Jan Bazner-Chandler CPNP, RN, MSN Orthopedic Disorders Jan Bazner-Chandler CPNP, RN, MSN

Musculoskeletal Differences in Children Epiphyseal growth plate present Bones are growing / heal faster Bones are more pliable Periosteum thicker and more active Abundant blood supply to the bone The younger the child the faster the healing.

Focused Physical Assessment Inspect child undressed Observe child walking Spinal alignment ROM Muscle strength Reflexes

Assessment Concerns: Pain or tenderness Muscle spasm Masses Soft tissue swelling

CoREminder If an injury has occurred, examine that area last and be gentle when palpating the injury site

Nursing Alert A child younger than 1 year who presents with a fracture should be evaluated for possible physical abuse or an underlying musculoskeletal disorder that would cause spontaneous bone injury.

Neurovascular Assessment Pain Where is it? Is it reduced by narcotics? Does the pain become worse when fingers or toes are flexed?

Neurovascular Assessment Sensation Can the child feel touch on the affected extremity Motion Can the child move fingers or toes below area of injury / nerve injury Temperature Is the extremity warm or cool to touch

Neurovascular Assessment Capillary refill Sluggish capillary refill may signals poor circulation Color Note color of extremity and compare with unaffected limb Pulses Assess distal to injury or cast

Neurovascular Impairment Restriction of circulation and nerve function from injury or immobilizing device.

Compartment Syndrome Complication of fractures. Pain is the hallmark sign, pain out of proportion to the normal clinical course. Must be diagnosed immediately or irreversible neurovascular, muscular, vascular damage occurs that can lead to renal failure and death.

Clinical Manifestations The classic sign of acute compartment syndrome is pain, especially when the muscle is stretched. There may also be a tingling or burning sensation (paresthesias) in the muscle. A child may report that the foot / hand is “a sleep” If the area becomes numb or paralysis sets in, cell death has begun and efforts to lower the pressure in the compartment may not be successful in restoring function.

Interventions Prevention Don’t elevate the affected limb above or below the level of the heart. Notify physician if there is pain (not relieved by pain med), decreased sensation, decreased pulses distal to injury or tingling / numbness.

Nerve Assessment Important to due on admission from ER or to the unit Repeat after cast, traction, or surgery done on the extremity

Radius and ulna nerve assessment

Ulnar Nerve Injury

Medial Nerve Injury

Radial Nerve Injury

Uses of Traction Realign bone fragments Provide rest Prevent or improve deformity Pre or post operative positioning Reduce muscle spasm immobilization

Fractures Treatment determined by type of fracture

Fractures RW Chandler MD

Salter Fracture I and II

Salter Fracture III, IV and V

Salter-Harris Classification If injury involves growth plate in an immature bone, growth disturbance may follow. Classification system describes the injury and the potential for growth disturbance.

Bucks Traction Ball & Bindler

Principles of Traction Counter traction with weights Make sure all ropes and pulleys are aligned and weights are hanging freely Do not remove weights unless instructed to do so Traction must be applied at all times

Skeletal Traction Pull directly applied to bone by pin Pin care Increased risk of infection Ball & Bindler

External Fixator

External Fixation RWChandler MD

Pin Care Provide pin care as ordered. Cleanse area around pin with normal saline or half-strength hydrogen peroxide. Have parent / caretaker demonstrate pin care before discharge

Plates and Pins Plates, screws, and wires are used to align bone fragments. R.Chandler MD

Post-operative Care Assess color, sensation, cap refill, movement, pain, and pulses Circle any drainage noted on cast or dressing. Pain control Edema = ice to area Pulmonary function = C&DB

Pulmonary Embolism A complication of a fractured leg is a pulmonary embolism. Fat escapes the marrow when the bone is fractured and can travel through the blood stream and become lodged in small vessels like the arterioles and capillaries of the lung. Primary symptom is shortness of breath and chest pain.

Interventions Place patient in high fowlers Administer oxygen Call MD Chest x-ray Outcomes are better for a health person; poorer for person with pre-existing lung problems.

Orthopedic Disorders Congenital Acquired / trauma Infectious

Tales Equinovarus Tales equinovarus or Club foot Obvious deformity noted at birth. Surgical correction Bowden & Greenberg

Tales 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 Surgery is performed between 4 to 12 months if full correction is not achieved with casting

Nursing Diagnosis Impaired physical mobility related to cast wear Altered parenting related to emotional reaction following birth of child with physical defect Risk for impaired skin integrity related to cast wear. Knowledge deficit: cast care and home care

Metatarsus Adductus Most common foot deformity 2 per 1000 Result of intrauterine positioning Forefoot is abducted and in varus, giving the foot a kidney bean shape.

