Chapter 24: Musculoskeletal Conditions & Pediatric Trauma

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Hello and welcome back to the Deep Dive.

Today is a bit of a special edition.

We are shifting gears just a little.

Usually, you know, we take a hot topic and we'll bounce around a few articles to give you the broad strokes.

Right, the big picture.

Exactly.

But today we're doing something very specific for our listeners who are deep in the trenches of nursing school.

Or maybe just really interested in the clinical side of pediatric care.

That's right.

We are treating this Deep Dive as a sort of audio study guide.

We're calling it the Last Minute Lecture Series.

I like that.

The goal here is to walk you through a specific textbook chapter and I mean literally in the exact order it's written.

So you can prep for that exam or that clinical rotation while you're, you know, on your commute, at the gym, doing laundry, whatever.

Exactly.

No fluff, just the core stuff you really need to know.

And today we are tackling chapter 24 from Lifer's Introduction to Maternity and Pediatric Nursing in Canada.

The chapter title is The Child with a Musculoskeletal Condition.

And it is a dense chapter, I won't lie, but it's so incredibly important.

It seems like it.

We aren't just talking about, you know, broken bones here.

We're talking about the system that supports the entire body,

allows for movement, protects all your vital organs, and even produces your blood.

So here's the mission for today.

We're going to turn this text into a conversation.

We'll start with the basics, how a child's bones are fundamentally different from an adult's.

Which is a huge deal in peds.

Then we'll move into the high octane stuff, like trauma,

fractures, and the art.

And it really does seem like an art of cast care.

Oh, for sure.

And then we have to talk about traction, which is a whole world unto itself with a lot of really specific, really important safety rules.

After that, we'll tour through specific congenital issues, things like clubfoot and hip dysplasia, some scary infections like osteomyelitis, and then chronic conditions like juvenile idiopathic arthritis.

We're going to end on a very serious, and I think very necessary note.

We have to.

The section on child abuse and the nurse's legal and ethical role in identifying it.

It's a full roadmap of the entire chapter.

It really is.

And before we get into the nitty gritty of, you know, the anatomy,

I think the text opens with a really good reminder.

The muscular skeletal system isn't just about walking or lifting things, is it?

No, absolutely not.

That's the hook.

It's so much more physiological than people think.

What do you mean by that?

Well, think about it.

Muscles move air in and out of your lungs.

That's breathing.

They pump blood through your vessels.

They move food through your digestive tract.

They even produce heat, which is vital for every single chemical reaction in your body.

And the bones, they're not just scaffolding.

Not at all.

The text points out the bone marrow.

It's a factory.

It's constantly producing red blood cells.

And the bones themselves are basically storage units for essential minerals like calcium and phosphorus.

So when this system goes down, it's not just a mobility issue.

No, it's a systemic issue.

It affects everything.

That's a great perspective to start with.

And for a pediatric nurse, understanding how the system develops is, while it's key,

the text mentions that skeletal growth is incredibly rapid in the fetus.

Yeah, particularly between the fourth and eighth weeks of life.

It's just explosive growth.

Wow.

And then after birth, locomotion, the ability to move around it, develops in this very orderly, predictable way.

So if you as a nurse see a marked deceleration in that growth or that movement, that's always a signal for investigation.

Okay, that makes sense.

Which brings us to our first major section.

The differences between a child and an adult.

Because kids aren't just many adults, are they?

Oh, definitely not.

Especially not their bones.

Figure 24 .1 in the text highlights this perfectly.

The pediatric skeletal system differs in some really fundamental ways.

So what's first big difference?

The first one you have to know is the epithesis.

The growth plate.

Right.

In children, the bone isn't completely ossified.

It's not hardened yet.

The epithesis is this cartilaginous plate at the ends of the long bones.

It's literally responsible for longitudinal growth.

It's how kids get taller.

Okay.

So why does that matter for a nurse?

What's the, so what?

So what is that the epithesis is the weak link.

