Orthopedic Disorders

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Orthopedic Disorders

• Jan Bazner-Chandler
• CPNP, RN, MSN

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Alterations in Musculoskeletal Status
Bowden Greenberg
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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.

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Focused Physical Assessment

• Inspect child undressed
• Observe child walking
• Spinal alignment
• ROM
• Muscle strength
• Reflexes

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Assessment

• Concerns
• Pain or tenderness
• Muscle spasm
• Masses
• Soft tissue swelling

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CoREminder

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

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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.

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Neurovascular Assessment

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

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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

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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

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Neurovascular Impairment

• Restriction of circulation and nerve function
  from injury or immobilizing device.

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Clinical Manifestations

• Increased pain
• Edema
• Decreased movement or sensation
• Diminished or absent pulses distal to injury
• Patient often described as restless pain
  medication do not work pain described as deep

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Interventions

• Assess area distal to injury, cast, splint,
  traction for adequate circulation
• Release pressure by splitting the cast or
  loosening restrictive bandage.
• Notify physician

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Compartment Syndrome

• 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.

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Clinical Manifestations

• A combination of signs and symptoms characterize
  compartment syndrome. 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.

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Physical Assessment

• Frequent pain assessment
• If pain med does not work something is wrong
• The muscle may feel tight or full.
• Measure the affected muscle group and compare
  with the unaffected side
• Pulses below area of injury

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Treatment

• Prevention
• Dont elevate the affected limb above or below
  the level of the heart.
• Dressings should be removed if CS is suspected.
• Casts should be bi-valved in high risk situations.

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Assessment

• Dont forget the five Ps
• Pain
• Paresthesia
• Passive stretch
• Pressure
• Pulse-less-ness

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Surgical Management
Siumed.edu
Fasciotomy to relieve pressure. The fascia is
divided along the length of the compartment to
release pressure within.
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Nerve Assessment

• Important to due on admission from ER or to the
  unit
• Repeat after cast, traction, or surgery done on
  the extremity

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Radius and ulna nerve assessment
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Ulnar Nerve Injury
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Medial Nerve Injury
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Radial Nerve Injury
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Peroneal Nerve Distribution
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Treatment Modalities

• Goals of fracture care
• To regain alignment and length of the bony
  fragments
• To retain alignment and length
• To restore function of the injured part

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Traction

• Realign bone fragments
• Provide rest
• Prevent or improve deformity
• Pre or post operative positioning
• Reduce muscle spasm
• immobilization

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Fractures
Treatment determined by type of fracture
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Fractures
RW Chandler MD
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Salter Fracture I and II
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Salter Fracture III, IV and V
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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.

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Bucks Traction
Ball Bindler
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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

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Bryants Traction
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Bryants Traction

• Used for child under 3 yrs
• Hip dysplasia / fractured femur
• Buttocks do not rest on mattress
• Assess neurovascular and restriction by ace
  bandages compartment syndrome

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Skeletal Traction

• Pull directly
• applied
• to bone by pin
• Pin care
• Increased risk of
• infection

Ball Bindler
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External Fixator
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External Fixation
RWChandler MD
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External Fixator
Ball Bindler
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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

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External Fixator
RW Chandler MD
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External Fixator
RW Chandler MD
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Plates and Pins
Plates, screws, and wires are used to align bone
fragments.
R.Chandler MD
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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 CDB

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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.

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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.

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Orthopedic Disorders

• Congenital
• Acquired / trauma
• Infectious

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

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Interventions

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

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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

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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.

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Metatarsus Adductus

• Turning in of foot
• Treatment
• Passive manipulation
• Soft shoes at night
• Serial casts

Bowden Greenberg
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Dysplasia of the Hip

• Abnormality in the development of the proximal
  femur, acetabulum, or both.
• Girls affected 61
• Familial history
• Breech presentation
• Maternal hormones
• Other ortho anomalies

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Clinical Manifestations

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

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Asymmetry of skin fold
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Hip Exam
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Interventions

• Maintain hips in flexed position
• Traction to stretch muscles
• Pavlik harness
• Hip surgery

Bowden Greenberg
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Pavlik Harness
Bowden Greenberg
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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

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Harness
JB Chandler
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Osteogenesis Imperfecta
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Osteogenesis Imperfecta

• Genetic disorder
• Caused by a genetic defect that affects the
  bodys production of collagen
• Collagen is the major protein of the bodys
  connective tissue
• Less than normal or poor collagen leads to weak
  bones that fracture easy

