The Child with Musculoskeletal or Articular Dysfunction

Epidemiology of Trauma

Trauma is a leading cause of death in children older than age 1 year (see Chapter 1) and an important cause of disability during childhood and adolescence. In many ways, childhood trauma differs little from trauma in adults. However, the child’s developmental stage affects many aspects of injury, including the type of injury incurred and the physiologic response to injury. The Centers for Disease Control and Prevention estimated that 9.2 million children ages 0 to 19 years visited an emergency department annually between 2000 and 2006 for treatment of an unintentional injury (Borse, Gilchrist, Dellinger, et al, 2008).

Prevention of Injury

Increasingly, health care providers are recognizing the importance of injury prevention efforts in preserving the health and well-being of children. Nurses have an important role to play in these efforts.

Leading causes of injury to children include falls, being struck by or against an object, motor vehicle accidents, fires, pedestrian-vehicle accidents, drowning, and firearms. Falls were the leading cause of nonfatal injury among children ages 0 to 15 years. Motor vehicle collisions were the leading cause of nonfatal injury in adolescents ages 15 to 19 years of age (Borse, Gilchrist, Dellinger, et al, 2008). Poisonings also occur in young children, especially those between 1 and 4 years of age, and sports injuries occur in school-age children and adolescents.

Unintentional, preventable injury is the primary cause of pediatric mortality and a significant contributor to morbidity, including permanent disability. Both morbidity and mortality could be reduced dramatically by improved efforts at injury prevention. Studies have indicated a general lack of public awareness regarding risks, causes, and prevention of injury to children. Studies also show that injury prevention counseling is effective both in reducing hazards in the home and in increasing car seat use. Nurses can be active in legislative efforts, public awareness campaigns, group classes on injury prevention, and individual prevention counseling with children and families.

Many injury prevention strategies have been suggested for nurses. Nursing history or hospital admission forms can include screening questions about safety issues. Discharge planning or primary care visits might be a time to provide a family with information on safety practices. Well-child visits to the practitioner for physicals and immunizations are an excellent time to visit with children and parents about injury prevention in the home and the community. Home health care nurses can easily assist a family in conducting a home safety assessment. School nurses can develop safety education programs for different age-groups and discuss injury prevention with children that is applicable to their specific age-group. Additional resources for discussing injury prevention with adolescents include automobile insurance companies and the police and first-rescue personnel.* Nurses in emergency department and outpatient clinic settings can provide instructions related to injury prevention on an individual basis as developmentally appropriate.

Accident prevention among adolescents presents a unique challenge to all health care workers. For accident prevention to be effective, adolescents must perceive the specific interventions as having an impact on their lives. Adolescents are concerned with body image and often feel indestructible unless their own life or the life of a close friend is touched by a catastrophic debilitating injury or death. With increased emphasis in society on having fun and enjoying life to its fullest (today) regardless of the consequences (tomorrow), it is difficult for adolescents to understand the need to follow the rules laid down by authority figures.

Concern is also increasing about injuries to older school-age children and adolescents from the use of all-terrain motor vehicles (for which many states have no laws on minimum age for riders), snowmobiles, personal water craft such as wave runners, in-line skates, trampolines, scooters, and motor vehicles. Activities involving such vehicles and equipment, although safe in and of themselves when conducted according to safety guidelines (of the manufacturer), may be dangerous for children and adolescents who are unable to appreciate the risks involved, not only to self but to others as well.

Emergency Management

The Emergency Treatment box outlines guidelines for care of the child at the scene of an injury. After level of consciousness is assessed, the concerns are for airway, breathing, and circulation (ABC), after which other injuries are managed as indicated by the assessment. When spinal trauma is a possibility, open the airway using the modified jaw thrust maneuver, which is accomplished by grasping the angles of the victim’s lower jaw and lifting with both hands, one on each side, and displacing the mandible upward and outward (without head tilt or chin lift). Otherwise a head tilt–chin lift maneuver is effective in opening the victim’s airway. (See Cardiopulmonary Resuscitation, Chapter 31.)

Spinal cord injury cannot be assessed adequately in the prehospital setting. Radiography, computed tomography (CT), or magnetic resonance imaging (MRI) is required for diagnosis. Spinal cord injury is always suspected in a patient with head, trunk, or multisystem trauma. Only in a fully equipped trauma center with radiography and other diagnostic testing can spinal cord injury be ruled out. Therefore the patient is treated as if injury were present. Immobilize the cervical spine by maintaining the head in a neutral position and not allowing movement of the head or body in any direction.

Breathing is assessed after the airway is opened. If the child is not breathing, rescue breaths are given at a rate of 20 breaths/min. Oxygen should be provided when possible. Circulation is assessed only after the airway has been maintained and breathing is established. In children younger than 1 year of age, a brachial pulse is assessed. In those older than 1 year of age, a carotid pulse is palpated. Chest compressions should be initiated if necessary. (See Cardiopulmonary Resuscitation, Chapter 31.)

Control of bleeding is first attempted by application of direct pressure with a gloved hand. If this does not work, a pressure dressing is applied. The next step is to elevate the body part and then attempt to control hemorrhage by pressing on arterial pressure points. A tourniquet is used only when the bleeding cannot be controlled with a pressure dressing (Laskowski-Jones, 2002). If used, the tourniquet should be applied only to control bleeding. Once applied, it should not be removed or loosened. Below the tourniquet site, skin and tissue necrosis begins. If the tourniquet is loosened or removed, the toxins can be released into the circulation in high concentrations and may induce a systemic, deadly, tourniquet shock. With the tourniquet in place, the patient has a better chance of survival, even though it may mean the loss of a limb. Tourniquet use in prehospital settings has been shown to be safe (Doyle and Taillac, 2008; Lee, Porter, and Hodgetts, 2007).

Assessment of the child involves observation from head to toe, since infants and young children are unable to communicate except by crying and other behaviors. Therefore pinpointing areas of pain is difficult. To check for any motor or sensory dysfunction in the extremities, the nurse should note any spontaneous movement, which provides the best clue in infants and young children. Older children are able to follow directions to wiggle toes or fingers, demonstrate a grasp, “push down on the gas pedal,” or lift legs off the bed. The child is identified as soon as feasible by anyone who knows the child. It is important to determine whether the child has any existing health problems that might have implications for the circumstances of the injury and for therapeutic management. Ask any witnesses for details about the incident to aid in assessment of the child’s emotional responses.

In the prehospital setting the nurse’s role consists of contacting emergency medical services (EMS) and providing basic life support until EMS personnel arrive on the scene. The nurse’s role is limited to basic life support because the nurse has no standing orders or protocols under which to work in the prehospital setting (see Emergency Treatment box). Call EMS as soon as possible so that the patient can receive advanced life support before and during transport. A pediatric trauma triage system with personnel designated to care for an injured child is essential to provide excellent trauma patient care.

