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

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

Congenital Hip Dislocation Asymmetry of the gluteal and thigh fat fold is a sign of dysplasia of the Hip Ball & Bindler

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

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

Nursing Diagnosis Knowledge deficit 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

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 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 fractures/demineralization Old rib fractures

Type II Autosomal Recessive Pre- or perinatal death Pulmonary hypoplasia

Fetus with severe OI Rib fractures / poorly developed spine / limbs & cranium

Type III Autosomal dominant Marked progressive limb and spine deformity

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 Group of disorders of movement and posture Prenatal causes = 44% Labor and delivery = 19% Perinatal = 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

Cerebral Palsy  Hypotonia or Hypertonia  Contractures  Scoliosis  Osteoporosis Ball & Bindler

Cerebral Palsy  Mental retardation  Language disorders  Learning disabilities  Visual disturbances  Hearing disorders  Seizures

Cerebral Palsy  Mulidisciplinary team approach  Parental support Whaley & Wong

Legg-Calve-Perthes Self-limiting disease Femoral head loses blood supply Four times more common in males Peak age 4 to 7 years

Clinical Manifestations Pain Limping Limited hip motion especially internal rotation and abduction is classic sign

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

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

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  Knee pads / sleeve

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 area  Limp  Limited abduction  Leg may be shorter

Management Surgery Teach crutch walking

Scoliosis Later curvature of spine Medline.com Pain is not a normal finding for idiopathic scoliosis.

Screening

Bowden & Greenberg

Mild Scoliosis Mild forms Strengthening and stretching Ball & Bindler

Moderate Scoliosis Milwaukee brace Whaley & Wong

Bracing Custom designed brace Child wears at night Bowden & Greenberg

Scoliosis Spinal Fusion

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

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.

Inflammatory Process Osteomyelitis Septic arthritis Juvenile arthritis

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

Osteomyelitis Most common organism Staphylococcus areus Osteomyelitis.com

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

Diagnosis X-ray Bone scan CBC ESR / erthyrocyte Sedimentation rate C-reactive protein 18-year-old boy with painful right arm

Diagnostic Tests: X-ray Bone scan CBC ESR / erythyrocyte Sedimentation rate C-reactive protein

Management Culture of the blood Aspiration at site of infection Intravenous antibiotics x 4 weeks Monitor ESR Decrease in levels

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

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 Medscape.com

Septic Hip

Diagnostic Tests X-ray Needle aspiration under fluoroscopy

WBC31,700 bands4% segs85% monos6% lymphs5% HgB12.4 MCT35.4 Platelets394,000 C- reactive protein 8.2 mg ESR /sed rate39

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: mm./hr Women:0 – 20 mm./hr Children:0 – 10 mm./hr

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 WBC80,000 Segs88% Monos1% Lymphs11% RBC16,000 Gram StainGram-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

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 or iris and ciliary body 2% to 21% in children with arthritis Highest incidence in children with multi joint involvement disease.