Epiphyseal Damage

Growth of bone originates from the epiphyseal plate, and damage to this structure can result in unequal lengths of the extremities. Surgical intervention involving the epiphysis on the affected extremity or the epiphyseal line on the opposite extremity is the usual treatment.

Nonunion

Bone healing and callus formation can span and repair only a limited space between bone fragments. When bone fragments cannot be maintained in correct alignment for repair due to inadequate reduction, poor immobilization, or a damaged or softened cast, bone healing is impaired. The factors most likely to interfere with bone healing and cause delayed union or nonunion, based on the physiologic needs for bone healing, are listed in Box 39-9.

The hematoma, which becomes the matrix for bone deposition in the break, must be free of infection or bits of adipose or connective tissue. The constant supply of nutrients and bone-forming cells brought to the area by way of the bloodstream provides the vital ingredients for repair.

Sometimes artificial means are employed to facilitate bone healing. Bone grafting becomes necessary when bone nonunion occurs. The donor site is usually the tibia or the iliac crest. Bleeding of bone ends may need to be artificially stimulated, and at times holes are drilled near the bone ends in an attempt to increase circulation. Postsurgical immobilization of the recipient area is crucial to the success of the graft. The Ilizarov external fixator and protocol for care are frequently used to assist bone healing in patients with nonunion (see p. 1650).

Malunion

Malunion is fracture union with increased angulation or deformity at the fracture site. It can be detected at any stage in the healing process or after complete healing. Unsatisfactory reduction is the usual reason for malunion. A cast or splint that allows fracture movement will also likely result in malunion. Periodic radiographic examinations help detect this complication and prevent it from becoming a major problem over a long period.

Excessive deformity can be corrected during the healing process through realignment and reimmobilization. However, attempts at correction may cause delayed union or nonunion; therefore the degree of deformity is carefully evaluated in light of these complications. The probability that sufficient spontaneous alignment will occur with growth and continuation of the healing process also is considered. Correction of the malunion when healing is near completion requires surgical intervention.

Infection

Osteomyelitis, infection of the bone, is often secondary to a bloodstream infection but is a potential problem when the fracture is an open one, when pressure ulcers develop, or when bone surgery has been performed. Any bacterial organism can cause this infectious process; however, Staphylococcus aureus is the pathogen most frequently identified (see p. 1673 for a discussion of osteomyelitis).

Kidney Stones

Although uncommon in children, development of renal calculi is a potential risk whenever the child has a limb that is non–weight bearing for a long time, especially if the circumstances also produce urinary stasis. Measures to prevent the formation of renal calculi include maintaining optimal hydration, mobilizing the child as much as possible, and checking closely the amount and characteristics of urinary output. Any urinary tract infection should be treated promptly with appropriate antimicrobials and urine acidification, since the nucleus of a calculus is often composed of bacterial debris or calcium and the buildup of stone is precipitated by alkaline urine. An associated problem, hypercalcemia, was reviewed in the section on problems of the immobilized child.

Pulmonary Emboli

Blood, air, or fat emboli can be a hazard to the child with a fracture. As postinjury bleeding and clotting occur, a small piece of the clot can travel to vital organs, such as the lung, heart, or brain, and produce a life-threatening vascular obstruction and ischemia. Generally the pulmonary system is the most frequent site of emboli deposition, but it may not occur until 6 to 8 weeks after the injury.

Fat emboli are the greatest threat in an individual with multiple fractures, particularly fractures of the long bones such as the femur. Fat droplets from the marrow are transferred to the general circulation by the venous-arterial route, where they can be transported to the lung or brain. This type of embolism occurs within the first 24 hours, generally in the second 12 hours after the injury occurs. Adolescents are those usually affected in the pediatric age-groups.

Intermittent compression devices are used to prevent venous pooling in the lower extremities when prolonged immobilization is required. These devices are inflatable sleeves that allow cyclic emptying and filling of leg veins; the devices are used in children with spinal cord injury once mobilization is initiated to decrease the effects of orthostatic intolerance. Anticoagulant drug therapy, passive and active range of motion, and early mobilization are also used to decrease venous stasis and prevent thrombus development.

Nursing Care Management

Lower extremity stump shaping is done postoperatively with special elastic bandaging using a figure-8 compression bandage, which applies pressure in a conical fashion. This technique decreases stump edema, controls hemorrhage, and aids in developing desired contours so that the child will bear weight on the posterior aspect of the skin flap rather than on the end of the stump. When appropriate, a stump shrinker, in addition to an elastic wrap, may be used. Some surgeons apply a prosthetic device in surgery after the amputation to reduce edema and promote early ambulation.

The stump may be elevated for the first 24 hours, but after this time the extremity should not be left in this position because contractures in the proximal joint will develop and seriously hamper ambulation. Monitoring proper body alignment further decreases the risk of flexion contractures. Postoperatively, children who undergo amputation of a lower extremity should be turned not only from side to side but also from front to back. Postoperative complications for which the nurse should be vigilant include hemorrhage and infection of the operative site. As the child progresses, encourage him or her to lie prone at least three times a day, increasing the time prone to tolerance of an hour at a time.

For older children and adolescents, arm exercises, bed pushups, and exercises with parallel bars (which are used in prosthesis training programs) help to build up the arm muscles necessary for walking with crutches. An overhead trapeze bar enhances mobilization and upper body strength building in the early postoperative period when a lower limb has been amputated. Full range-of-motion exercises of joints above the amputation must be performed several times daily, using active and isotonic exercises. Young children are spontaneously active and require little encouragement.

Depending on the child’s age, the child or parents need to learn stump care, including careful washing with soap and water every day and checking for skin irritation, breakdown, or infection. A tube of stockinette or talcum powder is used to make the prosthesis slide on more easily. A careful skin check must be performed every time the prosthesis is removed, and prosthesis tolerance time must be adjusted to prevent skin breakdown.

Evaluate limb pain, especially pain that increases with ambulation, to check for a possible neuroma at the free nerve endings in the stump or a poorly fitting prosthesis. Chronic pain may also be related to weakness or joint instability, injury to the nerve, or fibrosis of soft tissues. Pain in the contralateral extremity may result from asymmetric weight bearing.

For children who have had an amputation, phantom limb pain is an expected experience because the nerve-brain connections are still present. Phantom pain is real pain and should be treated appropriately with analgesics and other pain-relieving measures. Gradually these sensations fade, although in many amputees they persist for years. Preoperative discussion of this phenomenon helps a child understand these feelings and not hide the experience from others.

Preparation for Sports

Among adolescents of the same age, the degree of physical maturation varies greatly, and many of the physical characteristics important in sports are related to hormone production. Consequently, physical strength, coordination, endurance, and size vary considerably among children and adolescents who wish to compete against each other. Sports competition between young people who differ markedly in strength and agility is unfair and hazardous. Matching of candidates for sports should be based on physical maturity, height, weight, and physical fitness and skills, particularly in sports involving rigorous body contact. Age is a less important consideration.

The American Academy of Pediatrics (Rice and Council on Sports Medicine and Fitness, 2008) has developed a classification that categorizes sports according to probability of collision and strenuousness (Box 39-10). Collision sports such as tackle football, basketball, hockey, and soccer have the highest injury rates, followed by other contact sports (Figs. 39-29 and 39-30). In addition, the American Academy of Pediatrics (Rice and Council on Sports Medicine and Fitness, 2008) has developed and published guidelines that provide criteria for determining inclusion or exclusion of the young athlete based on common medical and surgical conditions and relative risks in various sports categories. This serves as a useful guideline for the health professional in counseling youth regarding sports activities.

