Orthopedic Lecture 06

8/20/2019 Orthopedic Lecture 06

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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 Diferences in Children

Epiphyseal growth plate present

Bones are growing / heal faster

Bones are more pliale Perioste!m thi"#er and more a"ti$e

%!ndant lood s!pply to the one

&he yo!nger the "hild the faster the healing'


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Focused Physical Assessment

(nspe"t "hild !ndressed

)ser$e "hild wal#ing

Spinal alignment R)M

M!s"le strength

Refle*es


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Assessment

Con"erns+

Pain or tenderness

M!s"le spasm Masses

Soft tiss!e swelling


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CoREminder

(f an in!ry has o""!rred, e*amine that area

last and e gentle when palpating the in!ry

site


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Nursing Alert

% "hild yo!nger than year who presents

with a fra"t!re sho!ld e e$al!ated for

possile physi"al a!se or an !nderlying

m!s"!los#eletal disorder that wo!ld "a!sespontaneo!s one in!ry'


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Neuroascular Assessment

Pain .here is it

(s it red!"ed y nar"oti"s

0oes the pain e"ome worse when fingers or toes

are fle*ed


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Sensation Can the "hild feel to!"h on the affe"ted e*tremity

Motion Can the "hild mo$e fingers or toes elow area of

in!ry / ner$e in!ry

&emperat!re (s the e*tremity warm or "ool to to!"h


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Capillary refill Sl!ggish "apillary refill may signals poor

"ir"!lation

Color Note "olor of e*tremity and "ompare with

!naffe"ted lim

P!lses %ssess distal to in!ry or "ast


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Neuroascular !mpairment

Restri"tion of "ir"!lation and ner$e f!n"tion

from in!ry or immoilizing de$i"e'


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Clinical Mani"estations

(n"reased pain Edema 0e"reased mo$ement or sensation 0iminished or asent p!lses distal to in!ry Patient often des"ried as restless 1 pain

medi"ation do not wor# 1 pain des"ried as

deep


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!nterentions

%ssess area distal to in!ry, "ast, splint,

tra"tion for ade2!ate "ir"!lation

Release press!re y splitting the "ast or

loosening restri"ti$e andage'

Notify physi"ian


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Compartment Syndrome

Pain is the hallmar# sign, pain o!t of

proportion to the normal "lini"al "o!rse'

M!st e diagnosed immediately or

irre$ersile ne!ro$as"!lar, m!s"!lar,

$as"!lar damage o""!rs that "an lead to

renal fail!re and death'


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Clinical Mani"estations

% "omination of signs and symptoms "hara"terize "ompartmentsyndrome' &he "lassi" sign of a"!te "ompartment syndrome ispain, espe"ially when the m!s"le is stret"hed'

&here may also e a tingling or !rning sensation 3paresthesias4in the m!s"le'

% "hild may report that the foot / hand is 5a sleep6

(f the area e"omes n!m or paralysis sets in, "ell death haseg!n and efforts to lower the press!re in the "ompartment maynot e s!""essf!l in restoring f!n"tion'


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Physical Assessment

7re2!ent pain assessment

(f pain med does not wor# something is wrong

&he m!s"le may feel tight or f!ll'

Meas!re the affe"ted m!s"le gro!p and

"ompare with the !naffe"ted side

P!lses elow area of in!ry


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#reatment

Prevention

0on8t ele$ate the affe"ted lim ao$e or

elow the le$el of the heart'

0ressings sho!ld e remo$ed if CS is

s!spe"ted'

Casts sho!ld e i-$al$ed in high ris#

sit!ations'


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Assessment

0on8t forget the fi$e P8s Pain

Paresthesia

Passi$e stret"h

Press!re

P!lse-less-ness


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Surgical Management

Fasciotomy to relieve pressure. The fascia is divided alonthe length of the compartment to release pressure within.

Siumed.edu


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Nere Assessment

(mportant to d!e on admission from ER or to

the !nit

Repeat after "ast, tra"tion, or s!rgery done

on the e*tremity


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Radius and ulna nereassessment


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$lnar Nere !n%ury


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Medial Nere !n%ury


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Radial Nere !n%ury


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Peroneal Nere Distri&ution


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#reatment Modalities

9oals of fra"t!re "are+

&o regain alignment and length of the ony

fragments

&o retain alignment and length

&o restore f!n"tion of the in!red part


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#raction

Realign one fragments

Pro$ide rest

Pre$ent or impro$e deformity

Pre or post operati$e positioning

Red!"e m!s"le spasm

immoilization


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Fractures

Treatment determinedby type of fracture


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Fractures

RW handler !"