The weak link?

Yes.

It's weaker than the ligaments around it.

So any kind of rotational or twisting force can stress that growth plate.

And if a fracture happens right there at the epithesis, it can actually stop the bone from growing.

It can interfere with that longitudinal growth permanently.

Wow.

So an injury that might be just a simple fracture in me could be a life altering event for a child.

Exactly.

It has huge implications.

Another difference is the periosteum.

That's the connective tissue covering the bone.

That's the one.

In children, it is much, much thicker and it produces callus.

That's the healing tissue way more rapidly than in adults.

So that means kids heal faster.

Much faster, which is the good news in all this.

But there's a flip side.

Children's bones are also more porous.

They have a lower mineral content.

Does that make them weaker?

It actually makes them strong in a different way.

They're more flexible.

You know, they can absorb more shock without snapping completely.

Ah, okay.

But it makes them susceptible to what we call green stick fractures.

Like a green twig on a tree.

You bend it and it splinters but doesn't break in half.

That's the perfect analogy.

The bone bends and splinters on one side rather than snapping clean in two.

You see it all the time in kids.

Okay.

And one more thing on anatomy spinal curvature.

A newborn doesn't have the same spine shape as you or me.

Not at all.

The text mentions a C curve.

A C curve?

Yeah.

The thoracic and sacral areas are convex.

The whole spine just looks like the letter C.

As the infant starts to strengthen their neck muscles, you know, getting head control, they develop that upper curve.

But not the full S shape we have?

No.

That final lumbar curve, the S shape or what we call lordosis that we see in adults, that only develops when the child starts creeping and crawling.

So crawling is actually what shapes the spine.

It is absolutely essential for proper postural alignment.

That's why we as nurses tell parents we want toddlers to have maximum opportunity to move on the floor.

Let them creep and crawl.

It's building their spine.

That is fascinating.

Okay.

Let's unpack assessment.

You're a nurse.

A child comes in.

What are you looking for?

Well, first and foremost, you're looking for symmetry and range of motion.

In a newborn, the hips have limited rotation and their legs are naturally flexed.

Right.

And their feet might turn in, which is called vorus or turnout valgus.

That can be totally normal just from how they were positioned in the womb.

Usually just stroking the foot helps itself correct.

But then they start walking and toddler walking is, well, it's unique.

It's a bit of a disaster, honestly, but completely normal one.

It's wide -based and unstable.

They don't swing their arms.

No, they hold them up kind of like a tightrope walker.

Yes, for balance.

Yeah.

And their feet look flat.

This is the big one parents ask about.

Their feet look really flat because there's a fat pad right in the arch.

So flat feet in a toddler is normal.

I shouldn't be worried.

Totally normal.

It's expected by 18 months that wide stance should start to narrow.

By age four, they should be able to hop on one foot.

And by age six, they pretty much walk like adults with normal arm swings.

Is there a red flag we should be watching for in that timeline?

The big one the text points out is the 18 month mark.

If a child is not walking independently by 18 months,

that is a signal for investigation.

Yeah.

It needs a skeletal issue.

Got it.

18 months.

And what about toe walking?

I've seen kids do that.

It can be just a habit for sure.

But if a child is still toe walking after age three, it can indicate a muscle problem.

So that's something to look into.

And things like knock knees,

bull legs.

Usually self -correcting.

Bull legs are common until about age five.

Knock knees are common too.

Unless there's pain or a functional problem, like it's interfering with their walking, we generally just reassure the parents that spontaneous resolution is the norm.

That's good to know.

Okay, let's move on to section two.

Pediatric trauma and soft tissue injuries.

Kids play hard, they fall down.

How do we figure out what's actually wrong?

We have a pretty good toolkit.

X -rays are the standard for fractures.

But we also have bone scans.

And what do those show?

They're great for spotting things X -rays might miss, like subtle infections, septic arthritis or tumors.

