Orthopedic Disorders
Alterations in Musculoskeletal Status
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.
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
Interventions
Assess area distal to injury, cast, splint, traction for adequate
circulation
Release pressure by splitting the cast or loosening restrictive bandage.
Notify physician
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.
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.
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
Treatment
Prevention
Don’t 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.
Assessment
Don’t forget the five P’s
Pain
Paresthesia
Passive stretch
Pressure
Pulse-less-ness
Surgical Management
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
Peroneal Nerve Distribution
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
Traction
Realign bone fragments
Provide rest
Prevent or improve deformity
Pre or post operative positioning
Reduce muscle spasm
immobilization
Fractures
Fractures
Salter Fracture I and II
Salter Fracture III, IV and V
Salter-Harris Classification
Bucks Traction
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
Bryants Traction
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
Skeletal Traction
External Fixator
External Fixation
External Fixator
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
External Fixator
External Fixator
Plates and Pins
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
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
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
Asymmetry of skin fold
Hip Exam
Interventions
Maintain hips in flexed position
Traction to stretch muscles
Pavlik harness
Hip surgery
Pavlik Harness
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
Harness
Osteogenesis Imperfecta
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
Type II
Autosomal Recessive
Pre- or perinatal death
Pulmonary hypoplasia
Fetus with severe OI
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%
Perinatal = 8%
Childhood = 5%
Cerebral Palsy
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
Team Management
Legg-Calve-Perthes
Self-limiting disease
Femoral head loses blood supply
Four times more common in males
Peak age 4 to 7 years
Clinical Manifestations
Pain
Limping
Limited hip motion especially internal rotation and abduction is classic
sign
Management
Goal of care is to: Keep femoral head in the hip joint
Traction
Anti-inflammatory
Physical therapy
Osgood-Schlatters
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
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
Clinical Manifestations
Pain is not a normal finding
for idiopathic scoliosis
Often present with uneven hemline
Unequal scapula
Unequal hips
Screening
Screening
Mild Scoliosis
Severe Scoliosis
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
Moderate Scoliosis
Scoliosis
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
Osteomyelitis
Infection of bone and tissue around bone.
Requires immediate treatment
Can cause massive bone destruction and life-threatening sepsis
Pathogenesis of Acute Osteo
Osteomyelitis
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
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
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
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
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
