Pediatric Orthopedics
139
PEDIATRIC ORTHOPEDICS Joyce Coffey RN MSN/ED City College of San Francisco NUR 54 Nursing of Children Fall 2013
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Transcript of Pediatric Orthopedics
PEDIATRIC ORTHOPEDICSJoyce Coffey RN MSN/EDCity College of San FranciscoNUR 54 Nursing of ChildrenFall 2013
Learning Objectives In this lecture students will learn:
Basic anatomy and physiology of the musculoskeletal system
Selected musculoskeletal disorders in the pediatric population
Common diagnostic tests for musculoskeletal problems
Orthopedic treatments and procedures Nursing care for children with alterations in
musculoskeletal function
Skeleton of Newborn Gaps between
bones indicate cartilage, which will develop into bone tissue as the child ages
Stages of Long Bone Growth Process of
cartilage calcifying and becoming mature and compact bone
Key Concepts Bone formation is incomplete at birth Bone growth and ossification continues
throughout childhood Treatment depends on cause
Malformation Infection Injury
DEFECTS IN PHYSICAL DEVELOPMENT
Causes of congenital malformations (anomalies) Genetic factors Environmental factors
MICROCEPHALY Definition
Reflects a small brain Autosomal recessive or chromosomal
abnormality
Microcephaly Primary
Intrauterine exposure to toxins (weeks 4 to 20) Secondary
Third-trimester exposure Perinatal exposure Exposure in early infancy
Effects Mild hyperkinesis, mild motor impairment Decerebration, complete unresponsiveness Autistic behavior
CRANIOSTENOSIS Premature closure
of 1 or more cranial sutures
Therapeutic Management Surgical excision of bone (strip
craniectomy) Along or parallel to suture Releases fused suture Directs new growth
Before 6 mo old Best cosmetic and neurodevelopmental
results Least amt of brain damage
Craniostenosis
Before tx After tx
PLAGIOCEPHALY Skull
progressively flattened
Not associated with brain malformation
Treatment Helmets,
bands( elastic bands to make it more symmetircal), time
Cranio Helmets after Release of Ossified Sutures
SKELETAL DEFECTS
DEVELOPMENTAL DYSPLASIA of the HIP (DDH)
Formerly called “congenital hip dysplasia” and “congenital dislocation of the hip”
Incidence 1-10/1000 live births More common in females (60%) More common in Caucasians than any
other group
Displaced Hips
Etiology of DDH Physiologic Mechanical Genetic
Classifications Acetabular Subluxation Dislocation
Configuration and Relationship of Structures
Clinical Manifestations of DDH
Positive Ortolani test Audible click when abducting and externally
rotating hip Barlow maneuver Shortening of limb (femur) on affected side Asymmetric gluteal, popliteal, and thigh
folds Broadening of the perineum Limited abduction of hip on affected side Waddling gait and lordosis
Clinical Manifestations (cont’d) In older infant and child
Affected leg shorter than the other Telescoping or piston mobility of joint Positive trendelenburg sign Greater trochanter is prominent and
appears above a line from anterior superior iliac spine to tuberosity of ischium
Marked lordosis if bilateral dislocations Waddling gait if bilateral dislocations
Assessment of DDH
Assess for Ortolani Click
Therapeutic Management of DDH
Directed toward enlarging and deepening acetabulum Place head of femur within acetabulum Apply constant pressure Legs slightly flexed and abducted
Splinting Spica cast Pavlik harness
Surgical intervention ORIF with casting
Age variations Newborn to 6 months 6 to 18 months Older child
Nursing Considerations for DDH Limit risk for hypostatic pneumonia( not
moving not moving lung) Maintain skin integrity Prevent constipation( they kcik their legs
and moving to increase peristatlsis) Encourage nutritious foods Move and position safely when in spica cast Meet emotional needs Provide parents with help and support
CONGENITAL CLUBFOOT
Congenital Clubfoot Bone deformity and malposition of foot
Soft tissue contracture Foot twisted out of alignment May be misshaped
Talipes equinovarus (TEV)( most common we see) Toes pointed downward and inward
Incidence 1-2 per 1000 live births More common in males Bilateral clubfeet in 50% of cases Familial tendency( does tend to run in family)
Clinical Findings Deformity apparent at birth Classification
Rigid or flexible Mild (positional) Syndromic (associated with other
congenital abnormalities) Congenital
Wide range of prognosis Usually requires surgical intervention
Therapeutic Interventions Started during newborn period
Delay causes abnormal development of leg muscles and bones with shortening of tendons
Non-surgical Passive exercise Serial casting Orthotics
Surgical Tight ligaments released Tendons lengthened
Nursing Considerations Assess and educate parents
Monitor CMS and skin( consider tissue breakdown)
Monitor cast and special orthopedic shoes Follow-up care( when the family has to