Then you've got CT which give us that detailed cross -sectional view.

And MRIs.

Why would you use an MRI?

MRIs are fantastic because they don't use any radiation, which is a huge plus in pediatrics.

We always want to limit radiation exposure in kids.

Good point.

And they give these incredibly detailed pictures of soft tissue ligaments, tendons, muscles.

Then there's ultrasound, which we use a lot for things like hip dysplasia.

Again, because there's no radiation.

What about lab work?

Why would we draw blood for, say, a sore leg?

Infection.

We're looking for infection.

We'll check a CVC, a complete blood count, and an ESR, which is the erythrocyte sedimentation rate.

If those are elevated, we might be looking at something like osteomyelitis or septic arthritis.

I see.

We also look at C -reactive protein, which is another inflammatory marker, especially for rheumatological disorders.

Okay, let's talk about the injuries themselves.

The text makes a clear distinction between a contusion, a sprain, and a strain.

Right.

And it's good to know the difference.

A contusion is basically just a bruise.

It's tearing of the subcutaneous tissue that causes hemorrhage.

A sprain is when a ligament is torn or stretched away from the bone.

Think of a sprained ankle.

And a strain.

A strain is a microscopic tear to the muscle with a tendon.

So you pull a muscle.

And the treatment for all of these, I feel like everyone knows rice, but the text uses the acronym PRICE.

Yes, PRICE.

The P is for protection.

You want to protect the area from further injury.

Okay.

Then R is for rest.

I is for ice.

C is for compression, like with an elastic bandage.

And E is for elevation.

Let's zoom in on the ice part.

There's a specific safety note in the text about this.

A huge safety note.

You apply ice, but only in 15 -minute intervals.

Do not leave it on for longer than that.

Why not?

What's the risk?

Because after about 15 minutes, you risk causing ischemia.

You're restricting the blood supply so much that you can actually start to damage the tissue.

It impedes perfusion.

Yeah.

So 15 minutes on, then you take a break.

That's a great clinical pearl.

And how do we know when a kid is ready to go back to soccer practice after a sprain?

We test them.

For an ankle sprain, for example, the text suggests having the child hop on the injured leg five times.

Okay.

Or run a zigzag pattern.

If they can do that without pain and with their full strength, they're probably good to go.

That's a practical test.

I like that.

Okay, section three, traumatic fractures.

We mentioned green stick fractures earlier.

Right.

But we also have simple fractures where the skin is closed and compound fractures where the skin is open.

And compound fractures are the dangerous ones.

Very dangerous.

The bone actually breaks through the skin, which introduces a really high risk of infection getting into the bone.

And then there is the spiral fracture.

This one comes with a big safety alert in the chapter.

It does.

And for good reason.

A spiral fracture is caused by a forceful twisting motion.

Okay.

If you see a spiral fracture in a non -ambulatory infant,

a baby who can't even walk yet,

or a young child,

and the story the parent gives you just doesn't make sense.

You have to suspect something else.

You have to suspect child abuse.

Yeah.

It strongly suggests that someone grabbed that limb and twisted it manually.

That is a chilling thought, but absolutely crucial for a nurse to recognize.

Non -negotiable.

Now you said kids heal faster because of that thick periosteum.

Does that mean they have fewer complications from fractures?

Generally, yes.

Their healing is much more robust.

But there is one very rare, but very life -threatening complication called a fat embolism.

What exactly is that?

It happens when fat particles from the bone marrow escape into the bloodstream after a fracture, usually of a long bone like the femur or if there are multiple fractures.

And what do these fat particles do?

They can travel through the bloodstream and get lodged in the lung, blocking circulation.

That sounds like a major medical emergency.

It is a true emergency.

The nurse needs to be watching for any changes in mental status, any respiratory distress, crackles or wheezes in the lungs.

Okay.

And patechiae, those are the little red pinpoint spots on the chest, neck, or in the axilla.

If you see that combination of symptoms after a fracture, you need to get help immediately.

