Chapter 44 Nursing Care of the Child with an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder

Question 1

Mobility

Answer 1

Refers to mechanisms that facilitate or impair a person’s ability to move

Question 2

Neuromuscular System

Answer 2

The combination of the nervous system and the muscles working together to create movement

Question 3

Function of Musculoskeletal System

Answer 3

Provides the body with form, support, stability, protection, and the ability to move

Question 4

Components of Musculoskeletal System

Answer 4

Made up of bones, muscles, cartilage, tendons, ligaments, joints, & connective tissue

Question 5

Alterations in Pediatric Neuromuscular System

Answer 5

Immaturity of the neurologic and musculoskeletal systems, place them at increased risk for the development of a neuromuscular and musculoskeletal disorder and may hinder the child’s growth and movement

Question 6

Brain & Spinal Cord Development

Answer 6

Around 3 to 4 weeks gestation, the neural tube of the embryo begins to differentiate into the brain and spinal cord
- If the fetus suffers infection, trauma, malnutrition, or teratogen exposure during this critical period of growth and differentiation, brain or spinal cord development may be altered

The premature infant’s central nervous system is less mature than the term newborn’s
- Places infant at a higher risk of CNS insult w/in the neonatal period, which may result in delayed motor skill attainment or cerebral palsy

Compared with the adult, the child’s spine is very mobile, especially the cervical spine region
- Higher risk for cervical spine injury

Question 7

Myelinization in Pediatric Patients

Answer 7

Myelinization is incomplete at birth
- Continues to progress and is complete by about 2 years of age

Myelinization proceeds in a cephalocaudal and proximodistal fashion, allowing the infant to gain head and neck control before becoming able to control the trunk and the extremities
- As myelinization proceeds, the speed and accuracy of nerve impulses increase
- Primitive reflexes are replaced with voluntary movement.

Question 8

Muscular Development in Children

Answer 8

At birth (term or preterm), the muscles, tendons, ligaments, and cartilage are all present and functional

The newborn infant is capable of spontaneous movement but lacks purposeful control
- Full range of motion is present at birth. Healthy infants and children demonstrate normal muscle tone
- Hypertonia or hypotonia is an abnormal finding.

Deep tendon reflexes are present at birth and are initially brisk in the newborn and progress to average over the first few months.
- Sluggish deep tendon reflexes indicate an abnormality

The infant’s muscles account for approximately 25% of total body weight, as compared with the adult’s muscle mass, which accounts for about 40% of total body weight

Muscles grow rapidly in adolescence ->contributes to clumsiness, which places the teen at increased risk for injury
- In response to testosterone release, the adolescent boy experiences a growth spurt, particularly in the trunk and legs, and develops bulkier muscles

Female infants tend to have laxer ligaments than male infants, possibly due to the presence of female hormones
- Increased risk for developmental dysplasia of the hip (DDH)

Question 9

Hypertonia

Answer 9

Increased muscle tone

Question 10

Hypotonia

Answer 10

Low muscle tone

Question 11

Measures to Promote Bone Health

Answer 11

Diet: Strong in Vitamin D, Calcium, and protein.
- School-age up need 1000mg Calcium daily (about 4 cups of milk a day)
- Adolescents need 1300 mg of Calcium a day.

Weight-bearing exercise increase bone density

Avoidance of Carbonated beverages: Decreases the bone’s ability to absorb calcium

Question 12

Pediatric Bone Anatomy

Answer 12

Infant skeleton not fully ossified at birth
- Contains increased amounts of cartilage compared with adolescents and adults
- Lower mineral content than adult

Thick, strong periosteum (better shock absorber)
- Bones will often bend than break during an injury

Bone ossification (cartilage to bone) complete by adolescence

Growth plate end of long bone composed of epiphysis and physis (Epiphyseal growth plate)
- Can bend up to ~45 degrees before breaking

Growth plate is most vulnerable part of the bone
- Damage to this area can interrupt blood supply and cause growth failure

During fetal development the spine displays kyphosis
- Cervical lordosis, inward curvature, develops as the infant starts to hold the head up

When the infant or toddler assumes an upright position, the primary and secondary curves of the spine begin to develop
- The balance of the curves allows the head to be centered over the pelvis

During the toddler years, the period of early walking, lumbar lordosis may be significant (also termed toddler lordosis), and the toddler appears quite swaybacked and potbellied.

As the child develops, the spine takes on more adult-like curves
- During adolescence thoracic kyphosis may become evident (posture)

Question 13

Ossification

Answer 13

Conversion of cartilage to bone

Continues throughout childhood and is complete at adolescence

Question 14

Kyphosis

Answer 14

Outward spinal curvature

Question 15

Lordosis

Answer 15

Inward spinal curvature

Question 16

Epiphysis

Answer 16

End of long bone

Question 17

Physis

Answer 17

Cartilaginous area between the epiphysis & metaphysis

Question 18

Growth Plate

Answer 18

Combination of the epiphysis (end of long bone) & physis

In infants, the epiphyses are cartilaginous and ossify over time. In children, the epiphysis is the secondary ossification center at the end of the bone

Growth of the bones occurs primarily in the epiphyseal region
- This area is vulnerable and structurally weak.