The American Academy of Pediatrics (2000a; Brenner and Council on Sports Medicine and Fitness, 2007) encourages sports participation by young persons and encourages adults close to sports activities to be aware of the early warning signs of fatigue, dehydration, and injury. Athletes should seek assistance when an injury is suspected and not “work through” injuries caused by overuse (shin splints, stress fractures, tendinitis, and apophysitis).

The role of health care professionals, specifically nurses, in relation to sports injuries focuses on prevention, treatment, and rehabilitation. Of these areas, prevention is perhaps the most important. It is difficult to “sell” prevention, however, especially to children. Anticipatory guidance is an important aspect of preventive counseling for sports injuries, since many injuries occur when children are tired and are not concentrating on their activities; injuries are also more common when participants are distracted by events off the field of play, such as not really wanting to play or thinking about personal problems.

Everyone wants to play the game, but not necessarily to practice. Often, if an 8- to 15-minute warm-up is suggested, adolescents and children warm up for 30 seconds and say they are ready to go. Youth who are actively involved in athletic programs need to undergo medical evaluation as a prerequisite to participation and to receive education in sports skills using correct training and conditioning methods. Tactics that are dangerous beyond the ordinary risk associated with the specific sport should be omitted. In addition, children should use appropriate protective equipment, properly maintained and suited to the individual. The sports environment should make maximum provision for safety and availability of first-aid and medical services.

The same protective principles apply to enthusiasts in noncompetitive sports. They need the same education in basic safety precautions, encouragement to acquire proper instruction in the skills required for performing the activity (such as water safety, skiing techniques), and proper maintenance of equipment.

Types of Injury

The injuries sustained in sports or recreational activities can involve any part of the body and range from relatively minor cuts, bruises, and abrasions to severe closed head injuries such as concussion or totally incapacitating central nervous system injuries or death. Some of these injuries are discussed in chapters devoted to the major topic (e.g., spinal cord injuries [Chapter 40] and head injuries [Chapter 37]). Fractures are discussed earlier in this chapter.

Some sports are particularly dangerous for children and adolescents. Snowmobiling, snowboarding, use of all-terrain motor vehicles, in-line skating, skateboarding, motorcycle riding, full contact hockey, bicycle riding, wave running, and trampoline use are examples of sports and recreational activities that can lead to significant injuries in connection with inappropriate use, failure to wear protective equipment, or participation by children who are under age. According to the American Academy of Orthopaedic Surgeons (2007), sports injuries account for approximately 20% of visits to the emergency department for injury. Basketball and pedal cycling account for the majority of injuries, followed by football, baseball or softball, and skate boarding or in-line skating. One study reported a high incidence of injuries in high school football athletic competition; boys’ soccer had a high rate of head, neck, and face injuries; and high rates of concussion injuries occurred in boys’ soccer (Rechel, Yard, and Comstock, 2008). Ankle injuries are the most common competitive sports-related injuries, with significant numbers occurring in boys’ and girls’ basketball (Nelson, Collins, Yard, et al, 2007).

A variety of injuries can result when an external force is applied that causes severe stress on tissue, muscle, and skeletal structures (Fig. 39-31). The body structures attempt to absorb the force, but when they are unable to do so, injuries occur. Two general types of injury are recognized. The first is acute trauma, which is defined as a sudden, acute injury from a major force. Among such injuries are fractures of long bones and the axial skeleton; sprains of joint ligaments; strains of muscle tendon units; and contusions, including those of muscle tendon units and overlying soft tissue. The second type is repetitive overuse injuries, or microtrauma, which result from repetitive injury to tissue over a long period. Overuse injuries include stress fractures, bursitis, tendonitis, apophysitis of tendon insertions, and at times injuries of the joint surface.

More than 95% of sports injuries involve the soft tissues, not the bony skeleton. About two thirds of these consist of strains and sprains, and most injuries involve the extremities. Acute overload injuries are those that occur suddenly during an activity and produce immediate symptoms. They can be caused by a blow or overstretching, twisting, or any other forces that cause a sudden stress to tissues.

Contusions

Contusions are probably the most common sports injuries and are often considered to be “part of the game.” A contusion is damage to the soft tissue, subcutaneous structures, and muscle. The tearing of these tissues and small blood vessels and the ensuing inflammatory response lead to hemorrhage, edema, and associated pain when the child or adolescent attempts to move the injured part. The escape of blood into the tissues is observed as ecchymosis, a black-and-blue discoloration.

The most serious contusions are those involving the quadriceps; they are common in strenuous, collision-type sports and usually result from being kicked or kneed in the thigh. Large contusions cause gross swelling, pain, and disability and usually receive immediate attention from health care personnel. The less spectacular smaller injuries may go unnoticed, so that continued participation is allowed. They can become disabling after rest, however, because of pain and muscle spasm. The young athlete is frequently instructed to “work it out” or disregard the pain. 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.

Immediate treatment of a contusion consists of application of cold for no more than 20 to 30 minutes, as in the treatment of sprains described below. Return to participation is allowed when the strength and range of motion of the affected extremity are equal to those of the opposite extremity.

Although they are not always directly related to sports, crush injuries 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. A subungual hematoma can be released by a special cautery device that “burns” a hole at the proximal end of the nail.

Dislocations

Long bones are held in approximation to one another at the joint by ligaments. Joints can be tight or loose, and loose joints are more likely to be dislocated. For certain sports (e.g., gymnastics and acrobatic dancing) the joints need to be limber. A tight joint is needed for sports such as football. One of the most vulnerable joints is the shoulder, which is structurally insecure, having only a rotator cuff to maintain the shoulder in place. The joint is shallow with relatively little muscle protection; therefore the capsule becomes stretched and the joint dislocates easily. There is a high incidence of shoulder injuries in male gymnasts and an even greater incidence of shoulder injuries in players of contact sports, such as football. Temporary restriction of the joint with a sling or bandage that secures the arm to the chest can provide sufficient comfort and immobilization until the individual receives medical attention.

Dislocations are less common in children than in older persons, but some types are specific to the younger age-groups. Before final closure of the epiphyses, injuries to the joints are more likely to cause epiphyseal separation than dislocation. For example, shoulder dislocation occurs most often in older adolescents, and dislocation unaccompanied by fracture is rare. Dislocations of the phalanges are the most common type seen in children, followed by elbow dislocations. Injury to the hip causes dislocation more frequently than femoral neck fracture (often experienced by persons in the older age-groups).

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. Children with naturally lax joints, such as those with Down syndrome, are more prone to recurrent dislocation of the hip.

A dislocation occurs when the force of stress on the ligament is great enough to disrupt the normal position of the opposing bone ends or the bone end and 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. Temporary restriction of the joint with a sling or bandage that secures the arm to the chest in a shoulder dislocation provides sufficient comfort and immobilization until the child or adolescent can receive medical help.

In hip dislocation the best chance for prevention of damage to the head of the femur is to relocate the hip within 60 minutes after the injury occurs. As the length of time between injury and hip relocation increases, the risk of irreparable damage increases. Simple dislocations should be reduced as soon as possible with the child under mild sedation and often local anesthesia. Sedative agents such as midazolam or propofol (Diprivan), and analgesics such as ketamine or fentanyl, can be used to produce partial or complete analgesia during the reduction. Increased swelling, which makes reduction difficult and increases the risk of neurovascular problems, can complicate an unreduced dislocation. Treatment depends on the severity of the injury.

Dislocation of the patella occurs spontaneously in some children; in others it is a result of injury. It is common among adolescent girls. The patella is always dislocated laterally. Most dislocations are reduced either spontaneously or by a companion before the child is seen by a practitioner. Therapy is immobilization for 3 to 4 weeks. Surgery may be needed to treat recurrent dislocations.