A paramedic-level ambulance provides at least one paramedic with skills in advanced cardiac life support, pediatric advanced life support, and neonatal resuscitation. A paramedic’s skills include electrocardiogram interpretation and defibrillation, advanced airway management (including endotracheal intubation, as well as intravenous [IV] and pharmacologic therapy), placement of a pneumatic antishock garment (PASG), pleural decompression (with a chest tube), and placement of a nasogastric tube and Foley catheter. Other advanced life support skills include expertise in spinal immobilization, extrication, management of fractures and bleeding, and emergency scene management. The paramedic remains in constant contact with the emergency department physician by means of a radio or cellular telephone for situations requiring medical control. Attempting to transport a child by automobile wastes valuable time in obtaining help. Transportation by EMS is recommended. Services in most large communities can institute advanced life support immediately or en route to a medical facility.

Systematic Assessment

Several factors can affect a child’s response to trauma. An undetected congenital anomaly can contribute to a complicated injury. Acute gastric distention occurs frequently in children because of the crying and screaming that accompany an injury. The temperature of young children is unstable because of their large surface area in relation to body mass, and temperature maintenance is critical in trauma management. Children also experience rapid metabolic changes. When they are ill, children are really ill; but as they recover, they change very rapidly. In addition, children have a small volume of blood in absolute terms. Whereas blood volume is 60% of total body weight in the adult, it is 70% to 85% in the child.

The first priority on admission to an emergency facility is rapid assessment of ABC status. Because the overwhelming majority of childhood injuries are the result of blunt-impact trauma, multiple organ involvement is a common finding. Therefore it is essential to perform a systematic assessment of the trauma victim.

The secondary survey is a systematic head-to-toe search for any additional injuries not originally addressed in the primary survey. However, children are often an exception to the head-to-toe approach. It may be preferable to complete the secondary survey on the injured child in a toe-to-head direction. This approach may allow the rescuer to gain the child’s trust as the survey progresses and the rescuer moves gradually into the child’s personal space. The Nursing Care Guidelines box gives an example of a complete secondary survey. Throughout the assessment, the nurse observes for areas of deformity, edema, ecchymosis, bleeding, hematoma, paralysis, or pain.

Causes of Immobilization

The usual reason for immobilizing or restricting the activity of a child without disabilities is illness or injury. Bed rest or mechanical restraining devices are frequently prescribed to aid in the healing and restorative processes. When children are ill, they are content to remain quiet, and most of them instinctively reduce their activity. It is children who are forced to remain inactive because of physical limitations or therapy who display the multiple effects of restricted movement.

The most frequent reasons for immobility are congenital defects (e.g., spina bifida); neuromuscular conditions (e.g., muscular dystrophy, spinal muscular atrophy); the need for prolonged mechanical ventilation and sedation; and infections or injuries that impair the integumentary system (severe burns), the musculoskeletal system (complex fractures or osteomyelitis), or the neurologic system (spinal cord injury, Guillain-Barré syndrome, or traumatic brain injury and coma). Sometimes therapies such as traction and spinal fusion are responsible for prolonged immobilization, although the trend is toward early mobilization, early discharge, and outpatient care.

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 occur in most of the body systems. Each has a direct influence on the child’s growth and development, since 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.

Although children usually become mobile once they feel well, the effects of immobility may be offset by a process termed prehabilitation, in which the individual’s functional capacity is enhanced before prolonged immobility to help withstand the stress on the body’s vital function. Prehabilitation has been implemented for adult patients in the intensive care unit and for those undergoing coronary artery bypass graft, knee arthroplasty, or orthopedic surgery who require prolonged immobilization; it could also be used for children anticipating immobility. Athletes use prehabilitation to decrease the incidence of injuries and increase vital functioning of the cardiorespiratory system, muscles, and metabolism.

Most of the pathologic changes that take place during immobilization arise from decreased muscle strength and mass, decreased metabolism, and bone demineralization. The three are closely interrelated, with one change leading to or affecting another. Some results of immobilization are primary and produce a direct effect; other pathophysiologic consequences occur frequently but seem to be more indirect and are therefore secondary effects. Many pathophysiologic changes affect more than one body system, with the primary or secondary effect being demonstrated in multiple systems.

Children who are confined to bed during an illness or traumatic injury are usually restricted in movement for a relatively short time or are sufficiently active to avoid the physical consequences of immobility.

The major effects of immobilization (Fig. 39-1) are related directly or indirectly to decreased muscle activity, which produces numerous primary changes in both muscular and bone structures along with secondary alterations in the cardiovascular, respiratory, metabolic, and renal systems. The major consequences are:

The larger the portion of the body immobilized and the longer the immobilization, the greater the hazards 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. It also serves children as an instrument for communication and expression and as a means for learning about and understanding their world. Activity helps them 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. Through movement children also gain sensory input, which provides an essential element for developing and maintaining a body image.

Active children have many opportunities for input from a wide variety of settings. When they are immobilized by disease or as a part of a treatment regimen, they experience diminished environmental stimuli with a loss of tactile, vestibular, and proprioceptive input and an altered perception of themselves and their environment. Sudden or gradual immobilization narrows the amount and variety of environmental stimuli they receive by means of all their senses: touch, sight, hearing, taste, smell, and proprioception. This sensory deprivation frequently leads to feelings of isolation, boredom, and being forgotten, especially by peers. Nursing interventions involving the use of diversional activities, schoolwork, structured television viewing, computer games, or interactive video programs can assist the child in maintaining usual activities. (See Chapter 26.)

The struggle for independence is thwarted by imposed immobility. For toddlers, exploration and imitative behaviors are essential to developing a sense of autonomy; preschoolers’ expression of initiative is evidenced by their penchant for vigorous physical activity; school-age children’s development is strongly influenced by physical achievement and competition; and adolescents rely on mobility to achieve independence. The quest for mastery at every stage of development is related to mobility. To children, the inability to move is threatening to self-preservation and reactivates the struggle between activity and passivity, and between dependence and independence.

Behavioral changes occur when children experience prolonged sensory deprivation. Some of these behaviors are indications of a higher-than-normal level of anxiety (Box 39-1). Children are likely to become depressed over their loss of ability to function or the marked changes in body image. Significant others often notice regressive behavior and a greater reliance on them for tasks the children are able to perform. Children seek their attention by reverting to earlier developmental behaviors, such as wanting to be fed, bed-wetting, and baby talk. In many ways immobilized children are realistically dependent on others; therefore intelligent and sensitive care is required to prevent major developmental regressions during the period of immobility.

