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 determinedby 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

R.Chandler MD

Plates, screws, andwires are used to alignbone fragments.

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 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

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 fractures/demineralization

Old rib fractures

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% 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

Under 1 yearthe epiphysis is nourished byarteries.

In children 1 yearto 15 years theinfection is restrictedto below the epiphysis.

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 aspirationunder 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