Transcript Alterations in Musculoskeletal Status

Orthopedic Disorders
Jan Bazner-Chandler
CPNP, RN, MSN
Musculoskeletal Differences in Children
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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
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Inspect child undressed
Observe child walking
Spinal alignment
ROM
Muscle strength
Reflexes
Assessment
Concerns:
 Pain or tenderness
 Muscle spasm
 Masses
 Soft tissue swelling
CoREminder
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If an injury has occurred, examine that area
last and be gentle when palpating the injury
site
Nursing Alert
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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
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Pain
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Where is it?
Is it reduced by narcotics?
Does the pain become worse when fingers or toes
are flexed?
Neurovascular Assessment
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Sensation
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Motion
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Can the child feel touch on the affected extremity
Can the child move fingers or toes below area of
injury / nerve injury
Temperature
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Is the extremity warm or cool to touch
Neurovascular Assessment
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Capillary refill
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Color
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Sluggish capillary refill may signals poor
circulation
Note color of extremity and compare with
unaffected limb
Pulses
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Assess distal to injury or cast
Neurovascular Impairment
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Restriction of circulation and nerve function
from injury or immobilizing device.
Compartment Syndrome
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Complication of fractures.
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
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The classic sign of acute compartment syndrome is pain,
especially when the muscle is stretched.
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There may also be a tingling or burning sensation (paresthesias)
in the muscle.
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A child may report that the foot / hand is “a sleep”
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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.
Interventions
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Prevention
Don’t elevate the affected limb above or
below the level of the heart.
Notify physician if there is pain (not relieved
by pain med), decreased sensation,
decreased pulses distal to injury or tingling /
numbness.
Nerve Assessment
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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
Uses of Traction
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Realign bone fragments
Provide rest
Prevent or improve deformity
Pre or post operative positioning
Reduce muscle spasm
immobilization
Fractures
Treatment determined
by type of fracture
Fractures
RW Chandler MD
Salter Fracture I and II
Salter Fracture III, IV and V
Salter-Harris Classification
If injury involves growth plate in an immature
bone, growth disturbance may follow.
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Classification system describes the injury and
the potential for growth disturbance.
Bucks Traction
Ball & Bindler
Principles of Traction
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Counter traction with weights
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Make sure all ropes and pulleys are aligned and
weights are hanging freely
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Do not remove weights unless instructed to do so
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Traction must be applied at all times
Skeletal Traction
Pull directly
applied
to bone by pin
Pin care
Increased risk of
infection
Ball & Bindler
External Fixator
External Fixation
RWChandler MD
Pin Care
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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
Plates and Pins
Plates, screws, and
wires are used to align
bone fragments.
R.Chandler MD
Post-operative Care
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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
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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
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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
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Congenital
Acquired / trauma
Infectious
Tales Equinovarus
Tales equinovarus or
Club foot
Obvious deformity noted
at birth.
Surgical correction
Bowden & Greenberg
Tales Equinovarus
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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
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Manipulation and serial casting
immediately
Surgery is performed between 4 to 12
months if full correction is not achieved
with casting
Nursing Diagnosis
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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
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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
Turning in of foot
Treatment:
Passive manipulation
Soft shoes at night
Serial casts
Bowden & Greenberg
Dysplasia of the Hip
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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
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Head of femur lies outside the acetabulum
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+ Ortolani maneuver
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Asymmetrical lower extremity skin folds
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Discrepancy in limb length
Hip Exam
Interventions
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Maintain hips in flexed position
Traction to stretch muscles
Pavlik harness
Hip surgery
Bowden & Greenberg
Pavlik Harness
Bowden & Greenberg
Nursing Diagnosis
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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
Osteogenesis Imperfecta
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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
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Often called “brittle bone disease”
Characteristics
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Demineralization, cortical thinning
Multiple fractures with pseudoarthrosis
Exuberant callus formation
Blue sclera
Wide sutures
Pre-senile deafness
Genetic Defect
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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
Old rib fractures
Old fractures/demineralization
New Born with OI
Nursing Diagnosis
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Risk of injury related to disease
process
Risk for altered growth and
development
Knowledge deficit: disease process
and care of child
CaReminder
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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.
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Bowden, 1998
Cerebral Palsy
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Group of disorders of movement and
posture
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Prenatal causes = 44%
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Labor and delivery = 19%
Neonatal = 8%
Childhood = 5%
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Assessment
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Developmental surveillance is key
Diagnoses often made when child is 6
to 12 months of age
Physical exam:
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Range of motion
Evaluation of muscle strength and tone
Presence of abnormal movement or
contractures
caReminder
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Reflexes that persist beyond the
expected age of disappearance (e.g.,
tonic neck reflex) or absence of
expected reflexes are highly
suggestive of CP.