The most common dislocation injury is subluxation or partial dislocation of the radial head in the elbow, also called pulled elbow or nursemaid’s elbow. In the vast majority of cases the injury occurs in a child between ages 1 and 3 years who receives a sudden longitudinal pull or traction at the wrist while the arm is fully extended and the forearm pronated. It usually occurs when an adult is holding the child by the hand or wrist and gives a sudden jerk to prevent a fall or attempts to lift the child by pulling the wrist, or the child suddenly pulls away by dropping to the floor (or ground). The child has an anxious expression, whines, complains of pain in the elbow and wrist, refuses to move the arm, and holds it with the opposite hand and in a slightly flexed and pronated position against his or her body.

The practitioner manipulates the arm by applying firm finger pressure to the head of the radius and then supinates and flexes the forearm to return the bone structures to normal alignment. A click or clunk may be heard or felt, and functional use of the arm returns within minutes. Immobilization of the arm is not necessary (Cornwall, 2007). The longer the subluxation is present, however, the longer it takes for the child to recover mobility after treatment. A radiograph may be needed if attempts to reduce the dislocation are not successful.

Sprains and Strains

A sprain occurs when trauma to a joint is so severe that a ligament is either stretched or partially or completely torn by the force created as a joint is twisted or wrenched. This is often accompanied by damage to associated blood vessels, muscles, tendons, and nerves. As a guideline for management and prognosis, sprains are classified according to the degree of injury (Box 39-11). Because of the number of ligaments required to maintain knee stability, the knee is one of the joints most commonly injured in sports. It is also the largest joint and consequently is more prone to injury. Ankle sprains in children account for approximately 75% of all ankle injuries; these injuries are common in individuals who participate in sports, especially in the pediatric age-group (Chorley, 2005).

The presence of joint laxity is the most valid indicator of the severity of a sprain. With a severe injury the athlete complains that the joint “feels 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.

A strain is a microscopic tear to the musculotendinous unit and has features in common with sprains. The area is painful to the touch and is swollen. The severity is evaluated as grade I, II, or III, as for sprains, except that the degree of laxity does not apply. Even with severe grade III injuries, complaints of laxity are rare. Most strains happen 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.

Overuse Injury

To excel in sports, the young athlete is forced to train longer, harder, and earlier in life than previously. The rewards are an increased level of fitness, better performance, faster times, and the satisfaction of attaining a personal goal. With the increase in the number of children participating in a wide variety of sports year-round, more overuse injuries are being seen in the pediatric age-group (Brenner and Council on Sports Medicine and Fitness, 2007).

The risk of overuse injury is always present and can be related to several factors: training errors, muscle-tendon imbalance, anatomic malalignment (e.g., femoral anteversion, excessive lumbar lordosis, tibial torsion), incorrect footwear or playing surface, an associated disease state, and growth (growth cartilage is less resistant to microtrauma). Athletes who run extensively frequently experience shin splints. The ligaments tear away from the tibial shaft, and this creates the pain. Ice, rest, and NSAIDs, such as ibuprofen or naproxen, are the usual treatment. Shin splints are rarely serious.

Chronic pain in athletes is often associated with overuse injury, which can occur at any level of athletic participation. The common feature in overuse injuries is the repetitive microtrauma that occurs to a particular anatomic structure (Brenner and Council on Sports Medicine and Fitness, 2007). Performing the same movements time and time again can cause several types of injury: (1) frictional, or rubbing of one structure against another; (2) tractional, or repeated pull on a ligament or tendon; and (3) cyclic, or repetitive loading of impact forces (stress fractures). The end result is inflammation of the involved structure with complaints of pain, tenderness, swelling, and disability.

Bursae, tendons, muscles, ligaments, joints, and bones are all subject to overuse. Table 39-4 outlines some of the common overuse syndromes. Plantar fasciitis is common in athletes, and Osgood-Schlatter disease often occurs in children who do a lot of jumping. The occurrence of overuse-type injuries, such as sore shoulders and strained elbows, may indicate that too much is being asked of the child in too short a period.

Exercise-Induced Heat Stress

Infants, children, and adolescents are at greater risk for heat-related illness than adults (American Academy of Pediatrics, 2000a). Several characteristics of infants and children render them more vulnerable to heat stress. The greater ratio of surface area to body mass in infants and young children leads to increased transfer of heat between the body and the environment. Children produce more metabolic heat for body mass during exercise and have a reduced capacity to convey heat from the body core to the skin. Also, children do not have the sweating capacity of adults and take longer to become acclimated to hot conditions. Young children may not feel the need to drink a sufficient amount of fluid during extended exercise.

Heat cramps are caused by sodium depletion, which in turn potentiates the effects of calcium on skeletal muscle. They most often occur as a result of strenuous exercise in a hot environment. Cramps most frequently involve the leg muscles. Vital signs are usually normal, but the core temperature may be elevated. The child sweats profusely, but mentation is normal. Treatment is rest and replacement of fluid and electrolytes. Ingestion of dilute sports drinks or electrolyte replacement liquids is helpful. Electrolyte replacement solutions are now available as popsicles and gelatin (like Jell-O), which are well tolerated with less vomiting. Replacement electrolyte strips that easily dissolve in the mouth are also available; small sips of a clear fluid such as water can be taken as tolerated.

Heat exhaustion, or heat stress, is a common condition that usually occurs during vigorous exercise in a hot environment. It results from excessive loss of fluids, especially in poorly acclimated and dehydrated children. The onset may be gradual, with initial complaints that include thirst, headache, fatigue, dizziness, anxiety, or nausea and vomiting. The child usually has a clear sensorium but may be somewhat disoriented. The temperature can be normal or mildly elevated; sweating is profuse. Tachycardia, hypotension (usually postural), and syncope may be observed secondary to intravascular volume depletion. Treatment is to move the child to a cool environment, provide rest, and replace fluid volume. The child with a clear sensorium can receive oral replacement fluids, but often IV fluids are required due to vomiting. External cooling methods are not necessary.

Heatstroke represents a failure of normal thermoregulatory mechanisms. Heatstroke usually occurs during or immediately after physical activity, especially in the unacclimated adolescent who is exercising vigorously. The onset is rapid with initial symptoms of headache, weakness, and disorientation. Central nervous system manifestations may be agitation, confusion, and lethargy. Loss of consciousness may occur without warning and may be accompanied by nuchal rigidity, posturing, and convulsions. Sweating may not be present. The temperature is typically higher than 40° C (104° F), and there is severe volume depletion. Immediate care is relocation to a cool environment, removal of clothing, application of cool water (wet towels or immersion), and use of fans. The child is transported to the hospital by EMS for intensive care.

Acute care includes rapid cooling until core temperature reaches 38.9° C (102° F) to prevent overcooling. Antipyretics are not used because they are metabolized by the liver, which is already not functioning properly. Renal and liver failure are common sequelae to heatstroke. Treatment includes careful monitoring of temperature and other vital signs, supportive care such as supplemental oxygen administration, and cautious fluid and electrolyte replacement. Prevention remains the best treatment for hyperthermia. If the temperature is elevated, time in the sun should be decreased. Activity should be stopped if the humidity is elevated as well. The athlete should drink plenty of fluids, preferably with low sugar content.

Nonexertional, or classic, heatstroke has a slow onset with insidious development of anorexia, nausea, vomiting, headache, mental manifestations, and loss of intravascular volume. Classic heatstroke occurs primarily in children with abnormal thermoregulation (e.g., children with cystic fibrosis) and infants subjected to prolonged neglect in a hot environment.

