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Enhance Self Care-Nursing Role in Children with Upper Limb Injury

Ms  Po-­‐yin  CHENG

Pediatric Orthopedic Nurse

•  Challenge and Rewarding – Childhood to adulthood

•  Provide knowledge at all stage of care and treatment and emotional support to the child and family

•  Assessing growth and development, intervene when necessary

•  Assisting the child and family in planning for care

Children development and trauma Development Problem Common injuries Psychosocial considerations

of the caregiver

Infants: 0-12 months Reaching and grasping Hand-to-hand mouth coordination. Rolling over Scooting and crawling Walking

Increased mobility Falls Involve the parents in the infant’s care when possible. Recognize the developing infant’s strong emotional need for the parent and do not separate the parent and child. Obtain a complete history from the parent or caregiver.

Toddlers: 12 months-age 3 Autonomy and independence Little concept of danger Fine and gross motor skill development Negative behavior

Need to explore the environment and little concept of danger

Falls Playground injuries

When possible do not separate the parent and child. Allow the child to have a security object. Allow the parent to hold and comfort the child. Speak to the child in a quiet, reassuring tone and use simple words and phrases.

Preschool: age 3-5 Fine and gross motor skill development Beginning socialization skills Magical thinking

Participation in group play activities and less parental supervision

Falls Playground injuries

When possible do not separate the parent and child. Explain procedures in clear, concise and simple statements Cover external injuries with band aids or dressings When possible allow the child to handle the equipment

School: age6-12 Well developed fine and gross motor skills Continued development of socialization skills Developing ties and peers Developing body image

Increasing independence and ties to peers

Sports related injuries Play activities Bike related injuries

Maintain privacy when possible Allow participation in care when possible Explain all procedure clearly and concisely Do not lie to the child Obtain a history from the patient when possible

Teenagers: age 13-18 Developing cognitive and motor skills Developing strong ties to peers Need to assert independence Concerned with body image

Need for group acceptance and lack of judgment Are present oriented and risk taker

Motor vehicles related accidents Sports activities Violence related

Maintain privacy when possible Explain all procedures Answer questions honestly Obtain a history from the patient when possible Be sensitive to family dynamics

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Nursing  Role  

•  Assessment •  Diagnosis •  Planning •  Intervention •  Evaluation •  Both the child and the family are the focus of

the nursing process •  Member of a team, coordinator

Fractures- clinical features •  Pain •  Bruising •  Swelling •  Deformity •  Whether the skin is intact or broken and

communicates with the fractures–open fracture •  Observed the posture of the distal extremity and

colour of skin ( for tell tale sign of nerve and vessel damage)

Fractures- Local complications

Vascular injury •  Artery may be cut, torn, compressed or

contused •  Common vascular injuries

Injury Vessel Shoulder dislocation Axillary

Humeral supracondylar fracture Brachial Elbow dislocation Brachial

Fracture-local complications •  Nerve injury •  Particular common with fractures of the humerus or injuries around the

elbow •  Most (90%) can recover spontaneously within 4 months •  Exploration is indicated if nerve injury appear after manipulation of the

fracture •  Common nerve injuries:

Injury Nerves Shoulder dislocation Axillary Humeral shaft fracture Radial Humeral supracondylar fracture

Radial or median

Elbow medial condyle Ulnar Monteggia fracture dislocation Posterior interosseous

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Fracture-local  complica9ons   Compartment Syndrome

•  Present with severe pain disproportional to the initial injury

•  Passive stretching with induced excruciating pain

•  Treatment: emergency fasciotomy

Fracture- local complications

•  Infection – More commonly seen in open fractures – Organism: Staphylococci – Treatment : prevention : radical debridement ± change of implant : antibiotics

•  Pressure sore

Fracture- complication Delayed union •  Fracture healing that is unduly prolonged is

termed a ‘delayed union’ •  Biological factors –  Inadequate blood supply –  Severe soft tissue damages –  Periosteal stripping

•  Biochemical factors –  Imperfect splintage – Over rigid fixation –  infection

Fracture- complications

Non-union •  In minority of case delayed union gradually

turns into non-union •  Fracture will never unite without intervention Malunion •  When a fragment join in a unsatisfactory

position (either in angulations, rotation or shortening), the fracture is said to be malunited