Good to know.

Okay.

Let's move to section four,

the art of cast care.

I say art because the text makes it sound like there's a lot of technique involved.

There really is.

You have two main materials, plaster of Paris and fiberglass.

Fiberglass seems to be the standard now.

It is.

It's light.

It's water resistant.

It dries in about 30 minutes.

And it comes in all these cool colors, which, you know, kids love.

It gives them a little bit control.

But plaster of Paris is still used sometimes.

It is.

And you have to know how to handle it.

It's heavy.

It takes a full 24 to 48 hours to dry completely.

And here's the technique part.

When you handle a wet plaster cast, you must use your open palms.

Why open palms specifically?

If you use your fingertips, you can create these little indentations in the wet plaster.

Those dents will then dry into hard pressure points that press against the child's skin inside the cast.

You can't see them.

You can't see them and they can cause serious pressure ulcers.

So always open palms.

That is a great tip.

Now, once the cast is on, what is the nurse's number one job?

The neurovascular check.

This isn't skilled 24 .1 in the text.

This is non -negotiable.

It is the absolute priority.

Okay.

So what does that involve?

You are checking the distal digits.

So the toes or the fingers that are sticking out of that cast to make sure that the blood supply and the nerves are still working properly.

And for that, we use the six P's, right?

The six P's plus a few extras.

We can run through them.

First is pain.

Is there pain?

Where is it?

And crucially, does medication help?

Okay.

Pain.

What's next?

Pulse.

Is the pulse distal to the cast strong?

You have to compare it to the pulse on the uninjured side.

Pulse.

Got it.

Third is pallor.

Are the toes pale or white?

That means you've got an arterial problem.

Blood isn't getting there.

Okay.

P number four.

Parasesia.

That's numbness or tingling.

You ask the child, do your toes feel funny like pins and needles?

Good question to ask.

Then paralysis.

Can they move?

Can they wiggle their toes or fingers?

And the last P.

Pressure.

Is there a lot of swelling?

Does the limb feel really tense and tight?

And you mentioned extras.

What about capillary refill?

Absolutely essential.

You gently squeeze the toenail bed or the fingernail bed.

The color should blanch and then return in less than three seconds.

Any delay is a warning sign of poor perfusion.

So what happens if we ignore these signs?

What's the worst case scenario here?

The worst case scenario is compartment syndrome.

This is a progressive loss of tissue perfusion because pressure builds up inside the fascia or the cast itself.

It's like an invisible tourniquet.

And what's the main sign that this is happening?

The absolute classic sign is pain that does not respond to medication.

If a kid has a broken arm, they get a cast.

You give them their pain meds and they are still screaming in agony.

That is compartment syndrome until proven otherwise.

And what's the fix?

How do you treat it?

You have to relieve the pressure immediately.

The physician will split the cast.

If that doesn't work, they might need an emergency fasciotomy, which is a surgery to slice open the muscle casing to let it swell.

Yikes.

Okay.

Let's keep the blood flowing and move to section five.

Traction.

This feels very old school medicine to me.

All the weights and police.

It is old school, but it's still very effective.

Sometimes a cast just isn't enough to align the bones properly.

We need to physically pull them into place using weights and counter -traction.

And the counter -traction is usually just the child's own body weight.

Exactly.

The text lists a few different types.

Bryant,

Buck, Russell.

Let's try to distinguish them.

Sure.

So Bryant traction is for the little kids, usually under two years old or under a certain weight.

For this one, the legs are suspended vertically in the air at a 90 degree angle to the body.

So their legs are pointing straight up at the ceiling.

Straight up.

And the key nursing check here, the thing you have to look for is that the buttocks must be slightly off the bed,

just enough to slide a hand under.

The child's body weight provides that counter -traction.

And if their butt is flat on the mattress?

It's not working.

The traction isn't effective.

Okay.

What about Buck and Russell traction?