come back every week)
THE CHILD AND TRAUMA
Epidemiology of Trauma Trauma is leading cause of death in
children older than 1 year Aspects of injury are affected by the
developmental stage of child
Trauma Types
Nonintentional injury Child abuse injury( multiple bruises does
the clinical picture match) Dependant on:
Age Developmental level Preventative measures
THE IMMOBILIZED CHILD Immobilization was once thought to be
restorative from illness and injury We know now that immobilization has
serious consequences Physical Social Psychologic
Immobilized Child
Physiologic Effects of Immobilization
Physiologic Effects of Immobility
Muscular system Decreased muscle strength and endurance Atrophy Loss of joint mobility
Skeletal system Bone demineralization Negative calcium balance
Physiologic Effects of Immobility
Metabolism Decreased metabolic rate( not moving,
decrease nitrogen balance) Negative nitrogen balance Hypercalcemia Decreased production of stress hormones
Physiologic Effects of Immobility Cardiovascular system
Decreased efficiency of orthostatic neurovascular reflexes
Diminished vasopressor mechanism( you are not using it )
Altered distribution of blood volume( its going to pool on whatever position is depended
Venous stasis Dependent edema
Physiologic Effects of Immobility Respiratory system
Decreased need for oxygen Diminished vital capacity Poor abdominal tone and distention Mechanical or biochemical secretion
retention Loss of respiratory muscle strength
Physiologic Effects of Immobility GI system
Distention caused by poor abdominal muscle tone( not using it not breathing , nost standing , moving our legs)
Difficulty feeding in prone position Gravitation effect on feces Anorexia( no nutrition)
Physiologic Effects of Immobility Integumentary system
Decreased circulation and pressure leading to decreased healing capacity
Urinary system Alteration of gravitational force Difficulty voiding in supine position Urinary retention Impaired ureteral peristalsis
Physiologic Effects of Immobility
Loss of innervation If nerve tissue is damaged by pressure If circulation to nerve tissue is interrupted Effects of improper positioning
Sensory and perceptual deprivation( stimulating the growth and development)
Tissue Breakdown
Psychologic Effects of Immobility Diminished environmental stimuli Altered perception of self and
environment Increased feelings of frustration,
helplessness, anxiety Depression, anger, aggressive behavior Developmental regression
Effect on Families Extended periods of immobilization
Logistical management of sick child Need for family support and home care
assistance Coping skills
Mobilization Devices
Orthotics Knee-Ankle-Foot Orthotic
Mobilization DevicesThoracolumbosacral Orthotic Rear-Rolling Walker
Mobilization Devices
Crutches Wheelchair
Mobilization Devices
Bike Walker Gait Walker with Suspension Belts
EPIPHYSEAL INJURIES Epiphysis
Growth end of long bones Growing cartilage to that hard bone
Growth plate located in the epiphysis Weakest point of long bones ( where the growing is
meeting the osfied bone) Frequent site of damage during trauma May affect future bone growth Treatment may include open reduction and
internal fixation to prevent growth disturbances
FRACTURES Common injury in children Clavicle most frequently broken bone in
child, especially younger than age 10 School age—bike, sports injuries Methods of treatment different in
pediatrics than in older adult population
Types of Fractures Compound or open
fractured bone protrudes through the skin Complicated
bone fragments have damaged other organs or tissues
Comminuted small fragments of bone are broken from the
fractured shaft and lie in surrounding tissue Greenstick( child abuse)
compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture
Clinical Manifestations of Fracture Generalized swelling Pain or tenderness Diminished functional use (decreased
movement) Deformity of bone Ecchymosis Guarding Severe muscular rigidity, crepitus
Diagnostic Evaluation Visual ( sometimes you can see it , ifyou
cant see it xray) X-ray is the most useful diagnostic tool
Immediate Interventions Immobilize Assess circulation Apply cool/cold compress Elevate limb ( keep in alignment) Sterile/clean dressing over open wound
Therapeutic Interventions Splints( non invasive, bc of swelling) Casts
Hard or soft Promote bone alignment Prevent further damage
Surgery Internal fixation (ORIF) External fixation
Traction
External Fixation Ilizarov external
fixator The induction of new
bone between bone surfaces that are pulled apart in a gradual, controlled manner
Permits limb lengthening by manual distraction
Stimulates new bone formation
Bone Healing and Remodeling Typically rapid healing in children Neonatal period—2 to 3 weeks Early childhood—4 weeks Later childhood—6 to 8 weeks Adolescence—8 to 12 weeks
