice C—Compression E—Elevation Crutches, air stirrups for ankle sprains, slings for arm injuries, and elastic wraps are used for compression. Compression limits further bleeding and swelling but should not be so tight that it limits perfusion (Karlin et al., 2020). Ice applied to the injury shunts blood flow from the injury, decreasing inflammation and swelling. This is best accomplished with crushed ice wrapped in a towel, a screw-top ice bag, or a resealable plastic storage bag. Chemical-activated ice packs are also effective for immediate treatment. A cloth barrier should be used between the ice container and the skin to prevent trauma to the tissues. Ice should be applied for 20 minutes three to four times per day until the swelling resolves. The application of heat is best suited for more chronic injuries, muscle soreness or pre-emptively before activity to improve blood flow to the site. The literature of the application of heat in acute soft tissue injuries is still variable and more research on its use is required. Elevating the extremity uses gravity to facilitate venous return and to 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. A nonsteroidal anti-inflammatory medication can be used to manage pain and decrease the edema. For minor ankle sprains, the child can start pain-free isometric strengthening and range-of-motion exercises as soon as possible (Karlin et al., 2020). Full weight-bearing is recommended in uncomplicated ankle sprains. The child can return to Musculoskeletal or Articular Conditions 1449 normal physical activities and sports when there is full range of movement and full strength to the joint. 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 should be cautioned against using any form of liniment or other heat-producing preparation before the injured area is examined. If the injury requires casting or splinting, the heat generated in the enclosed space can cause extreme discomfort and may even cause tissue damage. In some 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. Children who experience gait changes and restricted flexibility at 6 weeks after injury should be referred to a physiotherapy for more intensive rehabilitation (Tiemstra, 2012). Surgical reconstruction of the anterior cruciate ligament (ACL) may be warranted for severe ligamentous injuries. Successful surgical outcome correlates with age (Raines et al., 2017). 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 persons. Because childhood is a time of rapid bone growth, the pattern of fractures, issues of diagnosis, and methods of treatment in children differ from those for 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 that in 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—climbing, falling down, running into immovable objects, skateboarding, 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; thus bone injury in children of that age group warrants further investigation. In any small child, especially under the age of 24 months, radiographic evidence of fractures at various stages of healing is, with few exceptions, a result of nonaccidental injury (child maltreatment). If there is suspicion of child maltreatment, a full skeletal survey is completed to identify multiple fractures and the stage of healing for each fracture. Multiple fractures in varying stages of healing fractures are indicative of child maltreatment (Chauvin-Kimoff et al., 2018). However, any investigation of fractures in infants, particularly multiple fractures, should also include consideration of osteogenesis imperfecta. A distal forearm (radius, ulna, or both) is the most common fracture. The clavicle is also a bone that is commonly broken in childhood, with approximately half of clavicle fractures occurring in children under 10 years of age. Common mechanisms of injury include a fall with an outstretched hand or direct trauma to the bone. In newborns 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 an early 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 1450 UNIT 12 Health Conditions of Children 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 is or has protruded. If the bone fragments cause damage to other organs or tissues (such as the lung or bladder), 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 seen most often in children are described in Box 53.1 and Figure 53.2. BOX 53.1 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, to produce 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. Complete fracture—Divides the bone fragments. These fragments often remain attached by a periosteal hinge, which can aid or hinder reduction. 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., with anaesthesia) in order to realign the distal bone fragment to the proximal bone fragment. Growth Plate (Physeal) Injuries. The weakest point of long bones is the cartilage growth plate, or epiphyseal plate. Consequently, this is a common site of damage during trauma. Growth plate fractures are classified with the Salter-Harris classification system (Figure 53.3). Detection of epiphyseal injuries is sometimes difficult, but it is critical. Close monitoring and early treatment, if indicated, are essential to prevent longitudinal or angular growth deformities (or both). Treatment of these fractures may include open reduction and internal fixation to prevent or reduce growth disturbances. Bone Healing and Remodelling. Bone healing is rapid in growing children because of the thickened periosteum and generous blood supply. When there is a break in the continuity of bone, the osteoblasts are stimulated to maximum activity. New bone cells are formed in immense numbers almost immediately after the injury and, in time, are evidenced by a bulging growth of new bone tissue between the fractured bone fragments. This is followed by deposition of calcium salts to form a callus. Remodelling is a process that occurs in the healing of long bone fractures in growing children. The irregularities produced by the fracture become indistinct as the angles and bone overgrowth are smoothed out, giving the bone a straighter appearance. Fractures heal in less time in children than in adults. The approximate healing times for a femoral shaft are as follows: Newborn period—2 to 3 weeks Early childhood—4 weeks Later childhood—6 to 8 weeks Adolescence—8 to 12 weeks Diagnostic Evaluation. A history may be lacking in some childhood injuries. Infants and toddlers are unable to communicate, and older Plastic deformation Buckle I Greenstick Complete Complete with periosteal hinge Fig. 53.2 Types of fractures in children. II III IV V Fig. 53.3 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 R. B. Salter and W. R. Harris. (Salter, R. B., & Harris, W. R. [1963]. Injuries involving the physeal plate. Journal of Bone & Joint Surgery, 45[3], 587–622. Used with permission. Copyright © 1963 by The Journal of Bone and Joint Surgery, Incorporated.) CHAPTER 53 children may not volunteer information (even under direct questioning) when the injury occurred during suspicious or forbidden activities. Whenever possible, it is helpful to obtain information from someone who witnessed the injury. In cases of nonaccidental trauma providers may give false information to protect themselves or family members. The child may exhibit the same manifestations seen in adults (Box 53.2). However, often a fracture is remarkably stable because of an intact periosteum. The child may even be able to use an affected arm or walk on a fractured leg. Because bones have increased vascularity, a soft pliable hematoma may be felt around the fracture site. 