Limbs that are immobilized by casts, traction, or paralysis transmit less sensory data than normally. Sensory impairment may be a concomitant problem of the involved part. Numbness or loss of feeling markedly alters proprioception. Children who have limited ability to feel others touching them not only experience less tactile stimulation in a physical sense but are also deprived of warm, loving feelings that arise from being touched. The loss of feeling from touch can further add to their sense of being isolated and unwanted.

Children often react to immobility with active protest, anger, and aggressive behavior, or they may become quiet, passive, and submissive. Often children believe that the immobilization is a justified punishment for misbehavior. Children should be allowed to express their anger, but this expression should be within the limits of safety to their self-esteem and not damaging to the integrity of others. For example, providing an object to attack rather than a person or a valued possession is safe and therapeutic.

Adults may be confused by, resent, and find it difficult to deal with the acting-out behavior of children. Too often this behavior is considered “bad” even when it is a release of tension. In some cases, such as with a paralyzed child, parents and nurses may feel inadequate to cope with the child’s profound distress and feelings of hopelessness, and the professional help of a mental health specialist is necessary.

The most difficult situations are those involving major injuries and diseases that produce a disfigurement or a severe loss of function that directly affects a child’s self-image, such as burns; amputation; or the sudden, catastrophic effects of an accident that leaves a healthy, active child paralyzed for life. Children have difficulty expressing feelings of anger and hostility when they are at the mercy of the environment. They dare not speak out against or defy the authorities on whom they depend so completely. Consequently their aggression may be masked by cheerfulness or rigidity. When they are unable to express their anger, the aggression is often displayed inappropriately through regressive behavior and outbursts of crying or temper tantrums over insignificant irritations. Adolescents and older school-age children should vary their daily routine to fit their needs for independence; allowing this age-group to stay up late at night and sleep in during the daytime (within reasonable limits to accommodate treatment needs) may help decrease struggles over other inconsequential matters and at the same time allow a daily pattern of life. Encourage parents to continue setting limits and not abandon disciplinary measures with children who are confined to bed due to trauma or illness.

Effects of Immobilization on Families

Brief periods of child immobilization have few effects on the family; however, a child’s catastrophic illness or disability may severely tax their resources. The need for instruction concerning medical and nursing care, community resources to contact, and emotional support are paramount. Many families have unmet needs, operate from crisis to crisis, and are unable to use outside help appropriately. For these families the new situation can be disruptive; therefore the rehabilitation team must help the family members identify unmet needs and solve problems. The following are commonly occurring problems:

The family’s needs often must be met through the services of a multidisciplinary team, and nurses play a key role in anticipating the services the family will need and in coordinating appropriate care. In preparation for the child’s discharge from the hospital, home visits are recommended, and home management is frequently planned weeks in advance of the actual discharge, including special provisions for meeting cultural, economic, physical, and psychologic needs. A child with a severe disability is dependent, and caregivers need rest periods to revitalize themselves. Individual and group counseling is beneficial for problem-solving situations and provides an emotional support system. Parent groups are also helpful and often allow nonthreatening social contact. The families of children with permanent disabilities need long-term resources, since some of the most difficult problems arise as they try to sustain high-quality care for many years. (See Chapters 25 and 22.)

Nursing Care Management

Orthotics and Prosthetics

Developments in the fields of orthotics (fabrication and fitting of braces) and prosthetics (fabrication and fitting of artificial limbs) have resulted in lighter and better-fitting devices and thus greater patient compliance in using them. Orthoses are often used to prevent deformity, increase the energy efficiency of the gait, and control alignment. Braces that facilitate walking can sometimes stabilize paralyzed or markedly weakened extremities. Special joint hinges permit the hip, knee, and ankle to flex while sitting, whereas the leg is held rigid during ambulation. Well-fitted orthoses promote ambulation, whereas ill-fitting braces throw off the child’s balance and frequently cause muscle stress and tissue breakdown. In the growing child braces need frequent adjustment and replacement by the orthotist if long-term use is necessary.

A standing frame or a parapodium (a standing frame on a circular base) helps small children to assume an upright position and begin mobilization. Children learn to use their arms and shift their weight to swivel the base of the parapodium to mobilize. Four common types of orthoses are used in older children and are described based on the joints controlled by the orthosis. The ankle-foot orthosis (AFO) is used to prevent footdrop due to bed rest, trauma to the foot, or paralysis of muscles that flex the foot; to prevent heel cord tightening after heel cord–lengthening surgery; or to support the foot in proper position for standing and walking (Fig. 39-4). AFOs are now available in patterns and colors.

The knee-ankle-foot orthosis (KAFO) is used to prevent buckling of the knee, to support the extremity when there is paralysis or marked weakness of the knee extension or quadriceps muscle, or to protect the limb when the bone structure is weak (Fig. 39-5). The hip-knee-ankle-foot orthosis (HKAFO) is used to provide various types of control for the knee and ankle joints (as described earlier), as well as the hip (e.g., flail lower limb and paralysis). The reciprocal gait orthosis (RGO) is a type of HKAFO that has a mechanism allowing children with significant paraplegia to walk in a reciprocal fashion on a flat surface. RGOs are used in children with spinal cord injury, sacral agenesis, and spina bifida.

The thoracolumbosacral orthosis (TLSO) is custom molded and fits snugly around the trunk of the body to exert pressure on the ribs and back to support the spine in a straight position (Fig. 39-6). The Boston brace is an underarm orthosis customized from prefabricated plastic shells, with corrective forces for each patient supplied by lateral pads. These braces may prevent the progression of curves in the spine, such as scoliosis, or provide needed torso support in a child with paraplegia. The Jewett-Taylor brace is sometimes used to support the spine and trunk during ambulation to prevent compression after fracture of the spinal column.

An orthosis must fit each body curvature to avoid undue pressure on tissues and imbalance between muscle groups. Bony prominences where a brace has contact, such as along the spine, chin, and iliac crests, are observed closely for pressure or irritation and are padded as necessary.

When prostheses are prescribed, the provider considers many factors: level of amputation, age, weight, activity, agility, and skin condition. Each prosthesis is custom made or fabricated of various plastic and foam materials. The style of the prosthesis depends on the most distal joint involved in the amputation or prosthetic fitting. Common abbreviations used to describe types of amputations are listed in Box 39-2.

Advances are constantly occurring in both the fabrication and fitting of prosthetics. Development of myoelectric devices, use of new cosmetic materials in terminal gloves and feet, and socket construction using computer-aided design and computer-aided manufacturing are but a few of the recent changes with positive effects for patients who require prostheses.