Buck skin traction is a horizontal pull.

It pulls the hip and leg into extension.

It's often used for things like femur fractures or hip contracture.

And what's the key nursing care there?

The main thing is preventing the child from sliding down the bed because that ruins the counter -traction.

You have to keep the head of the bed flat or no higher than 20 degrees.

Okay.

And Russell?

Russell traction is a little more complex.

It uses a knee sling.

So you have a vertical pull on the knee and a horizontal pull on the foot at the same time.

And then there's skeletal traction.

That sounds a lot more invasive.

It is.

This is where pins like Steinman pins or Kirchner wires are actually drilled right through the bone.

The traction then pulls on the pin itself.

So infection must be a huge risk, though.

A massive risk.

Octomyelitis, a bone infection, is the big concern.

Pin care is a daily sterile ritual.

You clean the pin sites exactly according to protocol to keep bacteria from getting into that bone.

Now, there's a checklist for traction in the text, a nursing tip.

What are the big do -nots?

The biggest one, the one that should be in flashing neon light, is never lift the weights.

The weights must hang freely at all times.

If you lift them to make the bed or because they're clanging, you release the tension on that broken bone.

That causes intense pain and muscle spasms.

So the weights must hang free.

What else?

The ropes must be in the pulley grooves and the child's body must be in good alignment.

What about the complications of just lying in bed for weeks and weeks?

Oh, it affects every system.

The text mentions a specific circulation complication called Voltman's ischemia.

And that is?

It's similar to compartment syndrome.

Circulation gets obstructed, which leads to muscle anoxia, lack of oxygen, and that can cause permanent contractures.

But they're also just the basic bodily functions to worry about.

Right.

Constipation is a huge issue because they aren't moving.

So lots of fluids and roughage or fiber are key.

They'll probably need stool softeners.

And their lungs?

Fluid can pool in the lungs.

We need them to do deep breathing exercises.

For a kid, that means fun stuff like blowing bubbles or pinwheels to prevent pneumonia.

And boredom.

I can't imagine a six -year -old in traction for a month.

It's incredibly tough.

Diversional therapy is a huge part of nursing care.

We need toys they can reach, maybe suspended over the bed, games, and schooling.

And socially, they need to see people.

The text even mentions taking the entire crib to the playroom if possible.

That's great.

Let's shift gears to section six.

Congenital malformations.

These are things babies are born with.

First up, clubfoot.

The medical term is talipes equinevarus.

Basically, the feet are turned inward, so if it's left untreated, the child would end up walking on their ankles or the outer borders of their feet.

So how do we fix it?

We have to start immediately.

In infancy, the standard treatment is serial splinting and casting.

We change the cast every few weeks to gradually stretch that foot back into a normal position.

Passive stretching exercises help, too.

And if that doesn't work.

If the casting isn't effective by about three months of age, then surgery is usually the next step.

Next is DDH developmental dysplasia of the hip.

The text mentions this one seems to have a cultural component.

It does.

It's more common in cultures where infants are swaddled very tightly with their hips abducted, meaning their legs are straight and held together.

I see.

The text mentions higher rates in some Inuit populations who historically used cradle boards.

And conversely, cultures that carry babies on the hip with their legs spread wide have lower rates.

So how do we spot it in an infant?

In a newborn, you look for limited abduction.

The leg just won't open out fully to the side.

You also look for asymmetrical skin folds on the thighs.

One buttock might even look higher than the other.

And what about the famous click?

That's the Ortolani sign and the Barlow test.

A skilled practitioner manipulates the hip and can actually feel a click or a clunk as the head of the femur slips in or out of the socket.

But there's a safety alert here too.

A big one.

Nurses should not be going around doing the Ortolani test just to try it out.

Only very skilled, experienced providers should do it.

If you do it wrong or too forcefully, you can actually damage the hip cartilage or cause a permanent dislocation.

Good to know.

So once it's diagnosed, what is the treatment?

