Pain that keeps rising under a cast and is not relieved by analgesia is compartment syndrome.Report it — do not elevate above the heart.
💡 The one idea
A child’s bone is growing, so the growth plate is the weak point. An injury that
would sprain an adult ligament instead fractures a child’s physis — and
growth plate damage can affect limb length for life.
🚨 The 6 Ps of neurovascular compromise
Pain — especially out of proportion, or on passive stretch
Pallor · Pulselessness · Paraesthesia
Paralysis · Poikilothermia (cool limb)
Pain that keeps increasing under a cast, unrelieved by analgesia, is compartment syndrome until proven otherwise. Report immediately - do not elevate above heart level and never ignore it.
Avascular necrosis of femoral head; limit weight bearing
SCFE
Obese adolescent — hip/knee pain, out-toeing
Non-weight bearing, surgical
Scoliosis
Adolescent growth spurt
Forward-bend test; brace while growing
Duchenne MD
Boys 3–5 y — Gower sign, calf pseudohypertrophy
Progressive; maintain mobility, watch respiratory and cardiac
🧵 Cast and traction care
Elevate and apply ice for the first 24–48 h to limit swelling
Check circulation, movement and sensation distal to the cast regularly
Petal the edges; keep the cast dry
Nothing goes down inside a cast to scratch - it breaks skin you cannot see.
In traction, weights hang free and are never lifted off
⭐ High-yield — what the exam actually asks
Show 5 moreHide these 5
Pediatric bone has open growth plates and thick periosteum, so children get buckle and greenstick fractures and heal fast.
Neurovascular check is the priority after any cast, splint or traction — q15 min for the first hour, then hourly. 6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia.
Compartment syndrome is unrelenting pain that pain medication does not touch.
RICE: ice 15–20 min each hour for the first 24–48 hr; elevate above heart level.
Cast care: fiberglass dries in about 30 minutes, plaster 24–72 hours and must be handled with palms only. Keep it dry, cool blow dryer for itching, never insert objects. Expect constipation from immobility — push fiber and fluids.
Show 5 moreHide these 5
Only the provider adjusts traction weights, Pavlik straps or a brace.
DDH risk factors: breech, female, firstborn, large for gestational age. Ortolani and Barlow on exam; ultrasound under 6 months, x-ray after. Pavlik harness for under 6 months, worn 3–4 months.
Scoliosis by curve: <20° monitor; 20–40° Boston brace 23 hours a day (slows progression, does not correct); 40–80° spinal fusion; >80° halo traction. Log roll after fusion, and ask about headache as a CSF leak clue.
Duchenne: X-linked, onset 3–5 years, positive Gower sign, pseudohypertrophied calves, elevated CPK, wheelchair by about 12. No cure.
SCFE occurs in obese preadolescent males and often presents as knee pain. Legg-Calvé-Perthes is avascular necrosis of the femoral head with a painless limp.
Show 2 moreHide these 2
Osteomyelitis: elevated WBC/CRP/ESR with a positive blood culture. Long-course IV antibiotics.
A spiral fracture, or any fracture in a non-ambulatory infant, is an abuse red flag.
Cast drying: plaster is heavy, not water-resistant and takes 10–72 hours; fiberglass is light, water-resistant and dries in 5–30 minutes. Handle a wet plaster cast with your palms only — fingers leave dents that become pressure points.
Elevate for the first 24–72 hours and ice for the first 24, no more than 20 minutes at a time. Turn her every 2 hours so the cast dries evenly.
Report pain that is extreme or not relieved an hour after medication — that is the compartment syndrome question.
Capillary refill under 3 seconds distal to the cast, checked on a schedule.
Nothing goes down inside a cast — no coat hangers, no pencils, no powder.
Clubfoot: serial casts start in the first month and run about 5–8 weeks, then a heel cord tenotomy and 3 weeks in a long leg cast, then an abduction brace worn at night for 4–5 years.
DDH: Ortolani and Barlow at every well visit up to 12 months. Ultrasound is the imaging at 6 weeks; X-ray is only useful after 6 months, when the bone has ossified.
Legg-Calvé-Perthes affects ages 3–12, most often 5 to 7.
📚 From your Maternal & Child textbook
Pillitteri, Maternal and Child Health Nursing — musculoskeletal chapters.
Report pain that is extreme, or not relieved an hour after analgesia, in a casted limb — that is the compartment syndrome question.
