Orthopedics Disorders Pediatrics Part II Jan Bazner-Chandler RN, MSN, CNS, CPNP

Orthopedic Disorders  Congenital  Acquired / trauma  Infectious

Talipes Equinovarus Talipes equinovarus or Club foot Obvious deformity noted at birth. Surgical correction

Talipus Equinovarus  Club Foot  1 to 2 per 1000  Males more affected  Involves both the bony structures and soft tissue.  The entire foot is pointing downward.

Interventions  Manipulation and serial casting immediately.  The more rigid the foot the more likely surgery will be necessary.  Surgery performed between 4 and 12 months.

Metatarsus Adductus  Most common foot deformity  2 per 1000  Result of intrauterine positioning  Forefoot is adducted and in varus, giving the foot a kidney bean shape.  Most often resolves on own or with simple exercises.

Metatarsus Adductus

Dysplasia of the Hip  Abnormality in the development of the proximal femur, acetabulum, or both.  Girls affected 6:1  Familial history  Breech presentation  Maternal hormones  Other ortho anomalies

Developmental Dysplasia of Hip

Clinical Manifestations  + Ortolani maneuver  Asymmetrical lower extremity skin folds – soft sign not always seen.  In the older infant there would be decreased ROM in the affected hip especially with abduction.  In the child there might be discrepancy in limb length.

Asymmetry of skin fold

Hip Exam

Interventions  Maintain hips in flexed position  Traction to stretch muscles  Pavlik harness  Hip surgery Bowden & Greenberg

Pavlik Harness Bowden & Greenberg

Harness JB Chandler

Osteogenesis Imperfecta

 Genetic disorder  Caused by a genetic defect that affects the body’s production of collagen.  Collagen is the major protein of the body’s connective tissue.  Less than normal or poor collagen leads to weak bones that fracture easily.

Osteogenesis Imperfecta  Often called “brittle bone disease”  Characteristics  Demineralization, cortical thinning  Multiple fractures with pseudoarthrosis  Exuberant callus formation at fracture site  Blue sclera  Wide sutures  Pre-senile deafness

3-month-old with OI Old fractures/demineralization Old rib fractures

New Born with OI

CaReminder  Signs of a fracture, especially in an infant, are important items to teach caregivers. In a baby, these signs are general symptoms, such as fever, irritability, and refusal to eat.

Cerebral Palsy  Group of disorders of movement and posture  Prenatal causes = 44%  Labor and delivery = 19%  Perinatal = 8%  Childhood = 5%

Assessment  Developmental surveillance is key  Diagnosis often made when child is 6 to 12 months of age  Physical exam:  Range of motion  Evaluation of muscle strength and tone  Presence of abnormal movement or contractures

caReminder  Reflexes that persist beyond the expected age of disappearance (e.g., tonic neck reflex) or absence of expected reflexes are highly suggestive of CP.

Clinical Manifestations  Hypotonia or Hypertonia  Contractures  Scoliosis  Seizures  Mental Retardation  Visual, learning and hearing disorders  Osteoporosis – long term due to lack of movement

Legg-Calve-Perthes  Vascular disturbance leads to bone death in hip do to interruption of blood flow.  Four times more common in males  More common in Asians, Eskimos and Caucasians.  Peak age 6 ( years)

Clinical Manifestations  Pain – groin, hip or referred pain to knee.  Limping  Limited hip motion especially internal rotation and abduction is classic sign.

Right hip - LCP

Management  Goal of care is to: Keep femoral head in the hip joint  Traction  Anti-inflammatory  Physical therapy  Surgery if femoral head destroyed

Osgood-Schlatters Painful prominence of the tibial tubercle Gait.udel.ed u

Osgood-Schlatters  Due to repetitive motion  Affects children 10 to 14 years old  Males 3:1  Diagnosis is based on clinical signs and symptoms  Pain, heat, tenderness, and local swelling

Assessment  Tip: Asking the child to squat or extend his or her knee against resistance usually elicits pain and is a good indicator of Osgood-Schlatter Disease.

Management Reduce activity Stretching before activity Anti-inflammatory Avoid activity that cause pain

Slipped Capital Femoral Epiphysis  Top of femur slips through growth plate in a posterior direction.  Ages 10 to 14 in girls  Ages 10 to 16 in boys  High proportion are obese

Clinical Manifestations  Pain in groin, hip or knee  Limp (antalgic is limping on affected side)  Limited abduction  Leg may be shorter

Clinical Manifestations

Management  Surgery – fix with a pin  Crutch walking  Complications  Avascular necrosis of femoral head is compromise of circulation of the femoral head leading to ischemia. This may lead to collapse of the necrotic segment.

Scoliosis Lateral curvature of spine Medline.com

Mild Scoliosis Mild forms Strengthening and stretching

Clinical Manifestations Pain is not a normal finding for idiopathic scoliosis Often present with uneven hemline Unequal scapula Unequal hips

Assessment  Alert: If pain is a reported symptom of the child’s scoliosis, it should be investigated immediately. Pain is not a normal finding for idiopathic scoliosis, and the presence of this symptom could be signaling an underlying condition such as tumor of the spinal cord.

Screening

Bowden & Greenberg

Severe Scoliosis

Bracing

Milwaukee Brace

Scoliosis Spinal Fusion

Post-operative Care  Pain management  Chest tube in many cases  Turn, cough, and deep breathe  Log-roll

Muscular Dystrophy  Group of genetic diseases characterized by progressive weakness and degeneration of the skeletal muscles that control movement.  Most common: Duchenne muscular dystrophy (DMD)  Predominately male disease  X-linked recessive inherited disease

Pathophysiology  DMD is deficiency or absence of the protein dystrophin.  Protein is thought to strengthen the muscle cell membrane.  Laboratory values: Creatinine kinase levels are high.

Assessment  Infant may display mild delay in attaining milestone.  Sitting up, crawling, cruising  Toddler (between ages 2 to 3) may have a clumsy gait and have difficulty climbing stairs.  Classic physical finding: Gowers’ sign

Gowers’ Sign   Type in Gowers’ Sign

Interdisciplinary Interventions  Team of nursing, physicians, specialists  Pharmacologic Interventions  Glucocorticosteroids (prednisone and deflazacort): steroids have been found to increase muscle strength and pulmonary function.

Long Term Problems  Cardiomyopathy in 90% over 18 years of age  Respiratory complications  Obesity