For infants from about one to six months old, the primary treatment is the Pavlik harness.

What is that?

It's a little set of straps that holds the baby's legs in a frog -like position.

So flexed up and abducted out.

This position keeps the head of the femur seated deeply in the hip socket.

And do the parents have to keep it on all the time?

24 hours a day.

You do not take it off for diaper changes or baths, unless you are specifically instructed to.

You have to sponge bath the baby.

You put loose clothing on over the harness.

It's a big adjustment for the family.

And if the harness doesn't work?

Then we have to move to the Spica cast.

This is a heavy -duty cast that goes from the waist all the way down to the toes, holding the legs open in that frog -like position.

Wow.

That sounds incredibly difficult for diapering and just basic care.

It's a huge challenge.

The text talks about using a special fracture pan for toileting and meticulously checking the edges of the cast.

We often pedal the edges with tape to keep them soft and prevent skin breakdown.

Removing the child.

It's a two -person job.

You need two people to turn a child in a body cast to avoid twisting their spine.

And you never, ever use the crossbar, the bar between the legs, to lift or turn them.

It's not a handle and it can break right off.

Okay, section seven.

Disorders and dysfunction.

Let's run through a few of these.

First, osteomyelitis.

This is a bone infection.

It's usually caused by Staphylococcus aureus.

It often comes from something like a scrape or an infection somewhere else in the body that travels through the blood to the bone.

And what happens in the bone?

The infection creates pus, or exudate, which collects under the periosteum and it squeezes the blood vessels, cutting off circulation to that part of the bone.

That sounds incredibly painful.

It is.

The child will refuse to move the limb at all and the treatment is intense.

Four V antibiotics for four to six weeks.

It's a real marathon, not a sprint.

Next up, Duchenne muscular dystrophy, or DMD.

This is a genetic, sex -linked recessive disorder, so it mostly affects boys.

They are missing a critical protein called dystrophin.

Without it, their muscles degenerate and are replaced by fat.

The onset is usually between two and six years of age.

And there's a very specific sign for this, the Gower sign.

Yes.

It's a hallmark of the disease.

Because their leg and hip muscles are so weak, when the child tries to stand up from a squatting position, they have to use their hands to walk up their own legs to push themselves upright.

And sadly, the prognosis is not good.

No, it's a progressive disease.

Most children end up in wheelchairs by their teens and death often occurs from cardiac or respiratory failure.

Nursing care is really about supportive care -maintaining quality of life and preventing contractures for as long as possible.

Moving to the hip again, slipped capital femoral epiphysis, SCFE.

Right.

This happens in pre -adolescence, usually during a big growth spurt.

The heads of the femur literally slips off the neck of the bone at the growth plate.

And the text says it's strongly linked to something else.

Obesity.

The text notes that about 80 % of children with SCFE are obese.

The extra weight puts a huge amount of sheer stress on that vulnerable growth plate.

So what are the symptoms?

The child starts limping or complaining of thigh or knee pain.

The treatment is surgical.

They have to put a screw in to hold the bone back in place and they absolutely cannot bear any weight on it until it's surgically fixed.

And what about leg calvary perthase disease?

That sounds similar.

It affects the same area, the femoral head.

But it's a different problem.

It's a blood supply issue.

For some unknown reason, the femoral head loses its blood supply and becomes necrotic.

It starts to die.

That sounds terrible.

It does.

But the good news is that it's self -limiting.

The body eventually revascularizes the bone and it heals.

But it takes a very long time, like two to four years.

Two to four years.

Yes.

So the goal of treatment during that time is what we call containment.

We need to keep that softening femoral head deep inside the hip socket so it heals in a nice round shape.

So these kids spend years in abduction braces to keep their legs apart.

Lastly in this section, bone tumors,

osteosarcoma, and Ewing sarcoma.

Osteosarcoma usually hits adolescents during their rapid growth spurts around ages 10 to 15.