⚠️ Exam traps
The brace slows scoliosis progression. It does not correct the curve.
Knee pain that is actually hip pathology — SCFE and Perthes both do this.
Pain that nothing relieves after casting is compartment syndrome, not inadequate dosing.
🧠 Mind maps 3
One per disorder, built from the structure of your ATI chapter.
Fractures
🎯 Who gets it
Obesity and poor nutrition
Developmental stage and ordinary play — falls while climbing or running
Recreational trauma from skateboarding, skiing, soccer, or basketball
👀 What you see
Pain, crepitus, deformity, edema, ecchymosis, and reduced use of the affected part
Plastic deformation (bend): bone bends without breaking
Buckle (torus): porous bone compresses into a bulge at the fracture site
Greenstick: incomplete break
🧪 What confirms it
Radiograph confirms the diagnosis and shows bone position — help the child stay still during the film
🩺 What you do
Take a history of how the injury happened and maintain airway, breathing, and circulation
Monitor vital signs, pain, neurologic status, and the neurovascular status of the injured limb
Position supine for distal arm, pelvis, and lower extremity injuries; position sitting for shoulder or upper arm injuries
Remove jewelry or anything that could constrict the affected limb
💊 Drugs
Analgesics as prescribed; with opioids monitor for respiratory depression and constipation
Tetanus immunization for open fractures
Antibiotics for open fractures
💬 What you teach
The cast feels warm as it sets but will not burn
Report severe pain or pain not relieved 1 hr after analgesics
Teach caregivers and child how to do neurovascular checks and when to call the provider
⚠️ What goes wrong
Compartment syndrome — compression of nerves, vessels, and muscle in a closed space causing neuromuscular ischemia, most often with tibial or forearm fractures
Causes include casting, a constrictive dressing, skin traction, surgery, trauma, burns, hemorrhage, or severe IV infiltration
Signs: pain unrelieved by elevation or analgesics and increased by passive movement, early paresthesia or numbness, late pulselessness distal to the fracture
Management is removing the restrictive device, with fasciotomy if needed; untreated it leads to deformity, paralysis, and infection
Read left to right: who gets it → what you see → what confirms it → what you do → what goes wrong. Cover a column and rebuild it out loud.
Musculoskeletal Congenital Disorders
🎯 Who gets it
Clubfoot: hereditary factors, more common in boys
Osteogenesis imperfecta: a parent with the condition
Legg-Calve-Perthes: ages 3-12 years with peak at 5-7 years, more common in boys, trauma, decreased circulation or inflammation of the femoral head, family history, low birth weight, low socioeconomic status, smoke exposure
Developmental dysplasia of the hip: female sex, firstborn, family history, breech presentation, oligohydramnios, joint instability, large for gestational age, multiple births, and swaddling done improperly
👀 What you see
Clubfoot: affected foot is shorter and smaller with an empty heel pad and a visible plantar crease at midfoot; unilateral cases show calf atrophy
Talipes varus is inversion, valgus is eversion, calcaneus is dorsiflexion with toes above the heel, equinus is plantar flexion with toes below the heel, and equinovarus points the toes inward and below the heel
Osteogenesis imperfecta: multiple fractures with fragile bones and deformity, blue sclera, early hearing loss, small discolored teeth
Legg-Calve-Perthes: painful rotation of the thigh, pain with walking, intermittent painless limp, hip stiffness, limited range of motion, hip/thigh/knee pain, shortened affected leg, thigh and gluteal atrophy
🧪 What confirms it
Prenatal ultrasound can identify clubfoot
Bone biopsy for osteogenesis imperfecta
DDH screening: provider performs Ortolani and Barlow maneuvers at every well visit through 12 months
Ultrasound for DDH at 6 weeks of age; x-ray diagnoses DDH after 6 months
🩺 What you do
Encourage caregivers to hold and cuddle the child and to meet developmental needs
Perform neurovascular and skin integrity checks and provide cast care
Legg-Calve-Perthes treatment varies with age and femoral head condition — NSAIDs, initial rest with limited weight bearing, abduction brace or casts, physical therapy, traction, then progression to active range of motion, with hip or femoral osteotomy if surgery is needed
DDH treatment begins as soon as it is diagnosed and depends on age and severity
💊 Drugs
Bisphosphonate therapy such as pamidronate increases bone density and prevents fractures in osteogenesis imperfecta
💬 What you teach
Proper cast care and the importance of scheduled cast changes
Change diapers frequently with a spica cast
Report decreased circulation shown by pain, pallor, and coldness
⚠️ What goes wrong