Nursing Considerations Assessment of the “5 P’s”
Pain and point of tenderness Pallor Paresthesia distal to fx Pulselessness distal to fx site Paralysis; lack of movement distal to fx site
(late and ominous sign) Cause of injury
Nursing Interventions Use age appropriate pain rating scales
Medicate appropriately Monitor neurovascular status of distal extremity
Avoid using affected side for vital signs Allow cast to dry by exposing to air Provide age appropriate activity
Distraction and entertainment Monitor operative site
Internal and external fixation Maintain functional alignment with supportive
devices
Types of Casts
Spica Cast with Hip Abductor
Young Children Come to Regard Casts as Part of Their Body
THE CHILD in TRACTION Traction—extended pulling force may be
used to Provide rest for an extremity Help prevent or improve contracture
deformity Correct a deformity Treat a dislocation Allow position and alignment Provide immobilization Reduce muscle spasms (rare in children)
Traction- Essential Components Traction—forward force produced by
attaching weight to distal bone fragment Adjust by adding or subtracting weights
Countertraction—backward force provided by body weight Increase by elevating foot of bed
Frictional force—provided by patient’s contact with the bed
Application of Traction for Maintaining Equilibrium
Types of Traction Manual traction
applied to the body part by the hand placed distally to the fracture site
Skin traction pulling mechanisms are attached to the skin
with adhesive material or elastic bandage Skeletal traction
applied directly to skeletal structure by pin, wire, or tongs Inserted into or through the diameter of the bone distal to the fracture
Child in Skeletal Traction
Cervical Traction Crutchfield or Barton tongs Inserted through burr holes in skull with
weights attached to the hyperextended head
As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord is no longer pinched between vertebrae
Halo traction can be applied in some cases
TRAUMATIC INJURY Soft tissue injury—injuries to muscles,
ligaments, and tendons Sports injuries Mishaps during play
Types of Injuries Acute overload injuries Overuse syndromes( kids w/ yr round
sports) Repetitive microtrauma Inflammation of the involved structure Complaint of pain, tenderness, swelling,
disability Examples—tennis elbow, Osgood-Schlatter
disease
Types of Injuries Contusions Dislocations Sprains Strains Stress Fractures
Sites of Injuries to Bones, Joints, and Tissues
Therapeutic Management of Soft Tissue Injuries
RICE Rest the injured part Ice immediately (max 30 minutes at a time) Compression with wet elastic bandage Elevation of the extremity
ICES- Ice, Compression, Elevation, Support
Immobilization and support (casts or splints as appropriate to injury)
Correct and Incorrect Methods for Elevating a Lower Extremity
MUSCULOSKELETAL COMPLICATIONS
Circulatory impairment Nerve compression syndromes Compartment syndromes Volkmann contracture Epiphyseal damage Nonunion/malunion Infection Kidney stones Pulmonary emboli
COMPARTMENT SYNDROME Pressure within the muscles builds to
dangerous levels (from swelling or bleeding) Decreases blood flow Prevents nourishment and oxygen from
reaching nerve and muscle cells Causes cell damage and death
Acute or chronic More painful than would be expected
Not relieved by pain meds
Fasciotomy
OSTEOMYELITIS Bacteria infection of bone Direct infection (injury, hardware
insertion) Hematogenous Osteomyelitis common in
children Bacterial infection from one site of the
body travels through blood stream to bone
Osteomyelitis
Femur Calcaneus
Clinical Manifestations of Osteomyelitis
Localized Pain Swelling at site Warm at site Redness at site Pain upon weight bearing
Osteomyelitis Diagnosis Signs and symptoms begin abruptly;
resemble symptoms of arthritis and leukemia
Marked leukocytosis Bone cultures obtained from biopsy or
aspirate Early x-rays may appear normal Bone scans for diagnosis
Therapeutic Management of Osteomyelitis
May have subacute presentation with walled-off abscess rather than a spreading infection
Prompt, vigorous IV antibiotics for extended period (3 to 4 weeks or up to several months)
Monitor hematologic, renal, hepatic responses to treatment
Nursing Considerations Complete bed rest and immobility of
limb Pain management concerns Long-term IV access (for antibiotic
administration) Nutritional considerations Long-term hospitalization/therapy Psychosocial needs
LEGG-CALVÉ-PERTHES DISEASE
Avascular necrosis of femoral head Self-limited Idiopathic Affects children ages 3 to 12 More common in males ages 4 to 8 10-15% bilateral hip involvement Most have delayed bone age
Legg-Calvé-Perthes Disease
Legg-Calvé-Perthes Disease Pathophysiology—cause unknown but