Health Concerns Associated with Sports

Nurse’s Role in Children’s Sports

Nurses may become involved in children’s sports activities in preparation and evaluation of children for activities, provision of anticipatory guidance and counseling about athletic competition and nutrition, prevention of injuries, treatment of injuries, and rehabilitation after injuries. Selecting an appropriate sport for both recreation and competition is a joint effort of the child or adolescent, parents, and health professionals. Children are introduced to sports as part of family activities, neighborhood games, and school physical education programs, and both parents and children are influenced by media exposure to a variety of sports. Children are highly influenced by the popularity of and exposure afforded athletics in the school setting, especially in high school.

The best approach to counseling children and parents regarding sports participation is to encourage activities that are most likely to provide pleasure and physical benefits throughout childhood and into adulthood. Exposure to a variety of sports activities is probably better for young children than limitation to only one sport. Caution parents against overprogramming children to allow ample time for other activities and associations. Burnout among children and adolescents who continuously participate in sports is increasing in the United States. Children and adolescent are encouraged to take periodic breaks from such activities to allow physical healing, refresh the mind, and work on strength and conditioning (Brenner and Council on Sports Medicine and Fitness, 2007).

Nurses are sometimes members of a sports medicine team. Although certified sports trainers and other specialists in sports medicine usually manage training and rehabilitation, the nurse should have input regarding injury prevention. Nurses should be able to provide emergency treatment for most types of injuries and know when to refer the injured child for evaluation and care. Sports injuries can occur in free play as well as in organized athletic programs, and a school nurse is often the first person who attends an injured child.

When children sustain athletic injuries, nurses are often responsible for instructing the children and their parents regarding care and rehabilitation. Instructions regarding, for example, the need and schedule for follow-up appointments, application of ice, and any restrictions in activity should be delivered clearly and preferably accompanied by written directions. Emphasize the importance of taking medications as prescribed, since they may be needed for an extended period and compliance may be difficult. For children continuing with activities, nonnarcotic pain medication administration an hour before practice or competition is advantageous.

Prevention of sports injuries is probably the most important aspect of any athletic program. Nurses collaborate with coaches and athletic trainers to ensure that safety measures are carried out. Stretching exercises, warming-up and cooling-down activities, and an appropriate training program are only some of the requisites for safe participation. Protective measures, such as padding, taping, wrapping, or use of other devices, are employed for areas at risk. Nurses are also on the alert for environmental safety risks.

Participation of youth in sports programs has grown significantly in the past several decades. This trend toward greater participation by both genders has been encouraged because of its demonstrated effect in reducing obesity, lowering blood pressure, and lowering cholesterol and lipid levels.

For some athletes, their whole life revolves around sports participation. When a serious injury occurs, the athlete’s self-esteem and self-image may suffer a devastating blow. Nursing assessment may reveal an athlete who appears to have difficulty dealing with this event and actually rejects any positive reinforcement. The nurse may help the child and family in establishing a support system. The athlete may need to learn new coping skills and explore other avenues to foster feelings of increased self-worth and a sense of accomplishment.

Lack of participation, exercise aversion, and declining interest in sports are sometimes the aftermath of participation during the school years and adolescence. Motivation can be altered or permanently destroyed by failure to appreciate the child’s or adolescent’s needs related to sports activities. Ridicule or derogation during acquisition of motor skills can shatter a child’s or adolescent’s self-esteem, producing anxiety and self-doubt that may result in a lifelong aversion to sports. Every child should have the opportunity to develop a strong sense of personal worth through the process of motor learning and acquisition of skills. All participants should have the opportunity to participate and be rewarded with positive encouragement for their contribution, no matter how small; all participants should be rewarded for what they do right.

Torticollis

Torticollis (wry neck), which can be either congenital or acquired, is a condition of limited neck motion in which the neck is flexed and the head is drawn or tilted laterally to the affected side while the chin is pointed toward the opposite side. It is a manifestation rather than a disease entity and may be associated with a number of conditions, including congenital abnormality of the cervical spine or a traumatic lesion of the sternocleidomastoid muscle. Congenital muscular torticollis may occur as a result of abnormal positioning in utero, which causes contracture of the sternocleidomastoid muscle (Spiegel, Hosalkar, Dormans, et al, 2007). Infants with positional plagiocephaly may have muscular torticollis as well, which can be successfully treated with neck stretching exercises (Graham, Gomez, Halberg, et al, 2005; Persing, James, Swanson, et al, 2003).

In early infancy a firm, nontender mass may be felt in the midportion of the muscle. The mass regresses and is replaced by fibrous tissue. If the condition remains untreated, permanent limitation of neck movement results, and the head and face become asymmetric, probably because of impaired blood supply to the depressed side of the head. Plagiocephaly and facial asymmetry often occur as a result of the contractured sternocleidomastoid muscle. Patients may have other associated musculoskeletal conditions, including calcaneovalgus foot deformity and metatarsus adductus (Spiegel, Hosalkar, Dormans, et al, 2007).

Treatment of simple torticollis consists of gentle stretching exercises. The face is turned toward the affected muscle while the head is tilted in the opposite direction with the neck extended. A physical therapist typically establishes the treatment regimen to be followed by the nurse and family. The exercises are best performed by two persons—one to control the torso and one to manipulate the head. If stretching exercises are unsuccessful, surgical release of the sternocleidomastoid muscle may be needed. Increasingly, surgical correction by age 12 to 18 months is recommended to prevent muscle contractures and further progression of plagiocephaly. Other forms of torticollis occur in infancy or may develop at a later age but are not discussed in this text.

Legg-Calvé-Perthes Disease

Legg-Calvé-Perthes disease, sometimes called coxa plana or osteochondritis deformans juvenilis, is a self-limiting disorder in which there is aseptic necrosis of the femoral head. The disease affects children ages 2 to 12 years, but most cases occur as an isolated event in boys between 4 and 8 years of age. In approximately 10% of cases the involvement is bilateral; most of the affected children have a skeletal age significantly below their chronologic age (Hosalkar, Horn, Friedman, et al, 2007). The male/female ratio is 4 : 1 or 5 : 1. Caucasian children are affected 10 times more frequently than African-American children.

Critical Thinking Case Study—Legg-Calvé-Perthes Disease

Slipped Capital Femoral Epiphysis

Slipped capital femoral epiphysis (SCFE), or coxa vara, refers to the spontaneous displacement of the proximal femoral epiphysis in a posterior and inferior direction. It develops most frequently shortly before or during accelerated growth and the onset of puberty (children between the ages of 10 and 16 years; median age, 13 for boys, 12 for girls) and is most frequently observed in boys and obese children. Bilateral involvement occurs in up to 60% of cases. Osteonecrosis is a common complication of SCFE and is reported to occur in 17% to 47% of all patients (Hosalkar, Horn, Friedman, et al, 2007).

Kyphosis and Lordosis

The spine, which consists of numerous segments, can acquire deformation curves of three types: kyphosis, lordosis, and scoliosis (Fig. 39-33).

Animation—Spine Structure

Kyphosis is an abnormally increased convex angulation in the curvature of the thoracic spine (see Fig. 39-33, B). It can occur secondary to disease processes such as tuberculosis, chronic arthritis, osteodystrophy, or compression fractures of the thoracic spine. The most common form of kyphosis is postural. Children, especially during the time when skeletal growth outpaces growth of muscle, are prone to exaggeration of a tendency toward kyphosis. This is particularly common in self-conscious adolescent girls who assume a round-shouldered slouching posture in an attempt to hide their developing breasts and increasing height. Scheuermann kyphosis is a thoracic curve of greater than 45 degrees with wedging of more than 5 degrees of at least three adjacent vertebral bodies and vertebral irregularity.