Growth and development delays — monitor milestones and use strategies to support normal development
Effects of casting: skin breakdown and neurovascular alterations
Effects of immobilization: reduced muscle strength, bone demineralization, altered bowel motility
Cerebral palsy perinatal: premature rupture of membranes, long labor, premature birth, low birth weight, meconium aspiration, asphyxia, stroke, bleeding
Cerebral palsy postnatal: infections including cerebral infections, brain injury, seizures, head trauma such as shaken baby syndrome
Spina bifida: medications or substances during pregnancy, maternal malnutrition, insufficient folic acid, radiation or chemical exposure, genetic predisposition
👀 What you see
Cerebral palsy motor signs: gagging or choking with feeding, poor suck, persistent tongue thrust, asymmetric crawl, early hand preference, toe walking
Cerebral palsy reflexes and tone: persistent primitive reflexes such as Moro or tonic neck, hyperreflexia, rigid posture and extremities, scissoring and extension of the legs, arching back, stiff posture, difficulty diapering
Spastic cerebral palsy: hypertonicity, increased deep tendon reflexes, clonus, poor control of movement, balance, and posture
Associated cerebral palsy problems: vision, speech, or hearing impairment, seizures, cognitive impairment, impaired social relationships, and caregiver reports of missed milestones
🧪 What confirms it
Maternal alpha-fetoprotein in the second trimester suggests a possible neural tube defect
Infant blood cultures to identify a causative pathogen when appropriate
Juvenile idiopathic arthritis: elevated C-reactive protein and erythrocyte sedimentation rate, CBC with differential showing raised WBC especially during flares
Antinuclear antibodies indicate increased uveitis risk; rheumatoid factor is rarely detected in children
🩺 What you do
Individualize care to child and family and arrange hearing and speech evaluations as needed
Promote independence in self-care and support positive self-image and self-esteem
Assess family coping, support, and awareness of available resources
Assess developmental level and monitor milestones, structuring interventions and communication around developmental rather than chronologic age
💊 Drugs
Intrathecal baclofen through a surgically implanted pump is a centrally acting skeletal muscle relaxant that reduces spasm and severe spasticity in cerebral palsy
Diazepam is a skeletal muscle relaxant for muscle spasm and severe spasticity
Botulinum toxin A given IM reduces spasticity in specific muscle groups such as the quadriceps by blocking acetylcholine release, used mainly when spasticity is limited to the lower extremities
💬 What you teach
Watch for expected medication responses and know which adverse effects require a call to the provider
Never stop a medication without talking to the provider
Learn pump use, site care, and medication replacement for intrathecal therapy
⚠️ What goes wrong
Aspiration — keep the head elevated, have suction available for copious secretions or swallowing difficulty, use safe feeding techniques, and encourage caregivers to take CPR classes
Injury risk — raise and pad bed rails and wheelchair arms, secure the child in mobility devices, ensure adequate rest to avoid fatigue-related injury, and use helmets, seat belts, and other safety equipment
Skin ulceration from prolonged pressure — monitor skin and reposition frequently off bony prominences
Latex allergy risk with spina bifida, ranging from urticaria to wheezing and anaphylaxis, and linked to banana, avocado, kiwi, and chestnut allergy — test, avoid latex including water toys, pacifiers, and plastic storage bags, teach epinephrine use, and wear an allergy alert bracelet
Read left to right: who gets it → what you see → what confirms it → what you do → what goes wrong. Cover a column and rebuild it out loud.
🎥 Lecture recordings 2
Tap a card to open that recording in Google Drive. The same list lives in the lecture library.
ATI Active Learning Template — System DisorderFractures
Filled from ATI chapter 27, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
A fracture occurs when applied stress exceeds the bone's resistance and disrupts its integrity. Children heal and remodel faster than adults. Injury to the epiphyseal (growth) plate can alter future bone growth. Radiographs showing multiple fractures at different stages of healing, or fractures in infants, suggest physical maltreatment or osteogenesis imperfecta.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Helmets, correct car restraints, playground surfaces, and window guards.
Calcium, vitamin D and weight-bearing activity for bone strength.
Consider non-accidental injury where the history does not match the injury, in a non-mobile infant, or with multiple fractures of different ages. This must be raised, not hoped away.