It's a primary malignant tumor of the long bones.

And how does it present?

A classic story is a teenager complaining of growing pains that just won't go away, or what seems like a minor sports injury that turns out to be a tumor on an x -ray.

Treatment often involves amputation or a limb salvage surgery, plus chemotherapy.

The text also makes a point to mention phantom limb pain here.

Yes, and it's so important for nurses to understand.

After an amputation, the nerve tracks to the brain still report pain from the missing limb.

It is real physical pain, not imaginary, and nurses need to treat it with real pain medication.

Okay.

And Ewing sarcoma, how is that different?

Ewing sarcoma is a tumor that arises in the marrow of the long bones.

The key difference is that it's very sensitive to radiation and chemotherapy.

So amputation is much less common than with osteosarcoma.

But there's a different risk.

Yes.

The bone becomes very weak and brittle during treatment, so we have to be incredibly careful to prevent pathological fractures.

That means no weight bearing on that limb.

Section 8, juvenile idiopathic arthritis, or JIA.

This isn't your grandma's arthritis.

No, not at all.

It's an autoimmune disease.

The body is attacking its own joints.

It's actually the most common arthritic condition in all of childhood.

And the text says there are three main types.

Yes.

The first is oligoarthritis.

That means four or fewer joints are affected.

The big thing to know here is that these kids are at a very high risk for uveitis, which is inflammation of the eye.

So they need regular eye exams with an ophthalmologist.

OK, what's the second type?

Polyarthritis.

Poly means many, so five or more joints are affected.

And the third?

Systemic.

This is the most severe.

It comes with high fevers, a rash, and can involve internal organs like the heart, liver, and spleen.

Treatment involves meds like NSAIDs and methotrexate.

But what's the core of the nursing care?

It's all about pain management and preserving joint function.

Moist heat, like a warm bath in the morning, really helps with stiff joints.

They might wear resting splints at night to prevent flexion contractures.

And exercise.

Swimming.

Swimming is the best exercise because it's low impact and it moves all the joints through their range of motion.

We also have a couple of spinal issues in this section.

Torticollis.

Right, also known as rhinoch.

The sternocleidomastoid muscle in the neck is short, so the head is tilted to one side.

It's often associated with breech birth.

Simple stretching exercises usually fix it.

And the big one, scoliosis.

The S -shaped spine.

This is a huge topping in adolescent nursing and is particularly common in girls.

We differentiate between functional scoliosis, which is just from poor posture, and structural scoliosis, which involves actual changes to the spine.

Idiopathic scoliosis is the most common type.

How do we screen for it?

What are we looking for?

You're looking for asymmetry?

Are the shoulders at different heights?

Is one scapula more prominent than the other?

Then you have the child bend forward at the waist and you look for a rib hump on one side of the back.

If they have it, what do we do?

Well, it depends on the severity of the curve.

If the curve is under 20 degrees, we usually just recommend exercises to strengthen the core muscles.

If the curve is between 20 and 40 degrees, then we use a brace.

Like the Milwaukee brace.

And that must be a really tough sell for a teenager.

It's extremely tough.

They have to wear this hard, uncomfortable brace for 16 to 23 hours a day.

It has a huge impact on their body image and social life.

Any nursing tips for that?

Absolutely.

They should always wear a clean, dry, cotton t -shirt under the brace to protect their skin from breakdown.

And if the curve is really severe, say over 45 degrees?

Then the treatment is surgery.

A spinal fusion with rods, like Harrington rods, to straighten the spine.

Post -op care is intense.

The nurse has to log roll the patient to keep the spine perfectly straight and do constant, strict neurovascular checks on their legs.

Okay, section nine, sports injuries.

Prevention seems to be the name of the game here.

It is.

Warm -ups, proper equipment, good coaching, adult supervision, all the basics.

Concussions are a big topic, and the text specifically calls out hockey.

Yes, the Canadian Pediatric Society has recommendations on this.