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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
Osgood-Schlatters
Painful prominence of the
tibial tubercle
Gait.udel.ed
Assessment
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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
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Due to repetitive motion
Affects children 10 to 14 years old
Males 3:1
Diagnosis is based on clinical signs
and symptoms
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Pain, heat, tenderness, and local swelling
Management
Reduce activity
Stretching before activity
Anti-inflammatory
Avoid activity that cause pain
Slipped Capital Femoral Epiphysis
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Top of femur slips through growth plate in a
posterior direction.
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Ages 10 to 14 in girls
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Ages 10 to 16 in boys
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High proportion are obese
Clinical Manifestations
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Pain in groin
Limp
Limited abduction
Leg may be shorter
Clinical Manifestations
Management
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Surgery
Crutch walking
Scoliosis
Lateral curvature of spine
Medline.com
Clinical Manifestations
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Pain is not a normal finding
for idiopathic scoliosis
Often present with uneven hemline
Unequal scapula
Unequal hips
Screening
Screening
Bowden & Greenberg
Mild Scoliosis
Mild forms
Strengthening and
stretching
Ball & Bindler
Assessment
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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
Custom designed brace
Child wears at night
Bowden & Greenberg
Scoliosis
Spinal Fusion
Post-operative Care
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Pain management
Chest tube in many cases
Turn, cough, and deep breath
Log-roll
Nursing Diagnoses
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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
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Osteomyelitis
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Septic arthritis
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Juvenile arthritis
Osteomyelitis
Webmd.lycos.com
Osteomyelitis
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Infection of bone and tissue around
bone.
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Requires immediate treatment
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Can cause massive bone destruction
and life-threatening sepsis
Pathogenesis of Acute Osteo
Under 1 year
the epiphysis is
nourished by
arteries.
In children 1 year
to 15 years the
infection is restricted
to below the
epiphysis.
Clinical Manifestation
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Localized pain
Decreased movement of area
With spread of infection
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Redness
Swelling
Warm to touch
Diagnostic Tests:
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X-ray
CBC
ESR / erythrocyte sedimentation rate
C-reactive protein
Bone scan – most definitive test for
osteomyelitis
X-Ray
18-year-old boy with painful right arm
Osteomyelitis
Management
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Culture of the blood
Aspiration at site of infection
Intravenous antibiotics x 4 weeks
PO antibiotics if ESR rate going down
Monitor ESR
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Decrease in levels indicates improvement
Goals of Care
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To maintain integrity of infected joint /
joints
Septic Arthritis
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Infection within a joint or synovial
membrane
Infection transmitted by:
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Bloodstream
Penetrating wound
Foreign body in joint
Septic Arthritis of Hip
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Difficulty walking and fever
Diagnosis: x-ray, aspirate fluid from
joint, ESR
Septic Hip
Diagnostic Tests
X-ray
Needle aspiration
under fluoroscopy
Erythrocyte Sedimentation Rate
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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
WBC
31,700
bands
4%
segs
85%
monos
6%
lymphs
5%
HgB
12.4
MCT
35.4
Platelets
394,000
C- reactive protein
8.2 mg
ESR /sed rate
39
C-Reactive Protein
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During the course of an inflammatory
process an abnormal specific protein, CRP,
appears in the blood.
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The presence of the protein can be detected
within 6 hours of triggering stimulus.
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More sensitive than ESR / more expensive
Joint Space Fluid
WBC
80,000
Segs
88%
Monos
1%
Lymphs
11%
RBC
16,000
Gram Stain
Gram-positive cocci in
chains
Management
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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
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Maintain integrity of affected joint
Juvenile Rheumatoid Arthritis
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Chronic inflammatory condition of the joints
and surrounding tissues.
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Often triggered by a viral illness
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1 in 1000 children will develop JRA
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Higher incidence in girls
Clinical Manifestations
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Swelling or effusion of one or more
joints
Limited ROM
Warmth
Tenderness
Pain with movement
Diagnostic Evaluation
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Elevated ESR / erythrocyte
sedimentation rate
+ genetic marker / HLA b27
+ RF 9 antinuclear antibodies
Bone scan
MRI
Arthroscopic exam
Goals of Therapy
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To prevent deformities
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To keep discomfort to a minimum
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To preserve ability to do ADL
Management
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ASA
NASAIDS around the clock
Immunosuppressive drugs: azulvadine
Enbrel: new class of drugs to treat JRA
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Attacks a specific aspect of the immune
response
ASA Therapy
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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
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Physical therapy
Exercise program
Monitor ESR levels
Regular eye exams: Iriditis
Iriditis
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Intraocular inflammation of iris and
ciliary body
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2% to 21% in children with arthritis
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Highest incidence in children with multi
joint involvement disease.
Iriditis