Teach that a child’s bone can buckle or bend without breaking through — a child who will not use a limb needs assessment even without an obvious deformity.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Obesity and poor nutrition
Developmental stage and ordinary play — falls while climbing or running
Recreational trauma from skateboarding, skiing, soccer, or basketball
Assessment — Expected Findings
Pain, crepitus, deformity, edema, ecchymosis, and reduced use of the affected part
Plastic deformation (bend): bone bends without breaking
Buckle (torus): porous bone compresses into a bulge at the fracture site
Greenstick: incomplete break
Transverse: break straight across the bone; oblique: diagonal; spiral: winds around the bone
Physeal: injury at the growth plate of a long bone
Stress: small cracks from repeated weight-bearing pressure
Complete means fragments are separated; incomplete means they remain attached
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
From this module — built from the notes above on this page, not a section of the ATI chapter.
None for a simple fracture — it is an imaging diagnosis.
CBC and type and screen before operative fixation, or with significant blood loss.
Calcium, phosphate, vitamin D and alkaline phosphatase where bones break too easily.
Skeletal survey where non-accidental injury is suspected — it looks for older, healing fractures.
Diagnostic Procedures
Radiograph confirms the diagnosis and shows bone position — help the child stay still during the film
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Take a history of how the injury happened and maintain airway, breathing, and circulation
Monitor vital signs, pain, neurologic status, and the neurovascular status of the injured limb
Position supine for distal arm, pelvis, and lower extremity injuries; position sitting for shoulder or upper arm injuries
Remove jewelry or anything that could constrict the affected limb
Stabilize the injury and avoid unnecessary movement, splinting the joints above and below
With a suspected pelvic fracture watch for hypovolemic shock and check urine for blood
Elevate the affected extremity and apply cold rather than heat
Perform frequent neurovascular checks
Medications
Analgesics as prescribed; with opioids monitor for respiratory depression and constipation
Tetanus immunization for open fractures
Antibiotics for open fractures
Therapeutic Procedures
Casting immobilizes the limb, maintains alignment, and manages the fracture
Cast types include short-arm and long-arm, short-leg and long-leg, bilateral long-leg, shoulder spica, single spica, 1.5 spica, and full spica
Plaster of Paris is heavy, not water resistant, and dries in 10-72 hr; synthetic fiberglass is light, water resistant, and dries in 5-20 min
Before casting inspect, clean, and dry the skin, apply a stockinette or waterproof liner, and pad bony prominences to prevent breakdown
💬 Around the patientClient Education · Interprofessional Care
Client Education
The cast feels warm as it sets but will not burn
Report severe pain or pain not relieved 1 hr after analgesics
Teach caregivers and child how to do neurovascular checks and when to call the provider
Give crutch-walking instructions for lower extremity casts
Reinforce skin and perineal care with a spica cast and proper vehicle restraints for transport
Never put anything inside the cast, which can injure the skin
Explain cast removal and the cast cutter ahead of time
Interprofessional Care
Orthopedic specialists manage pediatric fracture care
Notify social services when maltreatment is suspected
⚠️ What goes wrongComplications
Complications
Compartment syndrome — compression of nerves, vessels, and muscle in a closed space causing neuromuscular ischemia, most often with tibial or forearm fractures
Causes include casting, a constrictive dressing, skin traction, surgery, trauma, burns, hemorrhage, or severe IV infiltration
Signs: pain unrelieved by elevation or analgesics and increased by passive movement, early paresthesia or numbness, late pulselessness distal to the fracture
Management is removing the restrictive device, with fasciotomy if needed; untreated it leads to deformity, paralysis, and infection
Volkmann contracture — permanent contracture of the forearm and hand
ATI Active Learning Template — System DisorderMusculoskeletal Congenital Disorders
Filled from ATI chapter 28, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Congenital musculoskeletal disorders may appear at birth or emerge later in infancy, childhood, or adolescence, and can be localized or affect the whole body. Clubfoot (congenital talipes equinovarus) is a complex ankle and foot deformity of one or both feet, occurring alone or with cerebral palsy or spina bifida, and classified as positional (intrauterine crowding), syndromic, or congenital/idiopathic. Legg-Calve-Perthes disease is impaired circulation to the femoral head causing aseptic necrosis, unilateral or bilateral, with insidious onset and stages of necrosis, fragmentation, reossification, and remodeling. Developmental dysplasia of the hip covers a range of abnormal hip development, including acetabular dysplasia where the acetabular roof is shallow and oblique. Osteogenesis imperfecta produces fragile bones. Scoliosis is lateral curvature of the spine.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Hip examination at every well-child visit until walking — Ortolani and Barlow, then leg length and gait.