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Fracture- complications

Avascular necrosis •  Commonly seen in proximal part of the scaphoid •  Clinical features –  Pain if fracture failed to unite or if the bone collapse – XR showed increase in bone density (new bone

ingrowths in the necrotic segment) Nerve compression •  Bone and join deformity may result in local nerve

entrapment – E.g. Ulnar nerve , Median nerve

Fractures- complications •  Myositis ossificans

–  Heterotopic ossification after injury –  Commonly occurs in injury around the elbow –  Joint movement is limited

•  Secondary osteoarthritis –  Due to cartilage damage –  Due to malunion of the metaphyseal fracture

•  Growth disturbance –  Happen in children with damage to the physis –  Result in angulations, slowing or even complete cessation

•  Bed sores •  Tendon injury •  Muscle Contracture •  Joint Instability •  Complex regional pain syndrome

Children Fractures

•  15% childhood injuries involve musculoskeletal system

•  Most paediatric trauma are single extremity low energy injuries

•  Basic principle of treatment is similar to adult # •  However there are several differences – Anatomical – Biomechanical –  physiological

Children Fractures •  Anatomic differences – Bone is less dense, more porotic & more vascular

•  Less force needed for # occur •  Bone # much more common than joint dislocation •  Faster Healing

–  Periosteum is thicker and stronger •  Forms callus quicker •  Good soft tissue splintage for # immobilization

–  Presence of a growth centres (physis & secondary ossification centres) •  Physeal injury •  Growth arrest resulting in shortening / angular deformity

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Children Fracture

•  Biomechanical differences – Less energy is needed to cause a fracture – Bone is more elastic with a thick periosteum

resulting in •  Greenstick, fracture •  Plastic deformation •  Torus (buckle) fracture

– Physeal plate is a relatively weak area & can be injured easily

– Ligament injury is less common

Children Fracture

•  Physiologic differences – More rapid healing of fractures •  (Physeal # > metaphyseal # > diaphyseal #) •  Less time of # immobilization

– May result in growth acceleration e.g. # proximal tibia, # femur •  Length discrepancy

– Good remodelling power •  certain deformity at fracture site is allowed •  Less a need for open reduction & internal fixation

Children Fracture

• Remodelling – Remodeling capacity of any deformity caused by a

fracture or epiphyseal injury depends: – The child’s age or the growth potential remaining – The distance of the fracture from the end of the

bone and the longitudinal growth potential of that physis

Children  Fracture  

•  Overall  Management  – Difficul9es:  •  Nervous  child  •  Unable  to  give  a  good  history  •  Un-­‐coopera9ve  in  physical  examina9on  •  Un-­‐coopera9ve  in  post-­‐op  rehabilita9on  •  Anxious  parents  

– Aim:  •  Relieve/reduce  anxiety  •  Gain  co-­‐opera9on  •  Obtain  a  full  picture  of  history  •  Gain  mutual  rapport  

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Children  Fracture •  Assessment – General: •  Ensure patent airway •  Ensure spontaneous breathing •  Ensure good circulation (stable BP/P) •  R/O life threatening injuries eg. Brain, lung, heart,

liver, GI tract… •  TOCC • Nursing assessment •  Fall precaution • Obtain detailed history

Children  Fracture •  Specific assessment –  Fracture assessment: look out for associated soft tissue

injuries – Open wound (open #) –  Skin blistering / abrasions / necrosis –  Skin impingement by # ends –  Subcutaneous tissue swelling – Nerve palsy: injury, impingement by # bone ends – Vascular injury: injury, impingement by # bone ends – Compartment syndrome

Children  Fracture

•  Special assessment –  Radiological examination –  To confirm # –  To assess configuration of # –  Spiral / oblique / transverse /

butterfly / comminuted –  Greenstick / torus / plastic

deformation –  To assess alignment of #

Greens9ck  Fracture

Torus  Fracture

Plas9c  Deforma9on

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Children  Fracture

•  Treatment – Conservative – Operative

Children  Fracture •  Conservative Treatment

–  Immobilization •  Undisplaced stable

–  Closed reduction + immobilization •  Displaced #

–  Traction •  Close reduction

–  Displaced # –  Sedation / GA –  Over-displacement to disengage fragments –  Traction + opposite force –  POP immobilization