Nursing Care Management

Meticulous skin care under a brace is necessary. At times, protective clothing should be worn under braces to protect the skin from friction and pressure. Assessment of all areas that make contact with the brace every 2 to 4 hours for the first few days after application is recommended. If any area is reddened, the brace should be removed for to 1 hour. If the redness does not disappear, the nurse should notify the practitioner or orthotist (see Family-Centered Care box).

Before a prosthesis is applied, the condition of the skin must be assessed, with special note taken of areas of redness or breaks in the integrity of the skin. Prevention of skin breakdown is best accomplished through good hygiene of the residual limb, proper fitting of the artificial limb, and prosthetic training (see Family-Centered Care box).

Safety is another important consideration. Parallel bars provide secure hand rails on both sides as the child learns to walk again with or without braces or a prosthesis. As the child becomes more proficient, a walker with or without wheels is substituted for the bars, and the child is no longer confined to a limited territory. The child then progresses to crutches if age and condition permit it.

Crutches and Canes

Crutches are used when children are not allowed to bear weight; need support for balance while walking in braces; or can place only part of their body weight on an extremity, such as with most lower leg injuries. There are many types of crutches, and the selection depends on the child’s individual needs. Axillary swing-through crutches are used most frequently as temporary assistance. Forearm crutches (Fig. 39-7) are the usual selection for children who anticipate permanent use, such as paraplegic children who are able to use braces. In children with limited hand and arm strength or function, the use of trough crutches allows the weight to be assumed by the elbow. For habilitating small children who have not yet learned to walk or who are unsteady, front- or rear-rolling walkers are typically used until the children can progress to crutches (Fig. 39-8).

Children must be properly fitted with a crutch or cane to prevent both poor posture and crutch pressure on the axilla during ambulation. A physical therapist usually measures the child for crutches and teaches crutch and cane use; however, nurses in some areas such as the emergency department do teach children crutch walking. Nurses also supervise the use of crutches and canes in pediatric units and in the home. The type of crutch gait taught to a child depends on how stable the child is on crutches, whether or not the knees can be flexed, how much weight bearing is allowed, and what specific goal is established for the child.

Performing upper body strengthening exercises to condition and strengthen arms and shoulders before crutch use is important if immobilization has been prolonged. The child gains confidence in ambulating by wearing a safety belt held by the therapist. The types of gaits used and instructions given to children are similar to those for adults. Instructions are conveyed in language children understand and with a demonstration. Most children adapt to the techniques readily.

Wheelchairs

Wheelchairs are used temporarily or permanently as a means of transportation. A wheelchair for temporary use should fit the child and contain any adaptations needed, such as an elevating leg rest or reclining back. The child learns how to transfer in and out of the chair and how to move it safely. Prescribing a wheelchair for permanent use is the joint responsibility of the physician and therapist after an assessment of home and surroundings. A wheelchair should be neither too small nor too large and preferably should be adaptable as the child grows (Fig. 39-9).

Detachable or rotating armrests, which permit easy transfer in and out, are needed for children with spinal cord injuries. Other desirable features are detachable and swing-away footrests and detachable desk arms. Elevating leg rests are required for children who are prone to contractures, and a reclining back rest is needed for those who may have poor trunk balance. A pressure-relief cushion should be provided for a child who has decreased sensation. Hand-rim and brake-lever projections are helpful for children with upper extremity weakness. For children who have the use of only one arm, a special “one-arm drive” wheelchair is available. Children with paraplegia require upper arm strengthening exercises and instruction on transfer techniques before wheelchair mobilization (Fig. 39-10). Often a tilt table is used to overcome the problem of orthostatic intolerance before the child is able to tolerate wheelchair sitting.

Various motorized chairs are available for children with marked upper extremity weakness, and mouth- or cheek-operated models are obtainable for children who do not have the use of upper extremities so that they can operate the wheelchairs independently. Very small children who have permanent paralysis of the lower extremities are provided with specially designed units that allow independent mobility. A detachable handle on these units permits their conversion to strollers.

Bicycles and tricycles (Figs. 39-11 and 39-12) can be modified for children with limited ambulatory mobility; these also promote muscle strengthening and prevent disuse contractures. Gait training may be accomplished with a number of special devices (Fig. 39-13).

Etiology

The causes of fracture injuries in children are those described for general traumatic injuries in childhood. Fractures in infancy are more often the result of birth trauma, injury, or child abuse. Aside from motor vehicle injuries, true accidents causing fracture are uncommon in infancy; therefore injuries in children in this age-group warrant further investigation. Most often, early bone trauma in infants consists of periosteal bleeding in the long bones of the arms and legs, usually caused by rough handling, twisting, and pulling, which is not evident on radiographic examination until 3 to 6 weeks after the injury. Any investigation of fractures in infants, particularly multiple fractures, should include the suspicion of osteogenesis imperfecta (OI) (see p. 1675). In any small child, radiographic evidence of fractures at various stages of healing, with few exceptions, indicates physical abuse (see Community Focus box, on p. 1620).

Fractures of the forearm are common bone injuries in childhood and are usually caused when the child extends the palm of the hand to break a fall. The force resulting from a fall on the outstretched hand progresses up the length of the extremity with the possibility of injury to the finger, wrist, elbow, shoulder, or clavicle (Fig. 39-15). DiFazio and Atkinson (2005) report that upper extremity fractures are more common in children than in adults. The radius is the most commonly fractured bone of the upper extremity, followed by the bones in the hand. The clavicle is another frequently broken bone in children; approximately half of clavicle fractures occur in children younger than 10 years of age. Many such fractures occur at birth. Hip fractures are uncommon in children and require a great deal of force to produce. A femoral neck fracture may be sustained in children 6 or 7 years of age as a result of pedestrian-automobile accidents because in these children the hip is at the same level as an automobile bumper. In older children the femur is the most likely target; in adolescents knee injuries are common.

Children fall from heights (e.g., trees, roofs, playground equipment) as their insatiable curiosity and immature judgment lure them to places of danger. Fractures in school-age children are often the result of bicycle-automobile collisions or skateboard injuries. Sports are a frequent cause of injury in the school-age child and adolescent.

At all ages motor vehicle mishaps are a frequent cause of bone injury. Most children who are hit by an automobile are between 4 and 7 years of age and sustain a triad of injuries, which must be kept in mind when making an assessment: (1) the child’s femur, which is at the level of the bumper, is fractured; (2) the hood of the automobile produces injuries to the child’s trunk; and (3) a contralateral head injury is usually sustained when the child is thrown to the ground by the impact. Therefore a child with any one of these injuries who was struck by an automobile should be examined for evidence of the other two.