Postural kyphosis is almost always accompanied by a compensatory postural lordosis, an abnormally exaggerated concave lumbar curvature. Treatment of kyphosis consists of exercises to strengthen shoulder and abdominal muscles and bracing for more marked deformity. With adolescents who are significantly self-conscious about their appearance, the best approach is to emphasize the cosmetic value of corrective therapy and to place the responsibility on the adolescent for carrying out an exercise program at home, with regular visits to and assessments by a physical therapist. Treatment with a brace may be indicated until skeletal maturity; surgical spinal fusion may be considered for severe, painful, or progressive deforming thoracic curves such as Scheuermann kyphosis.

Lordosis is an accentuation of the lumbar curvature beyond physiologic limits (see Fig. 39-33, C). It may be a secondary complication of a disease process, the result of trauma, or idiopathic. Lordosis is a normal observation in toddlers, and in older children it is often seen in association with flexion contractures of the hip, obesity, congenital dislocated hip, and SCFE. During the pubertal growth spurt, lordosis of varying degrees is observed in teenagers, especially girls. In obese children the weight of the abdominal fat alters the center of gravity, which causes a compensatory lordosis. Unlike kyphosis, severe lordosis is usually accompanied by pain.

Treatment involves management of the predisposing cause when possible, such as weight loss and correction of any existing orthopedic or neuromuscular conditions. Postural exercises or support garments are helpful in relieving symptoms in some cases; however, these do not usually effect a permanent cure.

Spondylolisthesis is the forward slipping of one vertebral body on another (“slipped disk”). It usually involves L5 and S1. Retrospondylolisthesis, or retrolisthesis, is the posterior slipping or displacement of one vertebral body on another. Either condition can have multiple causes, including congenital deficiency or fracture of part of the vertebra. The condition may be asymptomatic, or it may cause lower back pain or neurologic compromise. Spondylolisthesis can usually be treated nonsurgically, although spinal fusion may be indicated in cases of severe, progressive slip.

Idiopathic Scoliosis

Scoliosis is a complex spinal deformity in three planes, usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis (see Fig. 39-33, E-G, and Fig. 39-34). It is the most common spinal deformity and can be further classified according to age of onset: congenital, occurs in fetal development; infantile, at birth or up to 3 years of age; childhood (juvenile), occurs in children ages 4 to 10 years of age; or adolescent, during the growth spurt of early adolescence (the most common type). Scoliosis can be caused by a number of conditions and may occur alone or in association with other diseases, particularly neuromuscular conditions (neuromuscular scoliosis). In most cases, however, there is no apparent cause, hence the name idiopathic scoliosis. The following discussion involves the adolescent type, which is often called adolescent idiopathic scoliosis. There appears to be a genetic component to the etiology of idiopathic scoliosis; however, the exact relationship has yet to be established.

Critical Thinking Case Study—Scoliosis

Osteomyelitis

Osteomyelitis, an infectious process in the bone, can occur at any age but most frequently is seen in children 10 years of age or younger. S. aureus is the most common causative organism (Box 39-14). Neonates are also likely to have osteomyelitis caused by group B streptococci. Since the advent of Haemophilus influenzae type b immunization in the late 1980s, H. influenzae has become a less common causative pathogen. Children with sickle cell anemia may develop osteomyelitis from Salmonella organisms as well as S. aureus. Neisseria gonorrhoeae is a potential causative organism in the sexually active adolescent.

Case Study—Osteomyelitis

Animation—Osteomyelitis

Acute hematogenous osteomyelitis results when a blood-borne bacterium causes an infection in the bone. Common foci include infected lesions, upper respiratory tract infections, otitis media, tonsillitis, abscessed teeth, pyelonephritis, and infected burns. Exogenous osteomyelitis is acquired from direct inoculation of the bone from a puncture wound, open fracture, surgical contamination, or adjacent tissue infection. Subacute osteomyelitis has a longer course and may be caused by less virulent microbes with a walled-off abscess or Brodie abscess, typically in the proximal or distal tibia. Chronic osteomyelitis is a progression of acute osteomyelitis and is characterized by the presence of dead bone, bone loss, and drainage and sinus tracts. Generally healthy bone is not likely to become infected. Factors that contribute to infection include inoculation with a large number of organisms, presence of a foreign body, bone injury, high virulence of an organism, immunosuppression, and malnutrition. Certain types and locations of bone are also more vulnerable to infection.

Septic Arthritis

Septic (suppurative) arthritis is a bacterial infection in the joint. It usually results from hematogenous spread or from direct extension of an adjacent cellulitis or osteomyelitis. Direct inoculation from trauma accounts for 15% to 20% of septic arthritis cases. The most common causative organism is S. aureus (Lampe, 2007). Community-acquired methicillin-resistant S. aureus is commonly a cause of septic arthritis (Gutierrez, 2005). In addition to S. aureus, pathogens seen in neonates include group B streptococci, Escherichia coli, and Candida albicans. In children 2 months to 5 years of age, S. aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Kingella kingae are the primary organisms causing infection, whereas children older than 5 years are more likely to be infected by S. aureus and S. pyogenes; sexually active adolescents may be infected by N. gonorrhoeae (Gutierrez, 2005).

Knees, hips, ankles, and elbows are the most commonly affected joints. Clinical manifestations include severe joint pain, swelling, warmth of overlying tissue, and occasionally erythema. The child is resistant to any joint movement. Features of systemic illness such as fever, malaise, headache, nausea, vomiting, and irritability may also be present.

Skeletal Tuberculosis

In children tubercular infection of the bones and joints is acquired by lymphohematogenous spread at the time of primary infection. Occasionally it is from chronic pulmonary tuberculosis. Skeletal tubercular infection is not common in the United States but should be considered in communities with high tuberculosis case rates. The infection is most likely to involve the vertebrae, causing a tubercular spondylitis. If the infection is progressive, it causes Pott disease with destruction of the vertebral bodies and results in kyphosis. Symptoms are insidious. The child may report persistent or intermittent pain. Other findings include joint swelling and stiffness; fever and weight loss are not common. Tubercular arthritis can also affect single joints such as a knee or hip and tends to cause severe destruction of adjacent bone. Infection in the fingers causes spina ventosa, a tuberculous dactylitis.

As with pulmonary tuberculosis, the index case should be located. A family and environmental history needs to be obtained and skin tests performed. (See also Tuberculosis, Chapter 32.) Results of tuberculin skin tests are positive for the majority of children with tuberculous arthritis; however, the results are not diagnostic, and the clinical and laboratory features do not differentiate tubercular arthritis from a nontubercular septic arthritis. Diagnosis requires isolation of Mycobacterium tuberculosis from the site. Patients with the susceptible organism start treatment with combined antituberculosis chemotherapy (isoniazid, rifampin, and pyrazinamide); directly observed therapy is preferred.

Nursing care depends on the site and extent of infection. Tuberculous spondylitis and hip infection may require immobilization, casting, and fusion. Nursing care is the same as for osteomyelitis with the addition of isolation requirements.

Osteogenesis Imperfecta

OI is the most common osteoporosis syndrome in children, characterized by excessive fractures and bone deformity. There are at least five types of OI, accounting for significant disease variability. Clinical features include varying degrees of bone fragility, deformity, and fracture; blue sclerae; hearing loss; and dentinogenesis imperfecta (hypoplastic discolored teeth). The inheritance pattern is autosomal dominant in the majority of cases, although the most severe form demonstrates autosomal recessive inheritance.