Children  Fracture

•  Operative – ORIF • K-wire • Plating •  Intramedullary rod

– External fixator

Children  Fracture •  Pre-­‐op  management  

–  Haemodynamic  status  –  NPO  –  Immobilize  the  affected  part  –  +/-­‐  Eleva9on,  Trac9on  –  +/-­‐  ice  therapy  –  Check  Peripheral  pulse  and  assess  for  any  nerve  damages  –  ?  Compartment  syndrome  –  Accelerate  the  treatment  process  in  major  adverse  event  –  Ressaurance  –  Be  empathic  –  Show  concern  to  both  family    –  AUend  needs  ASAP  –  Tackle  the  complaints  during  wai9ng  for  OT  –  Prepare,  check  properly  &  escort  to  the  theatre  

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Children  Fracture

•  Post-op Care / Post-procedure – Haemodynamic status – Respiratory status – Neurovascular monitoring •  Skin colour •  Temperature •  Capillary return •  Pulse •  Numbness •  Weakness

Children Fracture •  Resume diet +/- IV maintenance •  Swelling control

–  Limb elevation, eg. Drip stand, 90-90degree elevation, pillow etc –  Avoid local pressure that will impair circulation –  Encourage active mobilization of an un-involved joints

•  Cast Care –  Check cast integrity, smooth edges, –  Circulation charting –  Observe for any complications: sore , itchiness, too tight or too loose,

etc –  Advise to keep cast dry –  Avoid pressure / plaster sores

•  Frequent change of position •  Bivalve POP if suspected impingement / excessive swelling

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Children Fracture •  Pain control

–  Analgesics –  Tender loving care –  Distraction therapy –  Beware of abnormal pain

•  Psychological support to parents , e.g. Religious support services •  +/- Psychological assessment & treatment in certain traumatic

clients •  In-hospital schooling/ activities eg. Red Cross School, Volunteer

activities etc •  Administration of medication,

–  e.g., antibiotics, anti-emetics, anti-coagulants •  Arrange Post-op/ post procedure X ray •  Provide comfort when transfer to the X ray

Children  fracture

•  +/-­‐  care  of  external  fixator  •  Allow  bathing  when  wound  healed  in  10-­‐14  days  

•  Keep  pin  site  clean  regularly  •  Daily  dressing  •  Weekly  swab  taking

Children  Fracture •  Arrange  post-­‐op/  post  procedure  Xray  •  Discharge  &  arrange  FU  

–  SOPD.  Physio,  Occup.  •  +/-­‐  FU  Xray  •  +/-­‐  GOPD  Dressing.  Open  wound,  pin  tract  •  Cast  care,  eg  pamphlet  •  Advise  on  home  eleva9on  •  +/-­‐  Use  of  the  triangular  bandage  •  +/-­‐  Sick  Leave  Cer9ficate  •  +/-­‐  LeUer  for  avoiding  the  vigorous  exercises/  PE  lessons  •  +/-­‐  LeUer  for  implants  in  situ

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Common  Injuries  in  Children    

1.  Physeal  injury  2.  Supracondylar  fracture  

Physeal Injury

•  If physis not damaged: great remodeling potential

•  If physeal damage: may result in growth retardation

Lateral condylar elbow fractures •  The Salter-Harris Classification (1963) –  Salter notes that the first lateral condyle fractures of

the distal humerus – The fracture line begins at the joint surface, passes

through the cartilaginous portion of the epiphysis medial to the capitulum, crosses the epiphyseal plates, and extends into the metaphysis.

– Thus, a fracture of the lateral condyle represents a type IV epiphyseal plate injury.

•  Fractures of the lateral humeral condyle are the second most common fracture of the paediatric elbow.