involves disturbed circulation to the femoral head with ischemic aseptic necrosis
After resolving, may have normal femoral head or may have severe alteration
Legg-Calvé-Perthes Disease Prognosis
Self-limited disease Outcome has wide variations due to
multiple factors Nursing considerations
Identification of affected children and referral
Teaching care and management Compliance issues with child/family
Therapeutic Management Treatment goal—keep head of femur in
acetabulum Containment with various appliances
and devices Rest, no weight bearing initially Surgery in some cases Home traction in some cases May take up to 4 years of therapy
SCOLIOSIS The most common spinal deformity Complex spinal deformity in three planes
Lateral curvature Spinal rotation causing rib asymmetry Thoracic hypokyphosis
May be congenital or develop during childhood Lordosis
Accentuation of the cervical or lumbar curvature beyond physiologic limits (swayback)
Kyphosis Abnormally increased convex angulation in the curvature of
the thoracic spine (round shoulders or hunched shoulders)
Scoliosis (cont’d) Multiple potential causes; most cases
idiopathic Generally becomes noticeable after
preadolescent growth spurt May have complaint of “ill-fitting
clothes” School screening controversial
Diagnostic Evaluation Standing radiographs to determine
degree of curvature Asymmetry
shoulder height scapular flank shape hip height
Often have a primary curve and a compensatory curve to align head with gluteal cleft
Clinical Manifestations Insidious onset
May have history of limp Soreness or stiffness Limited ROM Vague history of trauma
Pain and limp most evident on arising and at end of activity
Diagnosed by x-ray
Therapeutic Management Team approach to treatment Bracing
Must be worn 23 hrs/day Exercise Surgical intervention for severe
curvature (various systems of instrumentation and fusion) Harrington, Dwyer, Zielke, Luque, Cotrel-
Dubousset, Isola, TSRH (Texas Scottish Rite Hospital), and Moss Miami
TLSO Braces
Success with Bracing
Surgical repair
Nursing Interventions Maintain spinal alignment per protocol Provide care when wearing brace
Examine skin surfaces where contact with brace Implement corrective action for skin breakdown Help select appropriate apparel to wear over brace
to minimize altered appearance Encourage wearing low-heeled shoes for balance
Reinforce instructions regarding plan of care Use of appliance Activities Prepare for surgery when appropriate
Nursing Considerations Concerns of body image Concerns of prolonged treatment of
condition Preoperative care Postoperative care Family issues
JUVENILE IDIOPATHIC ARTHRITIS (JIA)
Formerly called JRA (juvenile rheumatoid arthritis)
Possible causes Chronic autoimmune inflammatory disease Affects joints and other tissue
1 in 1000 children Peak ages: 1-3 years and 8-10 years Female predominance 2:1 Often undiagnosed
JIA (cont’d) Actually a heterogeneous group of
diseases Pauciarticular onset (involves ≤4 joints) Polyarticular onset (involves ≥5 joints) Systemic onset (high fever, rash,
hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy)
JIA (cont’d) 90% children have negative rheumatoid
factor Symptoms may “burn out” and become
inactive Chronic inflammation of synovium with
joint effusion, destruction of cartilage, and ankylosis of joints as disease progresses
Symptoms of JIA Stiffness Swelling Loss of mobility in affected joints
Most common in morning and after inactivity
Warm to touch, usually without erythema
Tender to touch in some cases Symptoms increase with stressors Growth retardation
Diagnostic Evaluation of JIA No definitive diagnostic tests Elevated sedimentation rate in some
cases Antinuclear antibodies common but not
specific for JRA Leukocytosis during exacerbations Diagnosis based on criteria of American
College of Rheumatology
American College of Rheumatology Diagnostic Criteria
Age of onset younger than 16 years One or more affected joints Duration of arthritis more than 6 weeks Exclusion of other forms of arthritis
Therapeutic Management of JIA No specific cure Goals of therapy
Preserve function Prevent deformities Relieve symptoms
Iridocyclitis/uveitis Inflammation of iris and ciliary body Unique to JRA Requires treatment by ophthalmologist
Pharmacology for JIA NSAIDs (Nonsteroidal anti-inflammatory
drug) SAARDs (Slow-acting anti-rheumatic
drug) Used when first-line therapy (NSAIDs), fails
to control disease Corticosteroids Cytotoxic agents Immunomodulators
Management of JIA Therapy individualized to child PT, OT Nutrition Exercise Splinting devices Pain management Prognosis
Nursing Interventions Emphasize medication protocol Promote functional alignment Encourage warm baths or warm moist
compresses Offer nutritious diet Promote adequate rest and sleep Provide emotional support
THE END