Metatarsus Adductus Turning in of foot Treatment: Passive manipulation Soft shoes at night Serial casts Bowden & Greenberg

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

Clinical Manifestations Head of femur lies outside the acetabulum + Ortolani maneuver Asymmetrical lower extremity skin folds Discrepancy in limb length

Hip Exam

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

Pavlik Harness Bowden & Greenberg

Nursing Diagnosis Knowledge deficit regarding care of harness or cast Impaired physical mobility Risk for impaired skin integrity related to pressure from casts or braces Altered skin perfusion due to casts or braces Risk for altered growth and development due to limited mobility

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 easy

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

Genetic Defect Type I: autosomal dominant: age at presentation 2 – 6 years. Common age for child abuse. Often present as suspected child abuse

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

New Born with OI

Nursing Diagnosis Risk of injury related to disease process Risk for altered growth and development Knowledge deficit: disease process and care of child

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. Bowden, 1998

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

Assessment Developmental surveillance is key Diagnoses 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. Bowden, 1998

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

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

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.

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

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 Limp Limited abduction Leg may be shorter

Clinical Manifestations

Management Surgery Crutch walking

Scoliosis Lateral curvature of spine Medline.com

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

Screening

Screening Bowden & Greenberg

Mild Scoliosis Mild forms Strengthening and stretching Ball & Bindler

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.

Bracing Custom designed brace Child wears at night Bowden & Greenberg

Scoliosis Spinal Fusion

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

Nursing Diagnoses Body image disturbance related to bracing Risk of injury related to brace Impaired physical mobility related to brace wear Risk for non-compliance with treatment regimen

Inflammatory Process Osteomyelitis Septic arthritis Juvenile arthritis

Osteomyelitis Webmd.lycos.com

Osteomyelitis Infection of bone and tissue around bone. Requires immediate treatment Can cause massive bone destruction and life-threatening sepsis

Pathogenesis of Acute Osteo In children 1 year to 15 years the infection is restricted to below the epiphysis. Under 1 year the epiphysis is nourished by arteries.

Clinical Manifestation Localized pain Decreased movement of area With spread of infection Redness Swelling Warm to touch

Diagnostic Tests: X-ray CBC ESR / erythrocyte sedimentation rate C-reactive protein Bone scan – most definitive test for osteomyelitis

X-Ray 18-year-old boy with painful right arm

Osteomyelitis

Management Culture of the blood Aspiration at site of infection Intravenous antibiotics x 4 weeks PO antibiotics if ESR rate going down Monitor ESR Decrease in levels indicates improvement

Goals of Care To maintain integrity of infected joint / joints

Septic Arthritis Infection within a joint or synovial membrane Infection transmitted by: Bloodstream Penetrating wound Foreign body in joint

Septic Arthritis of Hip Difficulty walking and fever Diagnosis: x-ray, aspirate fluid from joint, ESR

Septic Hip

Diagnostic Tests X-ray Needle aspiration under fluoroscopy

Erythrocyte Sedimentation Rate ESR Used as a gauge for determining the progress of an inflammatory disease. Rises within 24 hours after onset of symptoms. Men: 0 - 15 mm./hr Women: 0 – 20 mm./hr Children: 0 – 10 mm./hr

WBC 31,700 bands 4% segs 85% monos 6% lymphs 5% HgB 12.4 MCT 35.4 Platelets 394,000 C- reactive protein 8.2 mg ESR /sed rate 39

C-Reactive Protein During the course of an inflammatory process an abnormal specific protein, CRP, appears in the blood. The presence of the protein can be detected within 6 hours of triggering stimulus. More sensitive than ESR / more expensive

Joint Space Fluid WBC 80,000 Segs 88% Monos 1% Lymphs 11% RBC 16,000 Gram Stain Gram-positive cocci in chains

Management Administration of antibiotics for 4 to 6 weeks. Oral antibiotics have been found to be effective if serum bactericidal levels are adequate. Fever control Ibuprofen for anti-inflammatory effect

Goals of Care Maintain integrity of affected joint

Juvenile Rheumatoid Arthritis Chronic inflammatory condition of the joints and surrounding tissues. Often triggered by a viral illness 1 in 1000 children will develop JRA Higher incidence in girls

Clinical Manifestations Swelling or effusion of one or more joints Limited ROM Warmth Tenderness Pain with movement

Diagnostic Evaluation Elevated ESR / erythrocyte sedimentation rate + genetic marker / HLA b27 + RF 9 antinuclear antibodies Bone scan MRI Arthroscopic exam

Goals of Therapy To prevent deformities To keep discomfort to a minimum To preserve ability to do ADL

Management ASA NASAIDS around the clock Immunosuppressive drugs: azulvadine Enbrel: new class of drugs to treat JRA Attacks a specific aspect of the immune response

ASA Therapy Alert: The use of aspirin has been highly associated with the development of Reye’s syndrome in children who have had chickenpox or flu. Because aspirin may be an an ongoing p art of the regimen of the arthritic child, parents should be warned of the relationship between viral illnesses an aspirin, and be taught the symptoms of Reye’s syndrome.

Management Physical therapy Exercise program Monitor ESR levels Regular eye exams: Iriditis

Iriditis Intraocular inflammation of iris and ciliary body 2% to 21% in children with arthritis Highest incidence in children with multi joint involvement disease.

Iriditis