They suggest delaying body checking and hockey until at least age 13 or 14.

Checking is the main cause of injuries and concussions in youth hockey.

There are also some other specific injuries mentioned, stingers or burners.

That's a nerve injury in the neck, common in contact sports.

It feels like an electrical shock or a jolt down the arm.

Shin splints.

Pain in the anterior tibia, usually from running on hard surfaces without proper footwear or conditioning.

And the text also notes some issues specific to female athletes.

Yes, especially in sports like gymnastics and ballet.

We need to be on the lookout for delayed menstruation and the potential for eating disorders, which are part of what's called the female athlete triad.

Finally, we arrive at section 10, violence and child abuse.

This is the heavy but critical final part of our discussion.

It is an absolutely critical section.

It defines abuse very broadly, physical, sexual, emotional and neglect, which isn't just ignoring a child is the failure to provide the basic necessities of life.

It also includes exposure to family violence.

And the text makes a point to note that in Canada,

Indigenous children are overrepresented here.

Yes, the data from Statistics Canada shows that Indigenous children are a major at -risk group.

The text alludes to this being due to complex systemic factors and the intergenerational trauma and social stress from the legacy of colonization.

As a nurse on the front line, you are often the detective.

How do you assess for abuse?

You look for inconsistencies.

Does the story match the injury?

If a parent says the three -month -old fell out of the crib, but the baby had a spiral fracture, that story just doesn't add up.

You also look for bruises in various stages of healing.

And bruise dating.

This is a science.

It really is.

Bruises change color in a predictable way as they heal.

For the first one, two days, a bruise is swollen and tender, maybe reddish.

Around five, seven days, it turns green.

At seven, ten days, it becomes yellow.

And from ten, fourteen days, it feeds to brown.

So if a child has bruises that are red, green, and yellow all at the same time?

It means they are being injured repeatedly over a period of time.

But the text also says we have to be careful about cultural mimics.

Yes.

This is so important for cultural safety.

Practices like coining, which is common in some Asian cultures, can leave red welts on the back.

Cupping leaves circular marks.

Some folk remedies, like garlic preparations, can cause blisters that look like burns.

And these aren't abuse?

No.

There are traditional healing practices intended to heal, not harm.

We need to be aware of them and ask questions respectfully.

If we do suspect abuse, what is our legal duty?

You have a legal duty to report.

In Canada, every province and territory has legislation that requires this.

You do not need proof.

So you don't have to be 100 % sure?

No.

You just need a good face suspicion.

If you suspect it, you report it to the local child protective services.

The law protects nurses from liability when they make these reports in good faith.

And documentation.

How should that be handled?

It must be factual and objective.

Quote, the parent and the child directly in your notes.

Don't write your opinion like parents seem defensive.

Instead, right,

parents stated, stop asking me so many questions and cross their arms.

Just the facts.

Only the facts.

Wow.

Okay.

We have covered a massive amount of ground.

From the first weeks of fetal bone growth, all the way to the complex legalities of child protection.

Really is a comprehensive system from top to bottom.

So after all that, what does this all mean?

What's the so what for the nursing student listening to this?

For me, it's that early detection changes a child's entire life trajectory.

Spotting DDH early means that child gets a pavlik harness and walks normally for the rest of their life.

Catching scoliosis early means bracing instead of a massive spinal fusion surgery.

And reporting a suspicious fracture might literally save a child's life from further abuse.

That's incredibly high stakes.

The stakes couldn't be higher.

Here's a final thought for you to chew on.

We talked about how bones can remodel and heal themselves.

But maybe you can consider the role of the nurse not just as a healer of bones, but as a detective for the safety and the future of that child.

You are reading the body like a text, the way they walk, the pattern of bruises, their reaction to pain.

You're the frontline.

That's a powerful thought to end on.

Thank you for listening to this last minute lecture on the deep dive.

Good luck with your studies and we will see you next time.

Thank you from the last minute lecture team.