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Salter Fracture ! and !!


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Salter Fracture !!!' !( and (


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Salter)*arris Classi+cation

(f in!ry in$ol$es growth plate in an immat!re

one, growth dist!ran"e may follow'

Classifi"ation system des"ries the in!ry and

the potential for growth dist!ran"e'


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,ucks #raction

Ball & Bindler


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Principles o" #raction

Co!nter tra"tion with weights

Ma#e s!re all ropes and p!lleys are aligned and

weights are hanging freely

0o not remo$e weights !nless instr!"ted to do so

&ra"tion m!st e applied at all times


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,ryants #raction


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,ryants #raction

:sed for "hild !nder ; yrs


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Skeletal #raction

#ull directlyapplied

to bone by pin

#in care

$ncreased ris% o

infection

Ball & Bindler


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E-ternal Fi-ator


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E-ternal Fi-ation

RWChandler


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E-ternal Fi-ator

Ball & Bindler


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Pin Care

Pro$ide pin "are as ordered' Cleanse area

aro!nd pin with normal saline or half-strength

hydrogen pero*ide'


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E-ternal Fi-ator

RW Chandler MD


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E-ternal Fi-ator

RW handler !"


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Plates and Pins

R.handler !"

#lates screws andwires are used to alignbone fragments.


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Post)operatie Care

%ssess "olor, sensation, "ap refill, mo$ement,

pain, and p!lses

Cir"le any drainage noted on "ast or

dressing' Pain "ontrol

Edema = i"e to area

P!lmonary f!n"tion = C>0B


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Pulmonary Em&olism

% "ompli"ation of a fra"t!red leg is a

p!lmonary emolism' 7at es"apes the

marrow when the one is fra"t!red and "an

tra$el thro!gh the lood stream and e"omelodged in small $essels li#e the arterioles and

"apillaries of the l!ng'

Primary symptom is shortness of reath and"hest pain'


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!nterentions

Pla"e patient in high fowlers

%dminister o*ygen

Call M0

Chest *-ray

)!t"omes are etter for a health person?

poorer for person with pre-e*isting l!ng

prolems'


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)rthopedi" 0isorders

Congenital

%"2!ired / tra!ma

(nfe"tio!s


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&ales E2!ino$ar!s

Tales e'uinovarus or

Club foot

(bvious deformity noteat birth.

Surgical correction

Bowden & Greenberg


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&ales E2!ino$ar!s

Cl! 7oot

to @ per AAA

Males more affe"ted

(n$ol$es oth the ony str!"t!res and

soft tiss!e'

&he entire foot is pointing downward'


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(nter$entions

Manip!lation and serial "asting

immediately S!rgery is performed etween to @

months if f!ll "orre"tion is not a"hie$ed

with "asting


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N!rsing 0iagnosis

(mpaired physi"al moility related to "ast

wear

%ltered parenting related to emotionalrea"tion following irth of "hild with physi"al

defe"t

Ris# for impaired s#in integrity related to

"ast wear' nowledge defi"it+ "ast "are and home "are


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Metatars!s %dd!"t!s

Most "ommon foot deformity

@ per AAA

Res!lt of intra!terine positioning

7orefoot is ad!"ted and in $ar!s,

gi$ing the foot a #idney ean shape'


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Metatars!s %dd!"t!s

Bowden & Greenberg

Turning in of foot

Treatment)

#assive manipulation

Soft shoes at night

Serial casts


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0ysplasia of the


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Clini"al Manifestations


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%symmetry of s#in fold


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(nter$entions

Maintain hips in fle*ed position

&ra"tion to stret"h m!s"les

Pa$li# harness


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Pa$li#


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N!rsing 0iagnosis

nowledge defi"it regarding "are of harness

or "ast

(mpaired physi"al moility Ris# for impaired s#in integrity related to

press!re from "asts or ra"es

%ltered s#in perf!sion d!e to "asts or ra"es

Ris# for altered growth and de$elopment d!e

to limited moility


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)steogenesis (mperfe"ta


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9eneti" disorder

Ca!sed y a geneti" defe"t that affe"ts

the ody8s prod!"tion of "ollagen Collagen is the maor protein of the

ody8s "onne"ti$e tiss!e

Fess than normal or poor "ollagenleads to wea# ones that fra"t!re easy


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)ften "alled 5rittle one disease6

Chara"teristi"s

0emineralization, "orti"al thinning M!ltiple fra"t!res with pse!doarthrosis

E*!erant "all!s formation

Bl!e s"lera .ide s!t!res

Pre-senile deafness


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9eneti" 0efe"t

&ype (+ a!tosomal dominant+ age at

presentation @ 1 D years'

