Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1

Types of TractionTypes of Traction

Bryant’s traction: used for children younger Bryant’s traction: used for children younger than 3 years and weighing less than than 3 years and weighing less than 35 pounds who have a fractured femur or 35 pounds who have a fractured femur or congenital hip dyplasiacongenital hip dyplasia

Buck’s traction: used for knee immobilization Buck’s traction: used for knee immobilization or for short-term immobilization of a fractureor for short-term immobilization of a fracture

Dunlop’s traction: used for supracondylar Dunlop’s traction: used for supracondylar fractures of the humerusfractures of the humerus

Russell’s traction: used for fractures of the Russell’s traction: used for fractures of the femur and lower legfemur and lower leg

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2

Types of TractionTypes of Traction

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3

Types of TractionTypes of Traction

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4

Disadvantages of TractionDisadvantages of Traction

Need for hospitalizationNeed for hospitalization Prolonged immobilityProlonged immobility Always assume that traction is continuous Always assume that traction is continuous

unless the physician states otherwiseunless the physician states otherwise

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5

Physiologic Effects of ImmobilizationPhysiologic Effects of Immobilization

Directly or indirectly relate to decreased Directly or indirectly relate to decreased muscle activity and have an impact on all muscle activity and have an impact on all systemssystems

IntegumentaryIntegumentary Red or irritated skinRed or irritated skin Presence of ulceration or drainagePresence of ulceration or drainage

GastrointestinalGastrointestinal Decreased mobility leads to constipationDecreased mobility leads to constipation

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6

Physiologic Effects of ImmobilizationPhysiologic Effects of Immobilization

RespiratoryRespiratory Lying supine for prolonged periods leads to Lying supine for prolonged periods leads to

altered respirationsaltered respirations GenitourinaryGenitourinary

Decreased urinary output from stasis or retentionDecreased urinary output from stasis or retention MusculoskeletalMusculoskeletal

Significant loss of muscle strength, endurance, Significant loss of muscle strength, endurance, and muscle massand muscle mass

Bone demineralizationBone demineralization Loss of joint mobilityLoss of joint mobility

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7

Psychologic Effects of ImmobilizationPsychologic Effects of Immobilization

Immobilization narrows the amount and Immobilization narrows the amount and variety of environmental stimuli a child variety of environmental stimuli a child receives through the sensesreceives through the senses

Physical interference with the activities of Physical interference with the activities of infants and young children gives them a infants and young children gives them a feeling of helplessness and has been found to feeling of helplessness and has been found to affect speech and language developmentaffect speech and language development

Sensory deprivation in the school-age child Sensory deprivation in the school-age child and adolescent leads to feelings of isolation, and adolescent leads to feelings of isolation, boredom, and being forgotten, especially by boredom, and being forgotten, especially by peerspeers

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8

The struggle for independence in each of The struggle for independence in each of Erikson’s phases is thwarted by imposed Erikson’s phases is thwarted by imposed immobilityimmobility Toddlers: need exploration and the ability to Toddlers: need exploration and the ability to

imitate behaviors to develop a sense of autonomyimitate behaviors to develop a sense of autonomy Preschoolers: expression of initiative is evidenced Preschoolers: expression of initiative is evidenced

by their need for vigorous physical activityby their need for vigorous physical activity

Psychologic Effects of ImmobilizationPsychologic Effects of Immobilization

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9

Psychologic Effects of ImmobilizationPsychologic Effects of Immobilization

School-age: industry is influenced by School-age: industry is influenced by physical achievement and competitionphysical achievement and competition

Adolescence: rely on mobility to achieve Adolescence: rely on mobility to achieve independence, one of the steps in creating independence, one of the steps in creating their identitytheir identity

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10

Behavioral Changes Behavioral Changes in Immobilized Childrenin Immobilized Children

Changes related to high levels of anxietyChanges related to high levels of anxiety RestlessnessRestlessness DepressionDepression RegressionRegression EgocentrismEgocentrism Difficulty with problem solvingDifficulty with problem solving Inability to concentrate on activitiesInability to concentrate on activities