Avoid swaddling with the legs straight and together — it raises the risk of hip dysplasia. Hips should be free to flex and abduct.
Earlier detection means simpler treatment: a harness in infancy rather than surgery later.
Screen siblings, since dysplasia and clubfoot both cluster in families.
Folic acid before conception reduces neural tube defects.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Assessment — Risk Factors
Clubfoot: hereditary factors, more common in boys
Osteogenesis imperfecta: a parent with the condition
Legg-Calve-Perthes: ages 3-12 years with peak at 5-7 years, more common in boys, trauma, decreased circulation or inflammation of the femoral head, family history, low birth weight, low socioeconomic status, smoke exposure
Developmental dysplasia of the hip: female sex, firstborn, family history, breech presentation, oligohydramnios, joint instability, large for gestational age, multiple births, and swaddling done improperly
Scoliosis: genetic tendency, more common in females, peak incidence ages 10-15 years
Assessment — Expected Findings
Clubfoot: affected foot is shorter and smaller with an empty heel pad and a visible plantar crease at midfoot; unilateral cases show calf atrophy
Talipes varus is inversion, valgus is eversion, calcaneus is dorsiflexion with toes above the heel, equinus is plantar flexion with toes below the heel, and equinovarus points the toes inward and below the heel
Osteogenesis imperfecta: multiple fractures with fragile bones and deformity, blue sclera, early hearing loss, small discolored teeth
Legg-Calve-Perthes: painful rotation of the thigh, pain with walking, intermittent painless limp, hip stiffness, limited range of motion, hip/thigh/knee pain, shortened affected leg, thigh and gluteal atrophy
DDH in infants: asymmetric and unequal gluteal/thigh skin folds, limited hip abduction, shortened femur on the affected side, audible clunk, positive Ortolani (hip reduces with abduction) and positive Barlow (hip dislocates with adduction)
DDH in older children: one leg shorter, toe walking on one side, limp, waddling gait with lumbar lordosis in bilateral dislocation, positive Trendelenburg sign
Scoliosis: asymmetry of scapulae, ribs, flanks, shoulders, and hips, with clothing that fits unevenly
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
From this module — built from the notes above on this page, not a section of the ATI chapter.
Usually none — these are diagnosed by examination and imaging.
Vitamin D and calcium where rickets or poor bone healing is suspected.
Genetic testing for suspected skeletal dysplasia or osteogenesis imperfecta.
Pre-operative CBC, type and screen before corrective surgery.
Diagnostic Procedures
Prenatal ultrasound can identify clubfoot
Bone biopsy for osteogenesis imperfecta
DDH screening: provider performs Ortolani and Barlow maneuvers at every well visit through 12 months
Ultrasound for DDH at 6 weeks of age; x-ray diagnoses DDH after 6 months
Scoliosis screening in preadolescence for both sexes, observing the child from behind wearing only underwear
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Encourage caregivers to hold and cuddle the child and to meet developmental needs
Perform neurovascular and skin integrity checks and provide cast care
Legg-Calve-Perthes treatment varies with age and femoral head condition — NSAIDs, initial rest with limited weight bearing, abduction brace or casts, physical therapy, traction, then progression to active range of motion, with hip or femoral osteotomy if surgery is needed
DDH treatment begins as soon as it is diagnosed and depends on age and severity
Pavlik harness for newborn to 6 months prevents hip flexion and adduction — worn 23 hr/day for 1-3 months until the hip stabilizes, then during sleep for another 4-6 weeks, with provider strap adjustment at least weekly and caregiver checks twice daily
Osteogenesis imperfecta: obtain manual blood pressures, position carefully to prevent fractures, provide frequent oral care, and monitor for respiratory infections
Bisphosphonate care: give IV and monitor for hypocalcemia, malaise, reflux, gastric ulcer, and osteonecrosis of the jaw
Spinal fusion preoperative care: arrange autologous blood donation if indicated, obtain labs including type and crossmatch, orient family to the pediatric ICU, and explain postoperative monitoring equipment, NG tube, chest tube, indwelling catheter, breathing exercises, and PCA use
Spinal fusion postoperative care: initial ICU monitoring, standard postoperative care, pain assessment with an age-appropriate tool, PCA analgesia, and frequent neurovascular checks
Medications
