orthopedic disorders congenital acquired / trauma infectious

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Orthopedic Disorders Congenital Acquired / trauma Infectious

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Orthopedic Disorders Congenital Acquired / trauma Infectious

Tales Equinovarus

Tales equinovarus or

Club foot

Obvious deformity notedat 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

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 PalsyHypotonia 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-SchlattersPainful 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

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 ManifestationsPain 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 findingfor idiopathic scoliosis.

Screening

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 andtissue around bone.

Requires immediate treatment

Can cause massive bonedestruction and life-threatening sepsis

Webmd.lycos.com

Osteomyelitis

Most common organismStaphylococcus 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 / erthyrocyteSedimentation 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 yearthe epiphysis is nourished byarteries.

In children 1 yearto 15 years theinfection is restrictedto 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 aspirationunder fluoroscopy

WBC 31,700

bands 4%

segs 85%

monos 6%

lymphs 5%

HgB 12.4

MCT 35.4

Platelets 394,000C- reactive protein

8.2 mg

ESR /sed rate

39

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

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 FluidWBC 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

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.