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. NURSING ALERT A fracture should be strongly suspected in a small child who refuses to walk or crawl. Therapeutic Management. The goals of fracture management are as follows: • To regain alignment and 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. Most fractures are splinted and casted to immobilize and protect the injured extremity. Children with displaced fractures may often require immediate surgical reduction and fixation (internal or external) rather than being immobilized by traction until healing takes place. This practice is more common and holds true for all types of fractures, including femur fractures, although there is variation based on health care provider preference and institutional practice. Some conditions, including open fractures, compartment syndrome, fractures associated with vascular or nerve injury, and joint dislocations that are unresponsive to reduction manoeuvres, require immediate medical attention. In children the bone fragments are usually realigned and immobilized by traction or by closed manipulation and casting until an 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 on lower extremity fractures and active movement for the purpose of regaining function can begin after the fracture site is determined to be stable by the health care provider. The child’s natural tendency to be active is usually sufficient to restore normal mobility, and physiotherapy is rarely needed. In most cases children’s fractures can be managed by closed reduction and cast BOX 53.2 Clinical Manifestations of a Fracture Signs of injury: • Generalized swelling • Pain or tenderness • Diminished functional use of affected part May be: • Bruising • Severe muscular rigidity • Crepitus (grating sensation at fracture site) Musculoskeletal or Articular Conditions 1451 immobilization, which is most often provided on an outpatient basis with re-evaluation in 7 to 10 days. Children are most frequently hospitalized for fractures of the femur and the supracondylar area of the distal humerus, which may require internal fixation and pinning. If simple reduction cannot be achieved or a neurovascular condition 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 (i.e., casting and traction) are described later in the chapter. Wrist buckle fractures are common in children who fall and extend their arm forward to break the fall. Radius or ulna buckle fractures in children can be treated with a cast or a removable splint for 3 to 4 weeks. Nursing Care. Nurses are frequently the persons who make the initial assessment of a child with a suspected fracture (see Emergency box: Fracture). The child and parents may be frightened and upset, and the child is often in pain. Therefore, if the child is alert and there is no evidence of hemorrhage, the initial nursing interventions are directed toward calming and reassuring the child and parents so that a more extensive assessment can be more easily accomplished. While remaining calm and speaking in a quiet voice, the nurse can ask the parents and an older child to describe how the injury occurred. EMERGENCY Fracture Determine the mechanism of injury. Assess the 6 P’s (Box 53.3). Move the injured part as little as possible. Cover open wounds with a sterile or clean dressing. Immobilize the limb, including joints above and below the fracture site; do not attempt to reduce the fracture or push protruding bone under the skin. Use a soft splint (pillow or folded towel) or rigid splint (rolled newspaper or magazine). The uninjured leg can serve as a splint for a leg fracture if no splint is available. Reassess neurovascular status. Apply traction if circulatory compromise is present. Elevate the injured limb if possible. Apply cold to the injured area. Call emergency medical services, or transport child to a medical facility. The child may arrive with the limb supported in some manner; if not, careful support or immobilization may be provided to the affected site. In the event that the limb is already supported or immobilized, it may be best not to touch the child but to ask them to point to the painful area and to wiggle their fingers or toes. By this time the child may feel relatively safe and will allow someone to gently touch the area just enough to feel the pulse and test for sensation. A child’s anxiety is greatly influenced by previous experiences with injury and with health care personnel; they need to be told what will happen and what to do to help. The affected limb need not be palpated, and it should not be moved unless properly splinted. Parental anxiety may be heightened by the child’s pain reaction and fear, and possibly other events surrounding the accident; thus it is important to communicate to the parents that the child will receive the necessary care, including pain management. The Child Requiring a Cast The completeness of the fracture, the type of bone involved, and the amount of weight bearing influence how much of the extremity must be included in the cast to immobilize the fracture site completely. In most cases the joints above and below the fracture are immobilized 1452 UNIT 12 Long leg cast Health Conditions of Children Short leg cast Bilateral Full spica cast Short arm cast Single spica Long arm cast Fig. 53.4 Types of casts. to eliminate the possibility of movement that might cause further displacement at the fracture site. Four major categories of casts are used for fractures: upper extremity to immobilize the wrist or elbow, lower extremity to immobilize the ankle or knee, spinal and cervical for immobilization of the spine, and spica casts to immobilize the hip and knee (Figure 53.4). 