Bisphosphonate therapy such as pamidronate increases bone density and prevents fractures in osteogenesis imperfecta
Therapeutic Procedures
Clubfoot: serial casting starting in the first month and continuing about 5-8 weeks, with weekly manipulation to stretch the muscles followed by a new long-leg cast
Clubfoot: heel cord tenotomy after casting, then a long-leg cast for 3 weeks, then an abduction brace of two shoes joined by a bar worn at bedtime for about 4-5 years to prevent recurrence
DDH closed reduction with hip spica cast when the Pavlik harness fails — the surgeon seats the femoral head in the acetabulum under anesthesia and the spica cast holds the position, confirmed by CT or MRI afterward
Hip spica cast maintains external rotation of the hip and is changed by the provider as the child grows
Older children with DDH: surgical reduction with presurgical traction, often with femoral osteotomy, reconstruction, and tenotomy
💬 Around the patientClient Education · Interprofessional Care
Client Education
Proper cast care and the importance of scheduled cast changes
Change diapers frequently with a spica cast
Report decreased circulation shown by pain, pallor, and coldness
Never adjust the Pavlik harness straps yourself; if removal is prescribed, learn to reapply it correctly
Pavlik skin care: dress the infant in an undershirt and knee socks, check skin under the straps, massage gently, avoid lotions and powders, and tuck the diaper under the straps
Understand the limited weight-bearing plan and learning and activity strategies during that period, and keep the child in school
Understand spica cast home management including positioning, turning, neurovascular checks, and cast care
Interprofessional Care
Orthopedic provider and physical therapist
⚠️ What goes wrongComplications
Complications
Growth and development delays — monitor milestones and use strategies to support normal development
Effects of casting: skin breakdown and neurovascular alterations
Effects of immobilization: reduced muscle strength, bone demineralization, altered bowel motility
Postoperative spinal fusion: atelectasis, ileus, wound infection, pneumothorax, hypotension from blood loss, spinal cord or neurologic injury
Superior mesenteric artery syndrome — the duodenum is compressed between the aorta and superior mesenteric artery, causing obstruction
Severe scoliosis curves cause breathing difficulty; support age-appropriate strategies for self-esteem
📋 Chronic Neuromusculoskeletal Disorders6 parts
ATI Active Learning Template — System DisorderChronic Neuromusculoskeletal Disorders
Filled from ATI chapter 29, row by row from that chapter’s own sections — 12 of 12 rows have content.
🧭 What it isAlterations in Health (Diagnosis) · Health Promotion & Disease Prevention
Alterations in Health (Diagnosis)
Chronic mobility problems arise from the musculoskeletal system or from disorders along the neural pathway between the cerebral cortex and the neuromuscular junction. Cerebral palsy is a nonprogressive impairment of motor function, muscle control, coordination, and posture that can also alter perception and sensation and bring vision, hearing, and speech impairment, seizures, and cognitive disability; it is congenital or acquired and classified as spastic/pyramidal (up to 80% of cases), dyskinetic/extrapyramidal (10-20%), or ataxic. Spina bifida is a neural tube defect in which the osseous spine fails to close — occulta usually affects the lumbosacral area, is not externally visible, and spares the cord, while cystica shows a protruding sac. Juvenile idiopathic arthritis is a chronic autoimmune inflammation of joints and other tissues where synovial inflammation erodes articular cartilage; it is rarely life-threatening and may remit, but can leave joint deformity and altered function. Its forms are oligoarthritis, polyarthritis with or without rheumatoid factor, systemic, psoriatic, enthesitis-related, and undifferentiated. Muscular dystrophy is a group of inherited disorders causing progressive degeneration of symmetric skeletal muscle groups; Duchenne (pseudohypertrophic) is the most common, X-linked recessive, with onset at 3-5 years, rapid progression, and life expectancy around 30 years.
Health Promotion & Disease Prevention
From this module — built from the notes above on this page, not a section of the ATI chapter.
Early intervention services from diagnosis — the earlier therapy starts, the better function is preserved.
Maintain range of motion and positioning to prevent contractures.
Nutrition and safe swallowing; aspiration is a leading cause of admission.
Skin protection where mobility and sensation are reduced.
Full immunization, including influenza, because respiratory infection is the main threat.