Common age for "hild a!se' )ften present as s!spe"ted "hild

a!se


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;-month-old with )(

(ldfractures deminerali,ation

(ld rib fractures


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&ype ((

G %!tosomal Re"essi$e

G Pre- or perinatal death

G P!lmonary hypoplasia


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7et!s with se$ere )(

Rib fractures + poorly developed spine + limbs & crani


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New Born with )(


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N!rsing 0iagnosis

Ris# of in!ry related to disease

pro"ess

Ris# for altered growth andde$elopment

nowledge defi"it+ disease pro"ess

and "are of "hild


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CaReminder

Signs of a fra"t!re, espe"ially in an

infant, are important items to tea"h

"aregi$ers' (n a ay, these signs aregeneral symptoms, s!"h as fe$er,

irritaility, and ref!sal to eat'

Bowden, HHI


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Cereral Palsy

9ro!p of disorders of mo$ement and

post!re

Prenatal causes = 44% Faor and deli$ery = H

Perinatal = I

Childhood = K


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Cereral Palsy

r


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%ssessment

0e$elopmental s!r$eillan"e is #ey

0iagnoses often made when "hild is D

to @ months of age Physi"al e*am+

Range of motion

E$al!ation of m!s"le strength and tone Presen"e of anormal mo$ement or

"ontra"t!res


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"aReminder

Refle*es that persist eyond the

e*pe"ted age of disappearan"e 3e'g',

toni" ne"# refle*4 or asen"e ofe*pe"ted refle*es are highly

s!ggesti$e of CP'

Bowden, HHI


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&eam Management


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Fegg-Cal$e-Perthes

Self-limiting disease

7emoral head loses lood s!pply

7o!r times more "ommon in males

Pea# age to years


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Pain

Fimping

Fimited hip motion espe"ially internal

rotation and ad!"tion is "lassi" sign


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Management

9oal of "are is to+ eep femoral head in

the hip oint

&ra"tion

%nti-inflammatory

Physi"al therapy


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)sgood-S"hlatters

#ainful prominence of the

tibial tubercle

Gait.udel.e


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%ssessment

&ip+ %s#ing the "hild to s2!at or e*tend

his or her #nee against resistan"e

!s!ally eli"its pain and is a goodindi"ator of )sgood-S"hlatter 0isease'


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)sgood-S"hlatters

0!e to repetiti$e motion

%ffe"ts "hildren A to years old

Males ;+ 0iagnosis is ased on "lini"al signs

and symptoms Pain, heat, tenderness, and lo"al swelling


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Management

Reduce activity

Stretching before activity

-ntiin/ammatory

-void activity that cause

pain


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Slipped Capital 7emoral Epiphysis

&op of fem!r slips thro!gh growth plate in a

posterior dire"tion'

%ges A to in girls

%ges A to D in oys


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Pain in groin

Fimp

Fimited ad!"tion Feg may e shorter


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Management

S!rgery

Cr!t"h wal#ing


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S"oliosis

0ateral curvature of spine

!edline.com


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G Pain is not a normal finding

for idiopathi" s"oliosis

G )ften present with !ne$en hemlineG :ne2!al s"ap!la

G :ne2!al hips


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S"reening


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S"reening

Bowden & Greenberg


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Mild S"oliosis

!ild forms

Strengthening and

stretching

Ball & Bindler


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Se$ere S"oliosis


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%ssessment

%lert+ (f pain is a reported symptom of

the "hild8s s"oliosis, it sho!ld e

in$estigated immediately' Pain is not anormal finding for idiopathi" s"oliosis,

and the presen"e of this symptom

"o!ld e signaling an !nderlying

"ondition s!"h as t!mor of the spinal

"ord'


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Bra"ing

ustom designed brace

hild wears at night

Bowden & Greenberg


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Moderate S"oliosis

!ilwau%ee brace

Whaley & Wong


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S"oliosis

Spinal Fusion


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Post-operati$e Care

Pain management

Chest t!e in many "ases

&!rn, "o!gh, and deep reath Fog-roll


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N!rsing 0iagnoses

Body image dist!ran"e related to

ra"ing

Ris# of in!ry related to ra"e (mpaired physi"al moility related to

ra"e wear

Ris# for non-"omplian"e withtreatment regimen


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(nflammatory Pro"ess

)steomyelitis

Septi" arthritis

J!$enile arthritis


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)steomyelitis

Webmd.lycos.com


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)steomyelitis

(nfe"tion of one and tiss!e aro!nd

one'

Re2!ires immediate treatment

Can "a!se massi$e one destr!"tionand life-threatening sepsis


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Pathogenesis of %"!te )steo

1nder 2 yearthe epiphysis is

nourished byarteries.