Pathophysiology

The anatomic, biomechanical, and physiologic nature of children’s skeletons causes differences from adults in the patterns of fracture, the problems of diagnosis, and the methods of treatment. The bones of the adult are strong and require a violent traumatic force to fracture, which is accompanied by massive injury to surrounding soft tissues. In children the bones are more easily injured, and fractures may result from minor falls or twists and are less likely to be accompanied by soft tissue damage. Features of children’s fractures not observed in adults are listed in Box 39-3.

Animation—Bone Fractures

Clinical Manifestations

Children demonstrate the usual signs of injury: generalized swelling, pain or tenderness, and diminished functional use of the affected part. There may be bruising, severe muscular rigidity, and sometimes crepitus (a grating sensation at the fracture site), which are also frequent signs in adults. More often the fracture is remarkably stable because of the usually intact periosteum. The child may even be able to use an affected arm or walk on a fractured leg.

Although neurologic and vascular damage is much less frequent in children than in adult patients, the integrity of these structures must be thoroughly assessed. This is often difficult in infants and young children, who are unable to cooperate. Vascular injury is most likely to occur with supracondylar fractures of the humerus and femur. Femoral and popliteal vessels and the sciatic nerve are prone to trauma in femoral fractures. Humeral fractures may cause damage to the medial, ulnar, or radial nerves and to the brachial artery.

During the assessment, include examination for the five Ps of ischemia from a vascular injury: pain, pallor, pulselessness, paresthesia, and paralysis.

Nursing Assessment

Nurses often conduct the initial assessment of a child with a suspected fracture (see Emergency Treatment box). The child and the parents are frightened and upset; the child is in pain; and, because some fractures are obvious, the parents and frequently the child are already convinced of the diagnosis. As a first step, the injured limb should be supported in some manner. Then, if the child is alert and there is no evidence of hemorrhage, direct the initial nursing interventions toward calming and reassuring the child and parents so that a thorough assessment is easier to accomplish.

Maintaining a calm manner, the nurse can ask the parents to describe what happened and what they think about it. As long as the limb is supported in some manner, this minute or two does not delay or endanger the treatment. It is best not to touch children initially but to ask them to point to the painful area and wiggle their fingers or toes distal to the injury. Previous experiences with injury and health care personnel will influence a child’s anxiety. However, children need to be told what will happen and what they can do to help. The affected limb need not be palpated and should not be moved unless properly splinted. A temporary splint should be applied carefully if the child must be transported to a hospital or clinic or to the radiology department.

Diagnostic Evaluation

A history of the injury or events leading up to the injury may be lacking for childhood injuries. Infants and toddlers are unable to clearly communicate the details of what occurred. Older children may not be reliable informants or volunteer information (even under direct questioning) if the injury occurred during questionable activities. In cases of child abuse, parents or caregivers may deliberately give false information to protect themselves. Whenever possible, it is helpful to get information from someone who witnessed the injury.

Therapeutic Management

The goals of fracture management are:

Some conditions may require immediate medical attention. These include open fractures, compartment syndrome with and without fracture, fractures associated with vascular or nerve injuries, and joint dislocations that cannot be reduced (DiFazio and Atkinson, 2005). Some fractures may be splinted to immobilize and protect the fractured (or suspected fractured) extremity (see Research Focus box), and pain management is initiated with nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen, oxycodone, or acetaminophen with codeine (Friday, Kanegaye, McCaslin, et al, 2009; Koller, Myers, Lorenz, et al, 2007). In one study ibuprofen was as effective as acetaminophen with codeine for the treatment of musculoskeletal trauma in children (Clark, Plint, Correll, et al, 2007), whereas another study reported no difference among these agents in reducing pain in a group of children with fractures (Drendel, Lyon, Bergholte, et al, 2006).

In children the bone fragments are usually realigned and immobilized by traction or by closed manipulation and casting until adequate callus is formed. Internal and external fixation is also used. Weight bearing and active movement for the purpose of regaining function can begin after the fracture site is stable. The child’s natural tendency to be active is usually sufficient to restore normal mobility, and physical therapy is usually required only with more complex traumatic injuries. Open reduction is seldom required and is limited to fractures that cannot be maintained by conservative methods and cases in which there is interposed tissue or injury to arteries or nerves, such as in a motor vehicle accident or other major trauma. In the majority of cases children’s fractures can be managed by closed reduction and immobilization with plaster or fiberglass; this is often done on an outpatient basis with reevaluation in 7 to 10 days.

For many fractures closed reduction may be carried out in the emergency department with administration of procedural sedation drugs such as midazolam (Versed), fentanyl (Sublimaze), and morphine (Cimpello, Khine, and Avner, 2004); a local or regional nerve block; fentanyl and midazolam; ketamine (Ketalar) and midazolam; or a combination of nitrous oxide and local or regional anesthesia (Kennedy, Luhmann, and Luhmann, 2004). Etomidate is a rapid-acting sedative that induces unconsciousness and is cleared rapidly from the system. This hypnotic drug may be used for procedural sedation; however, it does not have analgesic properties (Meredith, O’Keefe, and Galwankar, 2008). With any fracture appropriate pain management should be implemented in all children. Studies have shown that historically children have been inadequately treated for pain during procedures in the emergency department and pain scores have been underused (Brown, Klein, Lewis, et al, 2003).

Children are most frequently hospitalized for fractures of the femur and the supracondylar area of the distal humerus. If simple reduction cannot be achieved or a neurovascular problem is detected after injury, observation in a hospital unit is indicated. Severe contusions with profound swelling cannot be treated with a cast, which would act as a tourniquet on the extremity, and badly malaligned fractures may require traction for a time before a cast is applied. The trend, however, is to avoid hospitalization. Some malaligned fractures respond to treatment with external pinning and traction or, more commonly, the use of an Ilizarov external fixator (see p. 1650). Several factors determine the method of fracture reduction (Box 39-5).

Medical interventions to manage a fracture injury involve the physician, the nurse, and the family (Box 39-6). Specific interventions and nursing responsibilities associated with the care of a child with a fracture are discussed later in the chapter.

Bone Healing and Remodeling

Bone healing follows a patterned sequence. Fig. 39-18 shows three broad overlapping phases: inflammatory, restorative, and remodeling. Bone healing can be described more definitively in terms of five stages (Table 39-2). When the bone breaks, the envelope of subcutaneous tissue, muscle, and periosteal tissue surrounding the site is torn, blood vessels rupture, and a hematoma forms. The ends of the fractured bone segments, deprived of circulation, die as far back as the nearest collateral circulation. Necrotic tissue accumulates, and an inflammatory response takes place at the site, with its characteristic vasodilation, plasma exudation, and edema. The organization and reabsorption of the hematoma proceeds, and the restorative phase begins with the reestablishment of local circulation. Repair requires an adequate blood supply and immobilization of the fracture fragments.