👀 How it shows upAssessment — Risk Factors · Assessment — Expected Findings
Cerebral palsy perinatal: premature rupture of membranes, long labor, premature birth, low birth weight, meconium aspiration, asphyxia, stroke, bleeding
Cerebral palsy postnatal: infections including cerebral infections, brain injury, seizures, head trauma such as shaken baby syndrome
Spina bifida: medications or substances during pregnancy, maternal malnutrition, insufficient folic acid, radiation or chemical exposure, genetic predisposition
Juvenile idiopathic arthritis: immunogenic susceptibility, environmental triggers, female sex
Muscular dystrophy: family genetic history
Assessment — Expected Findings
Cerebral palsy motor signs: gagging or choking with feeding, poor suck, persistent tongue thrust, asymmetric crawl, early hand preference, toe walking
Cerebral palsy reflexes and tone: persistent primitive reflexes such as Moro or tonic neck, hyperreflexia, rigid posture and extremities, scissoring and extension of the legs, arching back, stiff posture, difficulty diapering
Spastic cerebral palsy: hypertonicity, increased deep tendon reflexes, clonus, poor control of movement, balance, and posture
Associated cerebral palsy problems: vision, speech, or hearing impairment, seizures, cognitive impairment, impaired social relationships, and caregiver reports of missed milestones
Spina bifida occulta: lumbosacral dimpling, port wine angioma nevi, dark hair tufts, subcutaneous lipoma
Spina bifida cystica: sac protruding midline from the osseous spine, flaccid muscles with flaccid paralysis and absent deep tendon reflexes, no bowel control, constant urine dribbling or overflow, foot contractures, scoliosis or kyphosis
Juvenile idiopathic arthritis: joint swelling and stiffness worse in the morning or after inactivity, limited mobility, limping gait, fever, rash, delayed growth, fatigue
Muscular dystrophy: muscle weakness starting in the lower extremities, unsteady waddling gait, lordosis, delayed motor development, frequent falls, learning difficulties
🧪 How it is confirmedLaboratory Tests · Diagnostic Procedures
Laboratory Tests
Maternal alpha-fetoprotein in the second trimester suggests a possible neural tube defect
Infant blood cultures to identify a causative pathogen when appropriate
Juvenile idiopathic arthritis: elevated C-reactive protein and erythrocyte sedimentation rate, CBC with differential showing raised WBC especially during flares
Antinuclear antibodies indicate increased uveitis risk; rheumatoid factor is rarely detected in children
Muscular dystrophy: blood PCR to detect the dystrophin gene mutation, elevated creatine kinase which can rise before symptoms, and genetic analysis
Diagnostic Procedures
General movements assessment from birth to 20 weeks post term
MRI evaluates structures and abnormal areas — keep the child still and sedate if prescribed
Prenatal ultrasound can visualize the defect; amniocentesis after elevated alpha-fetoprotein detects anencephaly or myelomeningocele; chorionic villus sampling rules out other birth defects and genetic conditions
After birth: MRI, ultrasonography, and CT of spine and brain, myelography, and spinal x-ray for occulta
Radiographs give a baseline in juvenile idiopathic arthritis — early films show increased synovial fluid with soft tissue swelling or joint widening, later films show narrowed joint space
🩺 What you doNursing Care · Medications · Therapeutic Procedures
Nursing Care
Individualize care to child and family and arrange hearing and speech evaluations as needed
Promote independence in self-care and support positive self-image and self-esteem
Assess family coping, support, and awareness of available resources
Assess developmental level and monitor milestones, structuring interventions and communication around developmental rather than chronologic age
Speak directly to the child while including caregivers, and support augmented communication with electronic devices, flash cards, picture boards, or touch-screen computers
Medications
Intrathecal baclofen through a surgically implanted pump is a centrally acting skeletal muscle relaxant that reduces spasm and severe spasticity in cerebral palsy
Diazepam is a skeletal muscle relaxant for muscle spasm and severe spasticity
Botulinum toxin A given IM reduces spasticity in specific muscle groups such as the quadriceps by blocking acetylcholine release, used mainly when spasticity is limited to the lower extremities
NSAIDs — ibuprofen, naproxen, diclofenac, indomethacin, tolmetin — control pain and inflammation
Prednisone increases muscle strength
Therapeutic Procedures
Myelomeningocele sac closure as soon as possible, generally within 24-72 hr of birth, to prevent injury and infection, with hydrocephalus risk afterward