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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

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Genetic Defect

• Type I autosomal dominant age at presentation 2
  6 years.
• Common age for child abuse.
• Often present as suspected child abuse

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3-month-old with OI
Old rib fractures
Old fractures/demineralization
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Type II

• Autosomal Recessive
• Pre- or perinatal death
• Pulmonary hypoplasia

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Fetus with severe OI
Rib fractures / poorly developed spine / limbs
cranium
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New Born with OI
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Nursing Diagnosis

• Risk of injury related to disease process
• Risk for altered growth and development
• Knowledge deficit disease process and care of
  child

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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

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Cerebral Palsy

• Group of disorders of movement and posture
• Prenatal causes 44
• Labor and delivery 19
• Perinatal 8
• Childhood 5

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Cerebral Palsy

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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

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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

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Clinical Manifestations

• Hypotonia or Hypertonia
• Contractures
• Scoliosis
• Seizures
• Mental Retardation
• Visual, learning and hearing disorders
• Osteoporosis long term due to lack of movement

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Team Management
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Legg-Calve-Perthes

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

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Clinical Manifestations

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

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Management

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

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

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Osgood-Schlatters

• Due to repetitive motion
• Affects children 10 to 14 years old
• Males 31
• Diagnosis is based on clinical signs and symptoms
• Pain, heat, tenderness, and local swelling

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Management

• Reduce activity
• Stretching before activity
• Anti-inflammatory
• Avoid activity that cause pain

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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

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Clinical Manifestations

• Pain in groin
• Limp
• Limited abduction
• Leg may be shorter

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Clinical Manifestations
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Management

• Surgery
• Crutch walking

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Scoliosis
Lateral curvature of spine
Medline.com
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Clinical Manifestations

• Pain is not a normal finding
• for idiopathic scoliosis
• Often present with uneven hemline
• Unequal scapula
• Unequal hips

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Screening
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Screening
Bowden Greenberg
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Mild Scoliosis
Mild forms Strengthening and stretching
Ball Bindler
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Severe Scoliosis
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Assessment

• Alert If pain is a reported symptom of the
  childs 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.

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Bracing
Custom designed brace Child wears at night
Bowden Greenberg
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Moderate Scoliosis
Whaley Wong
Milwaukee brace
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Scoliosis
Spinal Fusion
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Post-operative Care

• Pain management
• Chest tube in many cases
• Turn, cough, and deep breath
• Log-roll

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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

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Inflammatory Process

• Osteomyelitis
• Septic arthritis
• Juvenile arthritis

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Osteomyelitis
Webmd.lycos.com
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Osteomyelitis

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

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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.
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Osteomyelitis
Most common organism Staphylococcus areus
Osteomyelitis.com
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Clinical Manifestation

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

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Diagnostic Tests

• X-ray
• CBC
• ESR / erythrocyte sedimentation rate
• C-reactive protein
• Bone scan most definitive test for
  osteomyelitis

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X-Ray
18-year-old boy with painful right arm
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Osteomyelitis
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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

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Goals of Care

• To maintain integrity of infected joint / joints

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Septic Arthritis

• Infection within a joint or synovial membrane
• Infection transmitted by
• Bloodstream
• Penetrating wound
• Foreign body in joint

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Septic Arthritis of Hip

• Difficulty walking and fever
• Diagnosis x-ray, aspirate fluid from joint, ESR

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Septic Hip
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Diagnostic Tests
X-ray Needle aspiration under fluoroscopy
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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

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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

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Joint Space Fluid
121
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

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Goals of Care

• Maintain integrity of affected joint

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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

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Clinical Manifestations

• Swelling or effusion of one or more joints
• Limited ROM
• Warmth
• Tenderness
• Pain with movement

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Diagnostic Evaluation

• Elevated ESR / erythrocyte sedimentation rate
• genetic marker / HLA b27
• RF 9 antinuclear antibodies
• Bone scan
• MRI
• Arthroscopic exam

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Goals of Therapy

• To prevent deformities
• To keep discomfort to a minimum
• To preserve ability to do ADL

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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

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ASA Therapy

• Alert The use of aspirin has been highly
  associated with the development of Reyes
  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 Reyes syndrome.

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Management

• Physical therapy
• Exercise program
• Monitor ESR levels
• Regular eye exams Iriditis

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Iriditis

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

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Iriditis