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

2. 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.

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

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

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

6. 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.

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

8. 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

9. 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

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

11. 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.

12. 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.

13. 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.

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

15. Radius and ulna nerve assessment

16. Ulnar Nerve Injury

17. Medial Nerve Injury

18. Radial Nerve Injury

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

20. Fractures
Treatment determined
by type of fracture

21. Fractures
RW Chandler MD

22. Salter Fracture I and II

23. Salter Fracture III, IV and V

24. 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.

25. Bucks Traction
Ball & Bindler

26. 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

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

28. External Fixator

29. External Fixation
RWChandler MD

30. 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

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

32. 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

33. 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.

34. 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.

35. Orthopedic Disorders
Congenital
Acquired / trauma
Infectious

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

37. 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.

38. Interventions Manipulation and serial casting immediately
Surgery is performed between 4 to 12 months if full correction is not achieved with casting

39. 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

40. 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.

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

42. 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

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

44. Hip Exam

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

46. Pavlik Harness
Bowden & Greenberg

47. 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

48. 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

49. 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

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

51. 3-month-old with OI
Old rib fractures
Old fractures/demineralization

52. New Born with OI

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

54. 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

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

56. 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

57. 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

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

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

60. 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.

61. 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

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

63. 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

64. Clinical Manifestations
Pain in groin
Limp
Limited abduction
Leg may be shorter

65. Clinical Manifestations

66. Management
Surgery
Crutch walking

67. Scoliosis
Lateral curvature of spine
Medline.com

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

69. Screening

70. Screening
Bowden & Greenberg

71. Mild Scoliosis
Mild forms
Strengthening and
stretching
Ball & Bindler

72. 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.

73. Bracing
Custom designed brace
Child wears at night
Bowden & Greenberg

74. Scoliosis
Spinal Fusion

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

76. 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

77. Inflammatory Process
Osteomyelitis
Septic arthritis
Juvenile arthritis

78. Osteomyelitis
Webmd.lycos.com

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

80. 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.

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

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

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

84. Osteomyelitis

85. 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

86. Goals of Care
To maintain integrity of infected joint / joints

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

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

89. Septic Hip

90. Diagnostic Tests
X-ray
Needle aspiration
under fluoroscopy

91. 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

92. 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

93. 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

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

95. 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

96. Goals of Care
Maintain integrity of affected joint

97. 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

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

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

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

101. 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

102. 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.

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

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

105. Iriditis