                                                 

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Epiphyseal Injury •  Salter & Harris Classification –  I to V

Physeal Injury •  Type  I  – A  transverse  fracture  through  the  growth  plate    –  Infants & young children – May be minimally displaced if periosteum intact – May need stress view for diagnosis

•  Type II – Commonest, 75% – A  fracture  through  the  growth  plate  and  the  metaphysis,  sparing  epiphysis

Physeal Injury •  Type III

–  Intra-articular –  Risk of physeal arrest:

•  Physeal damage •  Bone bar formation

•  Type IV –  Intra-articular –  Risk of physeal arrest

•  Type  V  –    –  A  compression  fracture  of  the  growth  plate    –  resul9ng  in  a  decrease  in  the  perceived  space  between  the  epiphysis  and  diaphysis  

–  1%  incidence  

Supracondylar Fracture •  A supracondylar fracture is a fracture, usually of the distal humerus

joint above the epicondyles, although it may occur elsewhere •  Common fractures to occur in children around 6-7 y.o. Classification •  Extension type: most common, distal fragment is displaced

posteriorly •  Flexion type: least common, distal fragment is displaced anteriorly

relatively to proximal segment 3 types based on the degree of separation of the fractured segments •  Type I: Undisplaced or minimally dislaced fractures •  Type II: partially displaced •  Type III: fully displaced

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                                                                                                                                                              Supracondylar Fracture Presentation: The child presents with a history of fall on an outstretched hand followed by pain, swelling and inability to move the affected elbow On examination, unusual prominence of olecranon process but because it is a supracondylar fracture, the three bony point relationship is maintained, as in a normal elbow. •  Neurorascular complications a)  Tear or entrapment of the brachial artery b)  Spasm of the artery c)  Compression of the artery d)  Compression of median nerve

Supracondylar Fracture

Diagnosis •  X-ray •  Exam – look for –  swelling –  / deformity

Treatment •  Slab/Casting •  Surgery

Treatment 1.  Percutaneous pin fixation •  Displaced supracondylar fractures are reduced by

closed methods & stabilized by percutaneous pin •  This permits clinical evaluation of carrying angle once

fracture is stabilized 2. Open reduction: •  Indicated for difficult reduction (especially when the

proximal fragment has button-holed thru the brachialis) •  Indicated w/ vascular injuries or when closed reduction

fails to achieve adequate alignment

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Supracondylar  Fracture Nursing Care •  Assist in procedure +/-Pre-op preparation •  Post-op management •  Vital signs monitoring •  Elevation •  Cast care •  Observe circulations •  Administrating of medication •  Pain relief •  Clear explanation of care & gain co-op •  Encourage the care taker to participate in the

care •  Attend needs both physical & psychological •  Arrange in-hospital schooling, voluntary play •  Post procedure Xray •  Arrange FUs & Xray •  Advise on home care like elevation, cast care

Supracondylar Fracture

•  Complications – Cubitus Varus / Recurvatum – Volkmann’s Contracture – Neurologic Deficits – Vascular Injuries

Complications •  Cubitus Varus

–  The most common complication following supracondylar #

–  Resulted from: •  Mal-reduction à malunion •  Physeal damage

–  Cosmetic deformity but little function deficit

•  Cubitus Recurvatum –  Result from residual dorsal

angulation of the fracture

Complications •  Volkmann’s Contracture: –  Resulting from brachial artery injury usually associated w/

supracondylar fracture of humerus –  Compartment syndrome –  Loss of motor & sensory function, claw hand deformity –  Contracture results from insufficient arterial perfusion &

venous stasis followed by ischemic degeneration of muscle –  Irreversible muscle necrosis begins after 4-6 hrs –  Necrosis of the muscle with secondary fibrosis that may

develop followed by calcification in its final phase

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Volkmann’s  Contracture

Complications

•  Neurological Deficits – Most nerve palsies resulting from supracondylar

fracture neuropraxias, and therefore will resolve spontaneously

– Motor function usually recover by 3 months and sensory changes recover by 6 months

– A partial palsy may have a better prognosis than a complete palsy (motor and sensory loss)

Distal Radius Fracture Common injury in children Causes: •  Fall on an outstretched hand •  Fall from height Associated injuries •  Styloid fractures •  Scaphoid fractures •  Wrist dislocation •  Median nerve injury •  Acute carpal tunnel syndrome Diagnosis •  Clinical sign