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11

Behavioral Changes Behavioral Changes in Immobilized Childrenin Immobilized Children

Changes related to monotonyChanges related to monotony Hallucinations Hallucinations DisorientationDisorientation Dependence Dependence DepressionDepression Acting-out behavior Acting-out behavior Increased fantasizingIncreased fantasizing Sluggish intellectual responsesSluggish intellectual responses Sluggish psychomotor responsesSluggish psychomotor responses Decreased communication skillsDecreased communication skills

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12

Nursing ConsiderationsNursing Considerationsfor the Child in a Cast or in Tractionfor the Child in a Cast or in Traction

Monitor for complications of fracture reductionMonitor for complications of fracture reduction Infection Infection Nerve compression syndromeNerve compression syndrome Kidney stonesKidney stones Pulmonary emboli Pulmonary emboli Circulatory impairmentCirculatory impairment Fat embolism (pulmonary embolism)Fat embolism (pulmonary embolism)

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13

Nursing ConsiderationsNursing Considerationsfor the Child in a Cast or in Tractionfor the Child in a Cast or in Traction

Keep cast or other appliance clean and dry Keep cast or other appliance clean and dry (especially from urine or feces)(especially from urine or feces)

Monitor bowel soundsMonitor bowel sounds Assess for abdominal distentionAssess for abdominal distention Provide optimal nutrition for bone healing, Provide optimal nutrition for bone healing,

growth, and developmentgrowth, and development

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14

Nursing ConsiderationsNursing Considerationsfor the Child in a Cast or in Tractionfor the Child in a Cast or in Traction

Neurovascular assessment every 1 to 2 Neurovascular assessment every 1 to 2 hours after application of devicehours after application of device

Assessment of strength of pulse distal Assessment of strength of pulse distal to the siteto the site

Assessment of capillary refillAssessment of capillary refill Assessment of five P’sAssessment of five P’s Reposition every 2 hours; encourage mobility Reposition every 2 hours; encourage mobility

within the confines of traction or castwithin the confines of traction or cast Prevent skin breakdownPrevent skin breakdown

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15

Nursing ConsiderationsNursing Considerationsfor the Child in a Cast or in Tractionfor the Child in a Cast or in Traction

Maintain hydrationMaintain hydration Encourage or provide range of motion Encourage or provide range of motion

exercises as appropriate for cast or tractionexercises as appropriate for cast or traction Provide opportunities for therapeutic playProvide opportunities for therapeutic play Encourage and provide opportunities for Encourage and provide opportunities for

school-age child and adolescent to keep up school-age child and adolescent to keep up with school work and friendswith school work and friends

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16

Soft Tissue InjuriesSoft Tissue Injuries

Contusions: damage to the soft tissue, Contusions: damage to the soft tissue, subcutaneous structures, and musclesubcutaneous structures, and muscle

Dislocations: bone ends displaced from their Dislocations: bone ends displaced from their normal positionnormal position

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17

Soft Tissue InjuriesSoft Tissue Injuries

Sprains occur when trauma to a joint is so Sprains occur when trauma to a joint is so severe that a ligament is either stretched or severe that a ligament is either stretched or partially or completely torn by the force created partially or completely torn by the force created as a joint is twisted or wrenchedas a joint is twisted or wrenched

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18

Soft Tissue InjuriesSoft Tissue Injuries

Clinical manifestationsClinical manifestations PainPain SwellingSwelling Localized tendernessLocalized tenderness Limited range of motionLimited range of motion Poor weight bearingPoor weight bearing Popping or snapping sound (sprains)Popping or snapping sound (sprains) Diagnostic evaluationDiagnostic evaluation Clinical picture and historyClinical picture and history Radiographs to rule out fractureRadiographs to rule out fracture

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Soft Tissue Injuries:Soft Tissue Injuries:Nursing ConsiderationsNursing Considerations

RRestest IIcece CCompressionompression EElevationlevation

IIcece CCompressionompression EElevationlevation SSupportupport

Analgesics for pain management in combination with distraction as well as age-appropriate play activities