Traumatic force applied to the epiphysis during injury may result in fracture in that area of the bone.

Epiphyseal injury may result in early, incomplete, or partial closure of the growth plate, leading to deformity or shortening of the bone.

Epiphyseal growth continues until skeletal maturity is reached during adolescence.
- Production of androgens in adolescence gradually causes the growth plates to fuse, and thus long bone growth is complete

Question 19

Fractures in Children

Answer 19

Fractures are a common injury in children
- Rare in infants

Clavicle is the most frequently broken bone in childhood, especially in those less than 10 years old
- Head is top heavy

Question 20

What components do you include when describing a fracture?

Answer 20

Name bone affected

Note if open or closed

Note if distal or proximal

Part of bone injured: Epiphysis, metaphysis, diaphysis,
Physis (Salter Harris Classification)

Note if displaced or nondisplaced

Transverse, Oblique, Spiral, Depressed

Question 21

Greenstick Fracture

Answer 21

Compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture

Question 22

Spiral Fracture

Answer 22

Spiral appearance of fracture

Always investigate spiral fractures in children where mechanism of injury does not match fracture type, ESPECIALLY in non-ambulatory child

Question 23

Buckle Fracture

Answer 23

Produced by compression of the porous bone and appears like a raised or bulging projection at the site

Question 24

Open or Compound Fracture

Answer 24

Fractured bone protrudes through the skin

Question 25

Stress Fracture

Answer 25

Tiny cracks in a bone

Caused by repetitive force, such as repeatedly jumping up and down or running long distances

Question 26

Salter-Harris Classification System

Answer 26

Used to describe fractures involving the growth plate

These injuries have a higher possibility of difficult healing

Most common concern is:
- Growth arrest with thepotentialfor deformity and limb length discrepancy

Question 27

Salter-Harris Fracture Type I

Answer 27

Fracture is through the physis, widening it

Question 28

Salter-Harris Fracture Type II

Answer 28

Fracture is partially through the physis, extending into the metaphysis

Question 29

Treatment for Salter-Harris Type I & II Fractures

Answer 29

Can be treated with closed reduction, casting, or splinting

The reduction should be performed carefully to avoid damage to or grating of the physis on any metaphyseal bone fragments

Question 30

Salter-Harris Fracture Type III

Answer 30

Fracture is partially through the epiphysis, extending into the epiphysis

Question 31

Salter-Harris Fracture Type IV

Answer 31

Fracture is partially through the epiphysis, extending into the epiphysis

Question 32

Treatment for Salter-Harris Type III & IV

Answer 32

Usually require open reduction and internal fixation (avoiding crossing the physis)

Question 33

Salter-Harris Fracture Type V

Answer 33

Crushing injury to the physis

Diagnosis may be delayed unless there is a high degree of clinical suspicion, and often the diagnosis is not made at the initial presentation

An emergent orthopedic consultation should be obtained if the fracture is recognized

As these fractures involve the germinal matrix, they have a potential for growth arrest

Question 34

Bone Healing in Children

Answer 34

Bone healing occurs in the same fashion as in the adult, but because of the rich nutrient supply to the periosteum, it occurs more quickly in children

Children’s bones produce callus more rapidly and in larger quantities than do adults

As new bone cells quickly form, a bulge of new bone growth occurs at the site of the fracture

The younger the child, the more quickly the bone heals
- Also, the closer the fracture is to the growth plate (epiphysis), the more quickly the fracture heals

The capacity for remodeling (the process of breaking down and forming new bone) is increased in children as compared with adults. This means that straightening of the bone over time occurs more easily in children

Question 35

What are the stages of bone healing?

Answer 35

1) Inflammatory Phase
2) Reparative Phase
3) Remodeling Phase

Question 36

Inflammatory Phase

Question 37

Reparative Phase

Question 38

Remodeling Phase

Question 39

Nursing Measures for Casts & Splints

Answer 39

Assess injury & determine if open fracture is present

Peripheral vascular checks w/ initial assessment & prior to & after any immobilization and/or reductions

Pain Management
- Pharmacological: Ibuprofen, aspirin, morphine if displaced
- Non-Pharmacological: Traction, ice, elevate the extremity, immobilize, play music & utilize other distraction techniques

Apply splint, ensure proper placement of splint padding and splint.

Educate patient and family regarding warning signs of compartment syndrome and care of cast or splint
- Warmth
- Sudden increase in pain
- Loss of sensation in affected extremity