Preoperatively protect the sac, place the infant prone and unclothed in an incubator or radiant warmer
Apply a sterile moist nonadherent dressing with sterile 0.9% sodium chloride to the sac, changing every 2 hr; if it dries, add more sterile solution rather than pulling it off
Inspect the sac closely for leaks, irritation, abrasion, and local infection, and watch for systemic infection signs of fever, irritability, and lethargy
Orthopedic surgery to correct contractures and spastic deformities, including tendon release
Neurosurgical dorsal rhizotomy
💬 Around the patientClient Education · Interprofessional Care
Client Education
Watch for expected medication responses and know which adverse effects require a call to the provider
Never stop a medication without talking to the provider
Learn pump use, site care, and medication replacement for intrathecal therapy
Follow the therapeutic plan, nutritional guidelines, feeding schedule and techniques, and medication regimen
Build in rest periods and developmentally appropriate recreation and stimulation
Maintain dental hygiene and regular examinations, keep immunizations current
Understand wound care, ankle-foot orthoses, and pulmonary hygiene techniques if prescribed
Interprofessional Care
Cerebral palsy team may include neurologist, pulmonologist, speech-language pathologist, dietitian, physical and occupational therapy, and social work depending on severity
Refer for technical aids that improve coordination, speech, mobility, and independence, including voice-activated wheelchairs
Physical therapy provides range of motion to strengthen muscles, build endurance, and prevent contractures and deformity, plus orthotic devices such as braces and splints and adaptive equipment such as scooters and wheelchairs
Spina bifida team: neurosurgeon, urologist, orthopedics, pediatrician, physical and occupational therapy, social worker
Juvenile idiopathic arthritis team: physical and occupational therapy, ophthalmologist, dentist, rheumatologist, dietitian, social worker, school nurse, counselors, psychologists
⚠️ What goes wrongComplications
Complications
Aspiration — keep the head elevated, have suction available for copious secretions or swallowing difficulty, use safe feeding techniques, and encourage caregivers to take CPR classes
Injury risk — raise and pad bed rails and wheelchair arms, secure the child in mobility devices, ensure adequate rest to avoid fatigue-related injury, and use helmets, seat belts, and other safety equipment
Skin ulceration from prolonged pressure — monitor skin and reposition frequently off bony prominences
Latex allergy risk with spina bifida, ranging from urticaria to wheezing and anaphylaxis, and linked to banana, avocado, kiwi, and chestnut allergy — test, avoid latex including water toys, pacifiers, and plastic storage bags, teach epinephrine use, and wear an allergy alert bracelet
Increased ICP from shunt malfunction or hydrocephalus — infants show high-pitched cry, lethargy, vomiting, bulging fontanels, widening sutures, increasing head circumference; children show headache, lethargy, nausea, vomiting, double vision, declining school performance, decreased consciousness, seizures
For raised ICP prepare for shunt placement or revision, use gentle movements during range of motion, minimize noise and visitors, and manage pain
Neurogenic bladder with myelomeningocele causing spasm or flaccidity — monitor for dysfunction, infection, and hematuria, give antispasmodics or perform intermittent catheterization, and teach vesicostomy stoma care if present
📝 Notes & key concepts
The lines from this module that carry a number, a dose or an absolute rule — the ones that decide questions. Everything else is on the cards above.
Neurovascular check is the priority after any cast, splint or traction — q15 min for the first hour, then hourly. 6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia.
RICE: ice 15–20 min each hour for the first 24–48 hr; elevate above heart level.
Cast care: fiberglass dries in about 30 minutes, plaster 24–72 hours and must be handled with palms only. Keep it dry, cool blow dryer for itching, never insert objects. Expect constipation from immobility — push fiber and fluids.
DDH risk factors: breech, female, firstborn, large for gestational age. Ortolani and Barlow on exam; ultrasound under 6 months, x-ray after. Pavlik harness for under 6 months, worn 3–4 months.
Scoliosis by curve: <20° monitor; 20–40° Boston brace 23 hours a day (slows progression, does not correct); 40–80° spinal fusion; >80° halo traction. Log roll after fusion, and ask about headache as a CSF leak clue.
Duchenne: X-linked, onset 3–5 years, positive Gower sign, pseudohypertrophied calves, elevated CPK, wheelchair by about 12. No cure.
🎯 Module quiz
Questions for this module. They also feed the Mega Quiz.