When there is a break in the continuity of bone, the periosteal and intraosseous osteoblasts are in some way stimulated to maximum activity. New osteoblasts are formed in immense numbers almost immediately after the injury and begin building a bridge, as evidenced by a bulging growth of osteoblastic tissue and new bone matrix between the fractured bone fragments. This is followed by deposition of calcium salts to form callus, which provides stability (Fig. 39-19, B).

Bone healing is characteristically rapid in children because of the thickened periosteum and generous blood supply. In the young child, for example, there is frequently a solid union of the femoral shaft in 3 to 4 weeks, whereas in the adult, callus sufficient to avoid deformities from the constant muscle contraction associated with movement may not form in fewer than 10 to 16 weeks. The approximate healing times for a femoral shaft fracture are as follows:

Remodeling is a unique process that occurs in the healing of long bone fractures before epiphyseal closure. When a bone remodels, the irregularities produced by the fracture become indistinct because hollows are filled in and angles are rounded off in the healing process, which gives the bone a straighter appearance. It does not alter the alignment of the bone. The buildup of new bone or callus restores a portion of the normal bone structure in most cases despite observable malalignment. The younger the child and the closer the proximity of the fracture to the growth plate, the more likely that spontaneous correction will take place. In some instances a 90-degree angle will straighten in a year, but rotational deformities do not correct themselves. Various factors such as the type and location of the fracture, the child’s age, and the amount of fragment angulation or rotation influence the degree of correction in alignment that can be obtained by remodeling.

The position of the bone fragments in relation to one another influences the rapidity of healing and the residual deformity. For example, a gap between fragments delays (or prevents) healing (Fig. 39-20, A). Healing is prompt and complete with end-to-end apposition (Fig. 39-20, B), but the fracture stimulates accelerated growth of the neighboring epiphysis, which causes bony overgrowth and increased length of the extremity. Angulation deformity caused by an incomplete fracture (Fig. 39-20, C) may remodel in the young child, but the degree of residual deformity depends on the relationship of the angulation of the bone fragments to the angle of the joint. This requires careful evaluation and reduction to prevent permanent deformity.

Wolff’s law is applied in treating children with orthopedic problems. Paraphrased, it states that bone will grow in the direction in which stress is placed on it. Examples of the use of this law are the hip spica cast with an abduction bar for treating developmental hip dysplasias and application of casts or traction at a selected angle to influence the direction of bone healing.

Bone healing in any age-group is greatly influenced by the traumatized person’s general health. The child with a fracture requires adequate nutrition for optimum bone healing. When nutritional intake is insufficient, vitamin and mineral supplementation may be necessary. No special dietary changes need to be made except to correct any existing nutritional deficiencies. Monitoring for fluid and electrolyte balance, renal function, and possible anemia is equally important to promote the child’s wellness.

The Cast

Nursing Care Management

The complete evaporation of the water from a hip spica cast can take 24 to 48 hours when plaster materials are used. Drying occurs within minutes with fiberglass materials. The cast must remain uncovered to allow it to dry from the inside out. Turning the child in a plaster cast at least every 2 hours will help to dry a body cast evenly and prevent complications related to immobility. Use of a regular fan or a hair dryer on the cool setting to circulate air may be helpful when the humidity is high.

Handle a wet plaster cast using the palms of the hands to avoid indenting the cast and creating pressure areas, and support it with a pillow covered with plastic. A dry plaster of Paris cast produces a hollow sound when tapped with the finger.

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. One measure to reduce the likelihood of this problem is to elevate the body part and thereby increase 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). The cast and the involved extremity are observed frequently to assess neurovascular integrity and detect any signs of compromise. Within 6 to 8 hours permanent muscle and tissue damage can occur, for which nurses can be held liable. Once the cast has dried, “hot spots” felt on the cast surface or foul-smelling areas of the cast may indicate infection underneath and should be further evaluated. Often the cast is windowed over the area of suspicion to directly observe and treat the area if necessary.

When a cast is applied to an extremity that has sustained an open fracture, a window is often left over the wound area to allow for observation and dressing of the wound.

Usually the child is discharged to home care after a cast is applied in the emergency department or clinic. Parents need instructions on drying and caring for the cast and checking for signs and symptoms that indicate the cast is too tight (see Family-Centered Care box). They should also know to take the child to the health care professional for attention if the cast becomes too loose, since a loose cast no longer serves its purpose. A cast may represent a badge of honor for the child and serves as visible evidence of an otherwise invisible injury.

Purposes of Traction

When two forces of given direction and magnitude act on an object at the same point simultaneously from opposite directions, the object either changes its state of rest or motion or remains in equilibrium. The use of traction in the management of fractures is the direct application of such forces to produce equilibrium at the fracture site. A forward force (traction) is produced by attaching weight to the distal bone fragment. This force is balanced by the backward force of the muscle pull (countertraction) and the frictional force between the patient and the bed (Fig. 39-25).

To reduce or realign a fracture site, traction is provided by weights applied to the distal bone fragment; body weight provides countertraction. By adjusting the line of pull upward or downward or by adducting or abducting the extremity, the operator uses these forces to align the distal and proximal bone fragments. To attain equilibrium, the amount of forward force is adjusted by adding weight to or subtracting weight from the traction, or countertraction is increased by elevating the foot of the bed to create a greater gravitational pull in the backward force.

The three primary purposes of traction for reduction of fractures are:

In some cases traction may be used to treat a pathologic joint condition such as developmental hip dysplasia. The muscle is fatigued by applying constant stress to the muscle so that the buildup of lactic acid will produce muscle relaxation. The all-or-none law, which characterizes muscle contractility, applies to muscle relaxation as well. When the muscle is stretched, muscle spasm ceases, which permits the realignment of the bone ends. The continuous maintenance of traction is important during this phase, since releasing the traction allows the muscle to contract normally and again cause malpositioning of the bone ends.

The realignment of the bone fragments is a gradual process that is achieved more rapidly in infants, who have limited muscle tone, than in muscular teenagers. The line of pull and callus formation are checked periodically by radiographic examination. The traction pull to some degree immobilizes the fracture site; however, adjunct immobilizing devices such as splints or casts are sometimes used with skeletal traction. In injuries in which there is severe soft tissue swelling or vascular and nerve damage, it is customary to use traction until these complications have been resolved and it is safe to apply a cast. Immobilization with traction is maintained until the bone ends are in satisfactory realignment, after which a less-confining type of immobilization, usually a cast, is applied.