–  Swelling –  Deformity –  Tenderness –  Loss of wrist motion

•  X-ray •  CT •  MRI

Distal Radius Fracture Classification •  Type I extra articular, undisplaced •  Type II extra articular, displaced •  Type III intra articular, undisplaced •  Type IV intra articular, displaced Treatment •  Non-operative

–  CR + Casting –  XR

•  Surgery –  ORIF –  CRIF

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Distal Radius Fracture Nursing Care •  Assist in procedure +/-Pre-op preparation •  Post-op management •  Vital signs monitoring •  Elevation •  Cast care •  Observe circulations •  Administrating of medication •  Pain relief •  Clear explanation of care & gain co-op •  Encourage the care taker to participate in the care •  Attend needs both physical & psychological •  Arrange in-hospital schooling, voluntary play •  Post procedure Xray •  Arrange FUs & Xray •  Advise on home care like elevation, cast care

Hand Fracture •  Occur in either phalanges or metacarpals •  Causes

–  Twisting injury –  Fall –  Crush injury –  Direct contact in sports

•  Symptoms –  Swelling –  Tenderness –  Deformity –  Inability to move –  Shorten finger –  Finger crosses its neighbor when making a partial fist –  Depressed knuckle

Hand Fracture Diagnosis: •  Physical exam

–  Position of fingers –  Condition of skin –  ROM –  Assessment of feeling

•  X-ray: location extent of fracture Treatment •  Nonsurgical

–  Reduction realized by manipulating –  Cast / splint / brace –  Immobilize –  FU

•  Surgical –  Stabilize & align the bones –  Use implant wires, screws, plates

Complication •  Stiffness of joint •  Wound infection •  Malunion

Hand Fractures Nursing Management •  Reassurance •  Prepare for and assist in operation •  Post procedure / post-op management •  ± wound care •  Administer medication like pain killer antibiotics •  Monitor for the circulation of affected area •  Elevation •  Advise or splintage, bracing care •  Arrange XR •  Arrange FU’s SOPD, Physio, Occup •  ± GOPD dressing

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Re-plantation

•  Replantation – Direct admission from AED – Pre-operative preparation

Re-plantation

•  Preserve the amputated parts – Wrap with clear gauze or cloth –  Place in plastic bag with tightened opening –  Submerge the plastic bag with ½ H₂O & ½ ice – Labelling – Don’t try to detach if it is not detached totally – Don’t stretch – Moistened with NS – Loosen dressing & crepe –  Support with splint

Re-plantation

•  Care of the Stump – Wound care •  Irrigation with NS •  Dressing (?soaked with NS)

– Control bleeding •  Compression •  Elevate

– wound swab for culture

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Re-plantation • Pre-op Preparation

–  Consent & Mark site –  Investigations

•  Blood tests: CBP, L/RFT, clotting profile… •  T & S •  X-rays, CXR •  ECG •  +/- Doppler

• Donor site –  No blood taking or IV access –  Prevent injury –  Marking of skin area by surgeon –  ± prepare the donor site of skin graft –  NPO –  antibiotics

Re-plantation

•  Post-op Nursing Care – Complete Bed Rest – Keep Warm – Warm room (~26ºC) •  Body Temp at a comfortable level

– +/- Lamp treatment – Bed Cradle – Support the operated limb à Avoid torsion of pedicle

Re-plantation Post-op Nursing Care

–  Elevation •  Heart level •  Above heart level •  Prescribed degree of elevation

–  Vital Signs "  Blood pressure "   Pulse rate "   SaO2 "  Body temperature "   Intake and output

–  IVF (hydration) –  Foley’s catheter (measure output) –  DAT ± NPO –  Pain control (No Puncture on affected site)

Re-plantation

•  Post-op Nursing Care – Medication

•  Anti-platelet agent: IV Dextran 40 –  Anti-coagulant: Heparin infusion

:SC Fraxiparine Daily or BD •  Analgesic •  Antibiotics

– Wounds care •  Keep all wounds intact till inspected by surgeon •  No restriction / tight dressing •  Control bleeding