$n children 2 yearto 23 years theinfection is restricto below theepiphysis.


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)steomyelitis

!ost common organismStaphylococcus areus

(steomyelitis.com


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Clini"al Manifestation

Fo"alized pain

0e"reased mo$ement of area

.ith spread of infe"tion Redness

Swelling

.arm to to!"h


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0iagnosti" &ests+

-ray

CBC

ESR / erythro"yte sedimentation rate C-rea"ti$e protein

Bone s"an 1 most definiti$e test for

osteomyelitis


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-Ray

24yearold boy with painful rightarm


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)steomyelitis


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Management

C!lt!re of the lood

%spiration at site of infe"tion

(ntra$eno!s antiioti"s * wee#s P) antiioti"s if ESR rate going down

Monitor ESR 0e"rease in le$els indi"ates impro$ement


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9oals of Care

&o maintain integrity of infe"ted oint /

oints


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Septi" %rthritis

(nfe"tion within a oint or syno$ial

memrane

(nfe"tion transmitted y+ Bloodstream

Penetrating wo!nd

7oreign ody in oint


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Septi" %rthritis of


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Septi"


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0iagnosti" &ests

5ray

6eedle aspirationunder /uoroscop


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Erythro"yte Sedimentation Rate

ESR :sed as a ga!ge for determining the

progress of an inflammatory disease' Rises within @ ho!rs after onset of

symptoms'

Men+ A - K mm'/hr .omen+ A 1 @A mm'/hr Children+ A 1 A mm'/hr

WBC 31 700


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WBC 31,700

bands 4%

segs 85%

monos 6%

lymphs 5%

HgB 12.4

MCT 35.4

la!ele!s 3"4,000

C# ea&!'(e po!e'n 8.2 mg

)*+ sed a!e 3"

C R ti P t i


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C-Rea"ti$e Protein

0!ring the "o!rse of an inflammatory

pro"ess an anormal spe"ifi" protein, CRP,

appears in the lood'

&he presen"e of the protein "an e dete"ted

within D ho!rs of triggering stim!l!s'

More sensiti$e than ESR / more e*pensi$e

J i t S 7l id


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Joint Spa"e 7l!id

WBC 80,000

*egs 88%

Monos 1%

-ymphs 11%

+BC 16,000

am *!a'n am#pos'!'(e &o&&' 'n&ha'ns

M t


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Management

%dministration of antiioti"s for to D

wee#s'

)ral antiioti"s ha$e een fo!nd to eeffe"ti$e if ser!m a"teri"idal le$els

are ade2!ate'

7e$er "ontrol (!profen for anti-inflammatory effe"t

9 l f C


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9oals of Care

Maintain integrity of affe"ted oint

J il Rh t id % th iti


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J!$enile Rhe!matoid %rthritis

Chroni" inflammatory "ondition of the oints

and s!rro!nding tiss!es'

)ften triggered y a $iral illness

in AAA "hildren will de$elop JR%


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Swelling or eff!sion of one or more

oints

Fimited R)M .armth

&enderness

Pain with mo$ement

0i ti E l ti


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0iagnosti" E$al!ation

Ele$ated ESR / erythro"yte

sedimentation rate

geneti" mar#er /


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9oals of &herapy

&o pre$ent deformities

&o #eep dis"omfort to a minim!m

&o preser$e aility to do %0F

M t


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Management

%S%

N%S%(0S aro!nd the "lo"#

(mm!nos!ppressi$e dr!gs+ az!l$adine Enrel+ new "lass of dr!gs to treat

JR%

%tta"#s a spe"ifi" aspe"t of the imm!neresponse

%S% &h


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%S% &herapy

%lert+ &he !se of aspirin has een highly

asso"iated with the de$elopment of Reye8s

syndrome in "hildren who ha$e had

"hi"#enpo* or fl!' Be"a!se aspirin may ean an ongoing p art of the regimen of the

arthriti" "hild, parents sho!ld e warned of

the relationship etween $iral illnesses an

aspirin, and e ta!ght the symptoms of

Reye8s syndrome'

Management


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Management

Physi"al therapy

E*er"ise program

Monitor ESR le$els Reg!lar eye e*ams+ (riditis

(riditis


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(riditis

(ntrao"!lar inflammation of iris and

"iliary ody

@ to @ in "hildren with arthritis


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(riditis

Orthopedic Lecture 06

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