Most types of OI have defects in the COL1A1 or COL1A2 genes, which code for polypeptide chains in type 1 procollagen, a precursor of type 1 collagen, a major structural component of bone. The error results in faulty bone mineralization, abnormal bone architecture, and increased susceptibility to fracture.

Classifications for OI are based on clinical features and patterns of inheritance (Box 39-15). Clinically, type I is the most common, with wide variability of bone fragility; some affected family members have significant deformity and disability, whereas others lead agile, active lives. Type II variants are the most severe and are considered lethal in infancy. Type III OI is characterized by multiple fractures, bone deformity, and severe disability; affected individuals rarely live to 30 years of age. Type IV is similar to type I with blue or white sclerae. Another variant, or type V, has been described in which those affected have a hyperplastic callus, a radiodense metaphyseal band, and calcification of the interosseous membrane of the forearm; no collagen mutations are noted in this group (Marini, 2007). A type VI has been described with a characteristic mineralization defect, which does not respond to pamidronate therapy as do types I to V (Land, Rauch, Travers, et al, 2007). Children affected with this type have no dental involvement and normal sclerae; a bone biopsy is the only way to establish a diagnosis because of the similarities to other types.

Juvenile Idiopathic Arthritis (Juvenile Rheumatoid Arthritis)

Juvenile idiopathic arthritis (JIA), also commonly called juvenile rheumatoid arthritis (JRA), refers to chronic childhood arthritis. JIA is gradually replacing JRA in the research literature and is increasingly used in clinical practice; consequently, both JIA and JRA classifications are discussed here. The revision of JRA nomenclature to JIA was due in part to the minimally applicable reference to “rheumatoid” in childhood arthritis, which is relevant to only a small proportion of affected children yet burdens the family with images of disfiguring adult rheumatoid arthritis. Furthermore, the old subtyping of JRA into systemic, pauciarticular, and polyarticular disease reflects disease onset and not disease progression, which is of greater importance (Warren, Perez, Curry, et al, 2001).

JIA is a group of idiopathic chronic inflammatory diseases affecting the joints and other tissues in approximately 1 in 1000 children. Some theories speculate that the disorder arises when an infectious agent activates an autoimmune inflammatory process in a genetically predisposed child. Although a genetic susceptibility to JIA is known, such as human leukocyte antigen (HLA) polymorphisms and the PTPN22 gene, this accounts for less than half of the genetic susceptibility; additional genetic factors are being researched (Prahalad and Glass, 2008). There is a female predominance of 2:1 and two peak ages of onset: between 1 and 3 years and 8 and 10 years of age.

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease of the blood vessels and connective issue. The Lupus Foundation of America (2009) estimates 1.5 million individuals have lupus, and 10% to 15% of these adults were diagnosed with SLE as children or adolescents. It typically manifests between the ages of 10 and 19 years, and onset before age 5 years is unusual. There is a 5 : 1 female/male predominance.

Its course and symptoms are variable and unpredictable, with mild to life-threatening complications. SLE in children tends to be more severe at onset and has a more aggressive clinical course than adult-onset disease. Other types of lupus erythematosus include chronic cutaneous lupus erythematosus (discoid lupus erythematosus), drug-induced lupus erythematosus, subacute cutaneous lupus erythematosus, and neonatal lupus erythematosus. Neonatal lupus erythematosus occurs when maternal autoantibodies cross the placenta and cause transient lupuslike symptoms in the newborn, with the potential lethal complication of heart block. The remaining discussion focuses on SLE.

• Trauma is the leading cause of death in children and is caused by accidental injury, child abuse injury, and birth injury.

• Immobility has a profound effect on all elements of growth and development.

• The major consequences of immobilization are loss of muscle strength, endurance, and muscle mass; bone demineralization leading to osteoporosis; circulatory stasis and thrombus formation; loss of joint mobility; and contractures.

• In the care of the immobilized child, nurses are concerned with position changes, adequate dietary intake, adequate hydration, promotion of activity, and involvement of the child in self-care.

• Features of children’s bones not observed in those of adults include presence of a growth plate, a thicker and stronger periosteum, greater bone porosity, more rapid healing, and less joint stiffness.

• Types of fractures seen in children include bend, buckle, greenstick, and complete fractures.

• Goals of fracture management in children are to reestablish alignment and length of the bony fragments, retain alignment and length, and restore function to injured parts.

• The method of fracture reduction is determined by the child’s age, the degree of displacement, the amount of overriding bone, the amount of edema, the condition of the skin and soft tissues, and the integrity of sensation and circulation distal to the fracture.

• The primary purposes of traction are to fatigue involved muscle and reduce muscle spasm, to realign bone ends, and to immobilize the fracture site until realignment has been achieved to permit casting or splinting.

• Complications of fractures are circulatory impairment, nerve compression syndromes, compartment syndromes, epiphyseal damage, nonunion, malunion, infection, kidney stones, and pulmonary emboli.

• Participation in sports predisposes adolescents to acute injuries, such as contusions, dislocations, sprains, and strains, and to overuse syndromes, such as stress fractures.

• Health concerns associated with sports include menstrual dysfunction, substance misuse, and sudden death from sudden cardiac arrest.

• Musculoskeletal disorders in children include torticollis, Legg-Calvé-Perthes disease, SCFE, kyphosis, lordosis, and scoliosis.

• Observation for idiopathic scoliosis is an important part of a routine physical assessment.

• Management of idiopathic scoliosis includes bracing or surgery.

• Postoperative nursing care of the child with idiopathic scoliosis demands careful attention to peripheral neurovascular function, respiratory function, pain control, and skin care.

• Nursing care of the child with osteomyelitis is directed at positioning for comfort, administering antibiotics, monitoring IV equipment and site, and ensuring adequate nutrition.

• Osteomyelitis is acquired by direct or secondary invasion or hematogenous spread of infectious organisms.

• Goals of therapy for arthritis in children are to control pain, preserve joint range of motion and function, minimize the effects of inflammation such as joint deformity, and promote normal growth and development.

• Nursing care of the child with arthritis consists of relieving pain, promoting general health, preventing deformity, preserving optimum function, and encouraging self-care and maximum involvement in school and other activities.

• SLE is a chronic multisystem autoimmune disorder that affects the blood vessels and connective tissues of the body.

Alharbi, M, Pinto, G, Finidori, G, et al. Pamidronate treatment of children with moderate-to severe osteogenesis imperfect: a note of caution. Horm Res. 2009;71(1):38–44.

American Academy of Orthopaedic Surgeons, Keep injured high school athletes out of the game. Your Orthopaedic Connection 2007. available at http://orthoinfo.aaos.org/topic.cfm?topic=A00048 [(accessed August 1, 2009)].

American Academy of Pediatrics, Committee on Nutrition. Pediatric nutrition handbook, ed 6. Elk Grove Village, Ill: The Academy; 2009.

American Academy of Pediatrics. Use of performance-enhancing substances. Pediatrics. 2005;115(4):1103–1106.

American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Climatic heat stress and the exercising child and adolescent. Pediatrics. 2000;106(1):158–159.

American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics. 2000;106(3):610–613.

American Academy of Pediatrics, Section on Rheumatology and Section on Ophthalmology. Guidelines for ophthalmologic examinations in children with juvenile rheumatoid arthritis. Pediatrics. 1993;92(2):295–296.

Bachrach, LK, Ward, LM. Clinical review 1: bisphosphonate use in childhood osteoporosis. J Clin Endocrinol Metab. 2009;94(2):400–409.

Benseler, SM, Silverman, ED. Neuropsychiatric involvement in pediatric systemic lupus erythematosus. Lupus. 2007;16(3):564–571.