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Re-plantation •  Post-op Nursing Care

–  Check blood –  ± blood transfusion (Hb~10) –  Post-op X-ray

•  Monitoring –  Colour –  Capillary refill –  Tissue Turgor –  Temperature –  Doppler –  SpO₂ –  Pin Prick –  Compare with the Control site

Re-plantation Peripheral  Limbs  Circula1on  Chart

Replantation •  Monitoring –  Colour

•  Normal à Pink •  Arterial Occlusion à Pale •  Venous Occlusion à Cyanotic

–  Capillary Refill •  Normal à 1-2 sec •  Arterial Occlusion à slow •  Venous Occlusion à fast

–  Tissue turgor •  Normal à full •  Arterial Occlusion à Hollow, “Prune like” •  Venous Occlusion à Tense, Distended + blisters

Replantation •  Monitoring –  Temperature

•  Common use thermo Scan •  Control site: 30-37ºC •  Replanted or flap: ± 2-3ºC

Vessel thrombosis –  Fall below 30ºC

•  Differential 2.5ºC •  Arterial thrombosis

–  Rapid fall 3ºC •  Venous thrombosis

–  Slowly fall 1-2ºC / hr

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Replantation

•  Monitoring –  Pin Prick (prescribed by surgeon)

•  With 25 gauge needle •  With no. 11 blade •  ± heparin gauze to promote bleeding •  ± Leech Normal •  Bright red blood •  Slow to start bleeding •  Bleeds a short

Re-plantation •  Hand over •  Documentation •  Inform immediately if any abnormal findings •  Special Precaution – Adequate support: physical & psychological –  Prolong using oximeter – Occlude circulation – No pressure on flap or pedicle – Don’t stretch or kink –  Prevent pressure sore

Re-plantation

Acute complications occur usually in the first 48 hours – Venous insufficiency – Arterial insufficiency – Haematoma – Haemorrhage – Crystalluria from Dextran – Excessive edema –  Infection

Complications

•  Failed •  Skin necrosis •  Infection •  # non union, malunion •  Stiffness of joints •  Sensory deficits

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Re-plantation •  Discharge Instructions –  +/- Wound care – Keep warm –  Increase nutrition – Hydration – No caffeine, no alcohol – No pressure on flap –  Prevent injury – Observe colour, temperature –  physio & occup training –  Follow up & medication

Pull Elbow •  Common injury under 6 •  An anatomical predisposition to subluxation of the radial

head. •  The end is radial head is still rounded and made of cartilage

à easily slip out of the encircling annular ligament when the arm is pulled

•  Presentation –  No trauma history –  Elbow pain, sudden crying & upper limb immobility –  Arm moved at the shoulder but not at elbow –  Elbow slightly flexed and pronated –  Forearm is often held vs the abdomen –  Pain is centered around the radial head

Pull Elbow Diagnosis •  Examination on

–  Child is apprehensive & protects the affected arm –  Arm is held as above flexed slightly between 15º and 20º –  Child support the affected hand vs abdomen –  Reluctant to move –  Tenderness at the radial head –  Flexion, extension, pronation and supination of forearm are all

resisted •  X-ray •  ± use – evaluate the annular ligamentous injury and show

the displacement •  ± MRI – confirm subluxation and assess ligamentous

damage

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Pull Elbow Manipulation technique: supination •  Grasp the affected elbow with one hand to immobilize

the elbow and palpate (locate) the radial head (usually with the thumb)

•  With the other hand apply axial compression (‘pulsing in’) whilst supinating the forearm and flexing the elbow

•  A click or snap will be felt over the radial head Manipulation technique: pronation •  Grasp as above applying pressure over the radial head

with one hand (allow the thumb to palpate the radial head)

•  Pronate and flex the elbow with the other hand whilst grasping the affected wrist

Pull Elbow

Nursing Care •  Reassurance •  Assist in the examination & manipulation •  Give distraction therapy •  +/- Analgesics •  +/- Offer arm sling for support post-procedure •  Education to whole family – Avoid lifting children by one arm – Avoid lifting or swinging by arms