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, fibreglass, and polyurethane resin). Both types of casting produce heat from the chemical reaction activated by water immediately after application. Plaster casts mould closely to the body part, take 10 to 72 hours to dry, have a smooth exterior, and are inexpensive. The newer synthetic casting material is lighter, dries in 30 minutes, and permits earlier weight bearing. The disadvantage of synthetic casting is its inability to mould closely to body parts; its rough exterior, which may scratch surfaces; and increased cost. Synthetic casts have special advantages for children. They come in different colours and with designs (e.g., cartoons, stripes), and they are lightweight, durable, easy to clean, and relatively water resistant, depending on the type of inner lining used; only those with a GoreTex inner lining may be immersed in water without affecting the cast integrity. Bathing with a synthetic cast may be accomplished by covering the cast with a plastic bag; if the synthetic cast gets wet, it should be dried thoroughly. One drawback to immersion is the time necessary to completely dry the cast. The availability of casting materials varies at each clinical setting. The synthetic casts are more difficult to write on. 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 often ceases to exist. It is also helpful to explain that some synthetic cast material will become warm but will not burn. During the application of the cast various distraction methods can be used, such as blowing bubbles. In this age group explanations such as “This will help your arm get better” are futile because the child has no concept of causality. To assist with child coping and their overall understanding of the cast application procedure, child life specialists can be consulted. Before the cast is applied, the extremities are checked for any abrasions, cuts, or other alterations in the skin surface, and rings or other items that might cause constriction from swelling are removed. The skin is protected by a cloth stockinette and cotton batting, which is applied liberally to the area to be casted. Particular attention is given to bony prominences, where areas of pressure, friction, and shearing could be noted. The stockinette is pulled over the ends of the cast to protect the skin from rough edges. Waterproof tape can also be used over the cast edges to create a smoother surface; this is commonly referred to as “petalling” the cast. Nursing care. The complete evaporation of the water from a hip spica cast can take 24 to 72 hours when older types of plaster materials are used. Fibreglass cast material dries within 30 minutes and is preferred. The cast must remain uncovered to allow it to dry from the inside out. Children in hip spica casts should be turned every 2 hours to minimize prolonged pressure. A regular fan (set on cool) can be helpful in drying wet casts, if needed. 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 should be handled by the palms of the hands to avoid 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 odour may indicate an infection. This should be reported for further evaluation. The health care provider may decide to make an opening, or a “window,” to expose the area in question for evaluation. 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) (Box 53.3). To prevent swelling, elevation of the body part increases 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, Velcro, or straps). The cast and the involved extremity need to be observed frequently for neurovascular integrity and any signs of compromise. Permanent muscle and tissue damage can occur within 6 to 8 hours. BOX 53.3 Compartment Syndrome Evaluation Assess the extent of injury—“the 6 P’s”: 1. Pain: Severe pain that is not relieved by analgesics or elevation of the limb, movement that increases pain 2. Pulselessness: Inability to palpate a pulse distal to the fracture or compartment 3. Pallor: Pale appearing skin, poor perfusion, capillary refill greater than 3 seconds 4. Paresthesia: Tingling or burning sensations 5. Paralysis: Inability to move extremity or digits 6. Pressure: Involved limb or digits may feel tense and warm; skin is tight, shiny; pressure within the compartment is elevated CHAPTER 53 See Nursing Skills on Evolve: Monitoring Neurovascular Status for the Child in Traction or a Cast. NURSING ALERT Compartment syndrome is a serious complication that results from compression of nerves, blood vessels, and muscle inside a closed space. This injury may be devastating, resulting in tissue death, and thus requires emergency treatment (fasciotomy). The six P’s of ischemia from a vascular, soft tissue, nerve, or bone injury should be included in an assessment of any injury (see Box 53.3). NURSING ALERT Observations such as pain (unrelieved by pain medication 1 hour after administration), changes in sensation, swelling, discoloration (pallor or cyanosis) of the exposed skin, decreased pulses, decreased temperature, or the inability to move the distal exposed part(s) should be reported to the health care provider immediately. When an extremity that has sustained an open fracture is casted, a window is often left over the wound area to allow for observation and for dressing of the wound or a splint is used temporarily to allow for observation before casting. For the first few hours after surgery, there may be substantial bleeding that will soak through the cast. Periodically, the circumscribed blood-stained area should be outlined with a ballpoint pen or pencil and the time indicated to provide a guide for assessing the amount of bleeding. Appropriate cast care guidelines for the child’s caregiver are necessary before discharge. Parents need instructions on appropriate cast care and on monitoring for signs and symptoms that indicate the cast is too tight or is too loose (see Family-Centred Care box: Cast Care). 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) (Figure 53.5). Commonplace situations can 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 and may require special seating or a specialized seatbelt adaptive device called an “EZ on vest.” The adaptations must meet specific Canadian safety regulations (see Additional Resources at the end of this chapter). 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. Parents need to be taught the proper care of the cast (or immobilization device) and helped to devise means for maintaining cleanliness. With a hip spica cast, a superabsorbent disposable diaper may be 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. For tightly fitting casts, transparent film dressings can be cut into strips 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 al