Bloom, BJ, Owens, JA, McGuinn, M, et al. Sleep and its relationship to pain, dysfunction and disease activity in juvenile rheumatoid arthritis. J Rheumatol. 2002;29(1):169–173.

Borse, NN, Gilchrist, J, Dellinger, AM, et al. CDC childhood injury report: patterns of unintentional injuries among 0-19 year olds in the United States, 2000-2006. Atlanta: Centers for Disease Control and Prevention; 2008.

Boyd, AS, Benjamin, HJ, Asplund, C. Principles of casting and splinting. Am Fam Physician. 2009;79(1):16–22. [23-24].

Brenner, JS, Council on Sports Medicine and Fitness. Overuse injuries, overtraining, and burnout in child and adolescent athletes. Pediatrics. 2007;119(6):1242–1245.

Brown, JC, Klein, EJ, Lewis, CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42(2):197–205.

Bullock, DP, Koval, KJ, Moen, KY, et al. Hospitalized cases of child abuse in America: who, what, when, and where. J Pediatr Orthop. 2009;29(3):231–237.

Bunnell, WP. Selective screening for scoliosis. Clin Orthop Relat Res. 2005;434:40–45.

Burmester, GR, Mease, PJ, Dijkmans, BA, et al. Adalimumab safety and mortality rates from global clinical trials of six immune-mediated inflammatory diseases. Ann Rheum Dis. 2009;68(12):1863–1869.

Calfee, R, Fadale, P. Popular erogenic drugs and supplements in young athletes. Pediatrics. 2006;117(3):e577–e589.

Cassidy, J, Kivlin, J, Lindsley, C, et al. Ophthalmologic Examinations in Children with juvenile rheumatoid arthritis. Pediatrics. 2006;117(5):1843–1845.

Chorley, JN. Ankle sprain discharge instructions from the emergency department. Pediatr Emerg Care. 2005;21(8):498–501.

Cimpello, LB, Khine, H, Avner, JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care. 2004;20(4):228–232.

Clark, E, Plint, AC, Correll, R, et al. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics. 2007;119(3):460–467.

Cornwall, R. Upper limb. In Kliegman RM, Behrman RE, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Curley, MA, Razmus, IS, Roberts, KE, et al. Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nurs Res. 2003;52(1):22–33.

DiFazio, R, Atkinson, CC. Extremity fractures in children: when is it an emergency? J Pediatr Nurs. 2005;20(4):298–304.

Doyle, GS, Taillac, PP. Tourniquets: a review of current use with proposals for expanded prehospital use. Prehosp Emerg Care. 2008;12(2):241–256.

Drendel, AL, Lyon, R, Bergholte, J, et al. Outpatient pediatric pain management practices for fractures. Pediatr Emerg Care. 2006;22(2):94–99.

Drezner, JA, Chun, JS, Harmon, KG, et al. Survival trends in the United States following exercise-related cardiac arrest in the youth, 2000-2006. Heart Rhythm. 2008;5(6):794–799.

Drezner, JA, Courson, RW, Roberts, WO, et al. Inter Association Task Force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. Prehosp Emerg Care. 2007;11(3):253–271.

Drezner, JA, Rao, AL, Heistand, J, et al. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation. 2009;120(6):518–525.

Fisher, TJ, Williams, SL, Levine, AM. Spinal orthosis. In Browner BD, Jupiter JB, Levine AM, et al, eds.: Skeletal trauma: basic science, management, and reconstruction, ed 4, Philadelphia: Saunders, 2008.

Foeldvari, I, Wierk, A. Methotrexate is an effective treatment for chronic uveitis associated with juvenile idiopathic arthritis. J Rheumatol. 2005;33(2):362–365.

Freeman, BL, III. Scoliosis and kyphosis. In Canale ST, Beaty JH, eds.: Campbell’s operative orthopaedics, ed 11, Philadelphia: Mosby, 2007.

Friday, JH, Kanegaye, JT, McCaslin, I, et al. Ibuprofen provides analgesia equivalent to acetaminophen-codeine in the treatment of acute pain in children with extremity injuries: A randomized clinical trial. Acad Emerg Med. 2009;16(8):711–716.

Graham, JM, Gomez, M, Halberg, A, et al. Management of deformational plagiocephaly: repositioning versus orthotic therapy. J Pediatr. 2005;146(2):258–262.

Green, NE, Swiontkowski, MF. Skeletal trauma in children, ed 4. Philadelphia: Mosby/Elsevier; 2008.

Gregory, AJM, Fitch, RW. Sports medicine: performance-enhancing drugs. Pediatr Clin North Am. 2007;54(4):797–806.

Gutierrez, K. Bone and joint infections in children. Pediatr Clin North Am. 2005;52(3):779–794.

Hart, ES, Grottkau, BE, Albright, MB. Slipped capital femoral epiphysis: don’t miss this pediatric hip disorder. Nurs Pract. 2007;32(3):14. [16-18, 21].

Hayata, AL, Borba, EF, Bonfa, E, et al. The frequency of high/moderate lipoprotein risk factor for coronary artery disease is significant in juvenile-onset systemic lupus erythematosus. Lupus. 2005;14(8):613–617.

Hazinski, MF, Markenson, D, Neish, S, et al. Response to cardiac arrest and selected life-threatening medical emergencies: the medical emergency response plan for schools: a statement for healthcare providers, policymakers, school administrators, and community leaders. Pediatrics. 2004;113(1):155–168.

Holmes, SB, Brown, SJ, Pin Site Care Expert Panel. Skeletal pin site care: National Association of Orthopaedic Nurses guidelines for orthopaedic nursing. Orthop Nurs. 2005;24(2):99–107.

Hosalkar, HS, Horn, D, Friedman, J, et al. The hip. In Kliegman RM, Behrman RE, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Houghton, KM, Tucker, LB, Potts, JE, et al. Fitness, fatigue, disease activity, and quality of life in pediatric lupus. Arthritis Rheum. 2008;59(4):537–545.

Ilowite, NT. Update on biologics in juvenile idiopathic arthritis. Curr Opin Rheumatol. 2008;20(5):613–618.

Ivins, D. Acute ankle sprain: an update. Am Fam Physician. 2006;74(10):1714–1720. [1723-1724, 1725-1726].

Jarvis, J, Garbedian, S, Swamy, G. Juvenile idiopathic scoliosis: the effectiveness of part-time bracing. Spine (Phila 1976). 2008;33(10):1074–1078.

Joy, EA, Van Hala, S, Cooper, L. Health-related concerns of the female athlete: a lifespan approach. Am Fam Physician. 2009;79(6):489–495.

Kennedy, RM, Luhmann, JD, Luhmann, SJ. Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children. Pediatr Drugs. 2004;6(1):11–31.

Kerkhoffs GM, Struijs PA, Assendelft WJ, et al: Different functional treatment strategies for acute lateral ankle ligament injuries in adults, Cochrane Database Syst Rev (3):CD002938, 2002.

Klein-Gitelman, MS, Pachman, LM. Intravenous corticosteroids: adverse reactions are more variable than expected in children. J Rheumatol. 1998;25(10):1995–2002.

Klepper, SE. Exercise in pediatric rheumatic diseases. Curr Opin Rheumatol. 2008;20(5):619–624.

Koller, DM, Myers, AB, Lorenz, D, et al. Effectiveness of oxycodone, ibuprofen, or the combination in the initial management of orthopedic injury-related pain in children. Pediatr Emerg Care. 2007;23(9):627–633.