Types of Traction (General)

The two main types of traction are skin traction and skeletal traction. The pull needed for traction can be applied to the distal bone fragment in several ways (Box 39-8). The type of traction applied is determined primarily by the child’s age, the condition of the soft tissues, and the type and degree of displacement of the fracture. Fractures most commonly treated by application of traction are those involving the humerus, femur, and vertebrae.

Upper extremity traction is rarely used because of the urgency in management. Fractures of the humerus, which are usually the result of a fall with the arm in extension, frequently involve the supracondylar portion. Three major complications are associated with this injury: Volkmann contractures (p. 1651); traumatic injury to the median, ulnar, or radial nerve; and angulation deformities. The fracture must be carefully reduced with the child sedated or under anesthesia. Because of the danger of complications, children with closed reduction of supracondylar fractures are often hospitalized for observation.

In cases of upper extremity fracture the child is sedated, and treatment by closed reduction is attempted in the emergency department. Closed reduction with percutaneous pinning or open reduction with internal fixation is performed in the operating room as indicated.

The common site for a femoral fracture is the middle one third of the shaft (see Fig. 39-19, A). With such a fracture there is significant overriding but minimal displacement. In a fracture in the lower one third of the shaft, the pull of the gastrocnemius muscle causes the distal fragment to become downwardly displaced. The severity of the fracturing force and the ability of the muscles to hold the fracture out of alignment determine the fracture type and the amount of overriding of the fragments. The periosteum may remain intact, which helps maintain alignment.

Buck extension traction is a type of skin traction applied with the legs in an extended position (Fig. 39-26). Buck extension traction is used primarily for short-term immobilization, such as preoperative management of a child with a dislocated hip, or for correction of contractures or bone deformities, such as in Legg-Calvé-Perthes disease. A side-lying position may be permissible if the leg is stable.

Russell traction uses skin traction on the lower leg and a padded sling under the knee. Two lines of pull, one along the longitudinal axis of the lower leg and one perpendicular to the leg, are produced. This combination of pulls allows realignment of the lower extremity and immobilizes the hip and knee in a flexed position. The hip flexion must remain at the prescribed angle to prevent fracture malalignment, since there is no direct support under the fracture and the skin traction may slip. Because the traction is set up to have two ropes pulling in the same direction at the foot plate, the traction pull is twice the amount of weight at the end of the bed.

A common skeletal traction is 90-degree–90-degree traction (90-90 traction). The lower leg is put in a boot cast or supported in a sling, and a skeletal Steinmann pin or Kirschner wire is placed in the distal fragment of the femur. From a nursing standpoint, this type of traction facilitates position changes, toileting, and prevention of traction complications. This traction also:

Balanced suspension traction may be used with or without skin or skeletal traction. Unless it is combined with another type of traction, balanced suspension traction merely holds the leg in a desired flexed position to relax the hip and hamstring muscles and does not exert any traction directly on a body part. A Thomas splint extends from the thigh to midair above the foot, and a Pearson attachment supports the lower leg. Towels or pieces of felt covered with stockinette are clipped or pinned to the splints for leg support. Ropes are attached to create a balanced traction. When the child is lifted from the bed, the traction lifts as well, with no loss of alignment (see Fig. 39-3).

The Pearson attachment stays wherever it is positioned. Many times the practitioner puts a rope between the end of the Pearson attachment and the end of the Thomas splint to prevent any alteration in knee flexion when the child is moved. This type of traction requires very careful checking of splints and ropes to make certain that no slippage or fraying has occurred. This mode of traction is of great value when lifting the older and heavier child for care.

The cervical area is a vulnerable site for flexion or extension injuries to muscles, vertebrae, or the spinal cord. Cervical muscle trauma without other complications is treated with a cervical soft or hard collar to relieve the weight of the head on the fracture site. Intermittent cervical skin traction using a head halter and weight might be employed to decrease muscle spasms. Injuries limited to cervical muscles can be uncomfortable but, with prompt medical care, usually resolve with conservative treatment.

When a child’s cervical vertebra is displaced or fractured, the site must be reduced and immobilized with cervical skeletal traction. The spinal cord runs through the intravertebral canal, and dislocation or fracture of the vertebrae can also cause spinal cord trauma. Physical examination, especially a neurologic assessment, and radiographic studies are essential diagnostic aids to determine:

Cervical traction may be accomplished with halo ring traction, a halo vest (Fig. 39-27, A), or Gardner-Wells tongs (Fig. 39-27, B) (Fisher, Williams, and Levine, 2008). Gardner-Wells tongs are spring loaded, so making burr holes and shaving hair are not required; a local anesthetic may be used during application. The head is placed in a hyperextended position, and, as the neck muscles fatigue with constant traction pull, the vertebral bodies gradually are pulled apart and the cord is no longer pinched between the vertebrae. Immobilization until fracture healing can occur is an essential goal of cervical traction. If the injury has been limited to a vertebral fracture without neurologic deficit, a halo vest permits earlier ambulation (see Fig. 39-27, A). Halo vest devices are also used preoperatively and postoperatively to stabilize the cervical spine.

Nursing Care Management

To assess the child in traction, it is essential to know the purpose for which the traction is being applied. Regular assessment of both the child and the traction apparatus is required (see Nursing Care Guidelines box). The nurse also assesses the child for evidence of adverse effects of immobilization (see pp. 1624-1629).

Evaluating the therapeutic effects and possible negative consequences of traction is essential to good patient care. Many of the nursing problems associated with traction in a child are related to immobility. However, a number of physical needs related to traction require attention and vigilance.

In addition to routine skin observation and care (see The Immobilized Child, p. 1623), children in skeletal traction need special skin care at the pin site according to hospital policy or practitioner preference. In a review of pin site care in children and adults, it was concluded that pin sites should be frequently assessed and cleaned to prevent infection; after the first 48 to 72 hours pin site care may be performed once daily or weekly for mechanically stable pins (Holmes, Brown, and Pin Site Care Expert Panel, 2005). Use of a 2 mg/ml chlorhexidine solution has been proposed as best-practice care for skeletal pin sites by the National Association of Orthopaedic Nurses (Holmes, Brown, and Pin Site Care Expert Panel, 2005). Before the child’s discharge, teach parents and family pin site care, including how to observe for infection or pin instability, using a return demonstration method (Holmes, Brown, and Pin Site Care Expert Panel, 2005). A pressure reduction device, such as a foam overlay or an alternating-pressure mattress placed beneath the hips and back, reduces the chance of skin breakdown in these vulnerable areas.

When the child is first placed in traction, discomfort commonly increases because the traction pull fatigues the muscle. Muscle relaxants may be administered for muscle spasms. Orthopedic conditions are associated with a higher-than-average number of painful events and a higher percentage of bodily symptoms than other common conditions. Analgesics, including opioids, and muscle relaxants help during this phase of care and should be administered liberally.