Review principles of RICE/ICES with parents

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20

Congenital Musculoskeletal Congenital Musculoskeletal Health ProblemsHealth Problems

ClubfootClubfoot Developmental dysplasia of the hipDevelopmental dysplasia of the hip Osteogenesis imperfectaOsteogenesis imperfecta

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21

ClubfootClubfoot

Congenital malformation of the lower Congenital malformation of the lower extremity that affects the lower leg, ankle, extremity that affects the lower leg, ankle, and footand foot

Clinical manifestationsClinical manifestations One or a combination of One or a combination of

four deformitiesfour deformities Plantar flexionPlantar flexion DorsiflexionDorsiflexion Varus deviation (foot turns in)Varus deviation (foot turns in) Valgus deviation (foot turns out)Valgus deviation (foot turns out)

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22

ClubfootClubfoot

Involves bone deformity and malposition with Involves bone deformity and malposition with soft tissue contractionsoft tissue contraction

May be unilateral or bilateralMay be unilateral or bilateral Affected foot is usually smaller and shorter, Affected foot is usually smaller and shorter,

with an empty heel pad and transverse with an empty heel pad and transverse plantar creaseplantar crease

Easily recognized at birthEasily recognized at birthTherapeutic managementTherapeutic management Serial manipulation and castingSerial manipulation and casting If sufficient correction not achieved within 3 If sufficient correction not achieved within 3

to 6 months, surgery is performedto 6 months, surgery is performed Long-term follow-upLong-term follow-up

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23

Clubfoot Clubfoot

Postoperative nursing considerationsPostoperative nursing considerations Neurovascular checks at least every 2 hoursNeurovascular checks at least every 2 hours Observe for any swelling around cast edges Observe for any swelling around cast edges Elevate ankle and foot on pillows; apply iceElevate ankle and foot on pillows; apply ice Monitor drainage in castMonitor drainage in cast Pain management Pain management

(analgesics as ordered, distraction)(analgesics as ordered, distraction) Education for home management Education for home management

(discharge teaching)(discharge teaching)

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24

Developmental Developmental Dysplasia of the HipDysplasia of the Hip

Also called congenital Also called congenital dislocation of the hipdislocation of the hip

Refers to a variety of Refers to a variety of conditions in which the conditions in which the femoral head and femoral head and acetabulum are acetabulum are improperly alignedimproperly aligned

May be unilateral May be unilateral or bilateralor bilateral

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25

Developmental Developmental Dysplasia of the HipDysplasia of the Hip

Predisposing factorsPredisposing factors TwinsTwins Breech deliveryBreech delivery Maternal hormones relaxin and estrogenMaternal hormones relaxin and estrogen Large infantLarge infant

Clinical manifestations in the neonateClinical manifestations in the neonate Displaced femoral head from the acetabulum Displaced femoral head from the acetabulum

on manipulation (positive Ortolani’s on manipulation (positive Ortolani’s maneuver)maneuver)

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Developmental Developmental Dysplasia of the HipDysplasia of the Hip

Clinical manifestations Clinical manifestations in the infantin the infant Asymmetry of the gluteal Asymmetry of the gluteal

skin folds skin folds Limited range of motion Limited range of motion in the affected hipin the affected hip Asymmetric abductionAsymmetric abduction Femur on affected side Femur on affected side appears shortappears short

Clinical manifestations Clinical manifestations

in the childin the child Clinical manifestations Clinical manifestations

in the infant in the infant plusplus Minimal to pronounced Minimal to pronounced

variations in gait, with variations in gait, with lurching toward lurching toward

affected sideaffected side

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Developmental Developmental Dysplasia of the HipDysplasia of the Hip

Diagnostic evaluation Screening at birth with Ortolani’s and

Barlow's maneuvers Ultrasound is useful between 4 and 6

weeks of age Radiography in older infants and children

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Developmental Developmental Dysplasia of the HipDysplasia of the Hip

Therapeutic management in the neonatal periodTherapeutic management in the neonatal period Splinting the hips with a Splinting the hips with a

Pavlik harness to maintain Pavlik harness to maintain flexion, abduction, and flexion, abduction, and external rotationexternal rotation