Lampe, RM. Osteomyelitis and suppurative arthritis. In Kliegman RM, Behrman RE, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Land, C, Rauch, F, Travers, R, et al. Osteogenesis imperfecta type VI in childhood and adolescence: effects of cyclical intravenous pamidronate treatment. Bone. 2007;40(3):638–644.

Laskowski-Jones, L. Responding to an out-of-hospital emergency. Nursing 2002. 2002;32(9):36–42.

Lee, C, Porter, KM, Hodgetts, TJ. Tourniquet use in the civilian prehospital setting. Emerg Med J. 2007;24(8):584–587.

Loder, RT. Controversies in slipped capital femoral epiphysis. Orthop Clin North Am. 2006;37(2):211–221.

Loder, RT, Feinberg, JR. Orthopaedic injuries in children with nonaccidental trauma: demographics and incidence from the 2000 kids’ inpatient database. J Pediatr Orthop. 2007;27(4):421–426.

Lonner, BS. Emerging minimally invasive technologies for the management of scoliosis. Orthop Clin North Am. 2007;38(3):431–440.

Lovell, DJ, Giannini, EH, Reiff, A, et al. Long-term efficacy and safety of etanercept in children with polyarticular juvenile rheumatoid arthritis: interim results from an ongoing multicenter, open-label, extended-treatment trial. Arthritis Rheum. 2003;48(1):218–226.

Lovell, DJ, Reiff, A, Ilowite, NT, et al. Safety and efficacy of up to 8 years of continuous etanercept therapy in patients with juvenile rheumatoid arthritis. Arthritis Rheum. 2008;58(5):1496–1503.

Lovell, DJ, Ruperto, N, Goodman, S, et al. Adalimumab with or without methotrexate in juvenile rheumatoid arthritis. N Engl J Med. 2008;359(8):810–820.

Lucas, B, Davis, PS. Why restricting movement is important. In Kneale JD, Davis PS, eds.: Orthopaedic and trauma nursing,, ed 2, London: Elsevier, 2005.

Lupus Foundation of America, About lupus: what is lupus?. Washington, DC: The Foundation; 2009. accessed April 25, 2010, at www.lupus.org/webmodules/webarticlesnet/templates/new_learnunderstanding.aspx?articleid=2232&zoneid=523

Manzi, S, Meilahn, EN, Rairie, JE, et al. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham study. Am J Epidemiol. 1997;145(5):408–414.

Marini, JC. Osteogenesis imperfect. In Kliegman RM, Behrman RE, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Maron, BJ. Medical progress: sudden death in young athletes. N Engl J Med. 2003;349(11):1064–1075.

Maron, BJ, Doerer, JJ, Haas, TS, et al. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119(8):1085–1092.

Maron, BJ, Gohman, TE, Aeppli, D. Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes. J Am Coll Cardiol. 1998;32(7):1881–1884.

Meredith, JR, O’Keefe, KP, Galwankar, S. Pediatric procedural sedation and analgesia. J Emerg Trauma Shock. 2008;1(2):88–96.

Napierkowski, DB. Scoliosis: a case study in an adolescent boy. Orthop Nurs. 2007;26(3):147–153.

Nelson, AJ, Collins, CL, Yard, EE, et al. Ankle injuries among United States high school sports athletes, 2005-2006. J Athl Train. 2007;42(3):381–387.

Newton, PO, Wenger, DR. Idiopathic and congenital scoliosis. In: Morrissy RT, Weinstein SL, eds. Lovell and Winter’s pediatric orthopaedics. Philadelphia: Williams & Wilkins, 2001.

Nwobi, O, Abitbol, CL, Chandar, J, et al. Rituximab therapy for juvenile-onset systemic lupus erythematosus. Pediatr Nephrol. 2008;23(3):413–419.

Paredes, A. Can mycophenolate mofetil substitute cyclophosphamide treatment of pediatric lupus? Pediatr Nephrol. 2007;22(8):1077–1082.

Persing, J, James, H, Swanson, J, et al. Prevention and management of positional skull deformities in infants. Pediatrics. 2003;112(1):199–202.

Petty, RE, Southwood, TR, Baum, J, et al. Revision of the proposed classification criteria for juvenile idiopathic arthritis: Durban, 1997. J Rheumatol. 1998;25(10):1991–1994.

Petty, RE, Southwood, TR, Manners, P, et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol. 2004;31(2):390–392.

Plint, AC, Perry, JJ, Correll, R, et al. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006;117(3):691–697.

Prahalad, S, Glass, DN, A comprehensive review of the genetics of juvenile idiopathic arthritis. Pediatr Rheumatol 2008;11(6). available at www.ped-rheum.com/content/6/1/11 [(accessed April 24, 2009)].

Priori, R, Medda, E, Conti, F, et al. Familial autoimmunity as a risk factor for systemic lupus erythematosus and vice versa: a case-control study. Lupus. 2003;12(10):735–740.

Rauch, F, Munns, CF, Land, C, et al. Risedronate in the treatment of mild pediatric osteogenesis imperfecta: a randomized placebo-controlled study. J Bone Miner Res. 2009;24(7):1282–1289.

Ravelli, A, Ruperto, N, Martini, A. Outcome in juvenile onset lupus erythematosus. Curr Opin Rheumatol. 2005;17(5):568–573.

Rechel, JA, Yard, EE, Comstock, RD. An epidemiologic comparison of high school sports injuries sustained in practice and competition. J Athl Train. 2008;43(2):197–204.

Rice, SG, Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848.

Richards, BS, Vitale, MG. Screening for idiopathic scoliosis in adolescents: an information statement. J Bone Joint Surg. 2008;90(1):195–198.

Rodriguez, NR, DiMarco, NM, Langley, S, et al. Position of the American Dietetic Association, Dietitians of Canada, and the American College of Sports Medicine: nutrition and athletic performance. J Am Diet Assoc. 2009;109(3):509–527.

Sandborg, C, Ardoin, SP, Schanberg, L. Therapy insight: cardiovascular disease in pediatric systemic lupus erythematosus. Nat Clin Pract Rheumatol. 2008;4(5):258–265.

Slote, RJ. Psychological effects of caring for the adolescent undergoing spinal fusion for scoliosis. Orthop Nurs. 2002;21(6):19–28.

Spiegel, DA, Hosalkar, HS, Dormans, JP, et al. The neck. In Kliegman RM, Behrman RE, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Spiegel, DA, Hosalkar, HS, Dormans, JP. Bone and joint disorders: the spine. In Kliegman RM, Behrman RE, Jenson HB, et al, eds.: Nelson textbook of pediatrics, ed 18, Philadelphia: Saunders, 2007.

Tsao, BP, Wu, H. Genetics of human lupus. In Wallace DJ, Hahn BH, eds.: Dubois’ Lupus Erythematosus, ed 7, Philadelphia: Lippincott Williams & Wilkins, 2007.

Tucker, LB. Making the diagnosis of systemic lupus erythematosus in children and adolescents. Lupus. 2007;12(8):546–549.

Venables, MC, Shaw, L, Jeukendrup, AE, et al. Erosive effect of a new sports drink on dental enamel during exercise. Med Sci Sports Exerc. 2005;37(1):39–44.

Waldrop, J. Early identification and interventions for female athlete triad. J Pediatr Health Care. 2005;19(4):213–220.

Warren, RW, Perez, MD, Curry, MR, et al. Juvenile idiopathic arthritis (juvenile rheumatoid arthritis. In: Koopman WJ, ed. Arthritis and allied conditions. Philadelphia: Lippincott Williams & Wilkins, 2001.

Wipke-Tevis, DD, Rich, K. Vascular disorders. In Lewis SL, Heitkemper MM, Dirksen S, et al, eds.: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St Louis: Mosby, 2007.