Helping children cope with the confinement and new experience requires more than medications. Give an explanation about what is happening and why the child must remain in the device according to each child’s level of development. Reassure children that someone will always be available to aid them in adjusting to the traction and coping with the problems of immobilization.

Some devices assist children in performing activities independently. An overhead trapeze, which children can use to help lift themselves, facilitates hygiene and repositioning and provides exercise for uninvolved muscles. Encourage the child to move in bed as much as possible while maintaining the primary function of the device. Encourage active range of motion on unaffected joints and extremities and frequent repositioning.

Later, when traction is released, muscle spasms can be quite severe. Pain assessment and pain management should be a part of care at this phase. (See Chapter 7.)

Nursing Care Management

Successful use of external fixation depends on the child’s and family’s cooperation; therefore, before surgery, they must be fully informed about the appearance of the device, the way it accomplishes bone growth, required alterations in activities, and home and follow-up care. Children are involved in learning to adjust the device to accomplish distraction. Children who participate actively in their own care report less discomfort. With lower extremity fixation such as an Ilizarov fixator, partial weight bearing is allowed, and the child needs to learn to walk with crutches. Alterations in activity include modifications at school and in physical education. Full weight bearing is not allowed until the distraction is completed and bone consolidation has occurred. Instruct parents in pin care, including observation for infection and loosening of pins. Follow-up care is essential to maintain appropriate distraction until the desired leg length is achieved. The child may need to use crutches or have a cast for 4 to 6 weeks after removal of the device.

Circulatory Impairment

If the trauma or immobilizing device restricts blood flow in veins or arteries of the affected extremity, bone healing will be seriously impaired. Careful assessment of the pulses, capillary refill, skin color, and temperature is an important nursing responsibility. After injury, swelling of tissues occurs more rapidly in the child than in the adult. In the upper extremity, brachial, radial, ulnar, and digital pulses are felt. In the leg, femoral, popliteal, posterior tibial, and dorsalis pedis pulses are checked.

Skill—Monitoring Neurovascular Status

Closely associated with an inadequate blood supply is a low hematocrit value, which can result from the initial blood loss or surgically induced anemia. Although the blood flow may be adequate, a lowered amount of hemoglobin will not provide a sufficient supply of oxygen for tissue repair.

Nerve Compression Syndromes

Nerve damage can occur at the time of injury, develop in the process of realignment, or arise as a complication of use of an immobilizing apparatus. The syndromes are classified according to the anatomic area affected and can involve the median nerve (carpal tunnel syndrome), ulnar nerve (at wrist or elbow), radial nerve, posterior tibial nerve (tarsal tunnel syndrome), common peroneal nerve, or sciatic nerve. Peroneal nerve damage can result in footdrop, and radial nerve impairment produces wristdrop. Both these disabilities can significantly interfere with activities of daily living.

Sensory testing with touch and pinprick and evaluation of motor strength by asking the child to move the unaffected joint distal to the injury are common means of determining neurologic involvement. Subjective symptoms are pain or discomfort, muscular weakness, a burning sensation, limitation of motion, and altered sensation. Because the fear of pain limits the child’s cooperation, play can be the nurse’s most valuable tool.

Treatment is alleviation of pressure on the nerve. The practitioner determines whether correcting the alignment will alleviate pressure on the nerve or whether surgical intervention is necessary. At times sensory or motor changes indicate ischemia, and the treatment is correction of the vascular disturbance.

Compartment Syndromes

A compartment is a group of muscles surrounded by tough, inelastic fascial tissue. Compartment syndrome occurs when pressure within this closed space increases and compromises circulation to the muscles and nerves within the space. Muscles and nerves of both upper and lower extremities are enclosed within such compartments. The most frequent causes of compartment syndrome are tight dressings or casts, skin traction, hemorrhage, trauma, burns, and surgery. Other causes include an increase in compartment contents (hemorrhage, venous obstruction, infiltrated IV infusion, exudate) and externally applied pressure, such as lying on the affected limb. Intraarterial medication administration through an arterial line and prolonged operation time may also contribute to compartment syndrome (Green and Swiontkowski, 2008).

Signs and symptoms of compartment syndrome reflect a deficit in or deterioration of neuromuscular status in the anatomic area surrounding the involved structures. These include motor weakness and pain that is out of proportion to the injury and requires opioids for control (Lucas and Davis, 2005). Clinical manifestations may be difficult to recognize in small children or in those who have a head injury. A palpable peripheral pulse and brisk capillary refill may be present despite increasing compartmental pressure. Sensory deficit in the affected limb is reported to be the most reliable physical finding in compartment syndrome (Green and Swiontkowski, 2008). Clinical manifestations of compartment syndrome may occur as early as 30 minutes after the ischemia develops. Tenseness may be noted on palpation of the area. Because early detection is important in preventing permanent damage to tissues, in certain high-risk situations specialists may recommend continuous monitoring of compartment pressures by way of a small, slit-tip catheter; Wick catheter; or needle inserted into the compartment. Treatment of compartment syndrome is immediate relief of pressure, which sometimes requires fasciotomy.

Volkmann contracture (ischemic muscular atrophy) is a serious, persistent flexion contraction of the forearm and hand caused by massive infarction of muscle. Pressure caused by a cast or tight bandage or by swelling from the injury in the area of the elbow begins with arterial occlusion and then progresses to muscle anoxia and reflex vasospasms. Finally, the lack of blood supply leads to muscle necrosis and replacement with fibrous tissue, which produces paralysis and a clawlike hand contracture. Any fracture that requires excessive traction can be complicated by Volkmann contracture; however, it occurs most often in the elbow.

The neuromuscular symptoms are severe pain (although pain is not always a manifestation), pallor or cyanosis, edema, absence of pulses in the extremity, and loss of sensitivity. Unrelieved, the occlusive hypoxic process can cause some contracture if ischemia lasts as little as 6 hours. A great deal of muscle damage occurs after 12 to 24 hours; 48 hours of ischemia produces severe deformity, with muscle fibrosis and contractures in 5 to 10 days. If not treated, the contracture leads to severe deformity and paralysis.

The immediate treatment is to remove any mechanically obstructive materials, such as tight bandages, and extend the joint to free blood vessels. If the symptoms do not improve within a few hours, arteriography is done in anticipation of a possible need for surgical intervention (fasciotomy) to decrease arterial spasms and to improve the blood supply by separation of the fascial sheaths of the involved muscles. Elevation of the affected extremity is not recommended and may further decrease blood flow to the area (Green and Swiontkowski, 2008).