Orthopedics Disorders Pediatrics Part II

Jan Bazner-ChandlerRN, MSN, CNS, CPNP

Orthopedic Disorders Congenital Acquired / trauma Infectious

Talipes Equinovarus

Talipes equinovarus or

Club foot

Obvious deformity notedat birth.

Surgical correction

Talipus 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. The more rigid the foot the more likely

surgery will be necessary. Surgery performed between 4 and 12 months.

Metatarsus Adductus Most common foot deformity 2 per 1000 Result of intrauterine positioning Forefoot is adducted and in varus, giving the

foot a kidney bean shape. Most often resolves on own or with simple

exercises.

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

Developmental Dysplasia of Hip

Clinical Manifestations

+ Ortolani maneuver Asymmetrical lower extremity skin folds –

soft sign not always seen. In the older infant there would be

decreased ROM in the affected hip especially with abduction.

In the child there might be discrepancy in limb length.

Asymmetry of skin fold

Hip Exam

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

Bowden & Greenberg

Pavlik Harness

Bowden & Greenberg

Harness

JB Chandler

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 easily.

Osteogenesis Imperfecta Often called “brittle bone disease” Characteristics

Demineralization, cortical thinning Multiple fractures with pseudoarthrosis Exuberant callus formation at fracture site Blue sclera Wide sutures Pre-senile deafness

3-month-old with OI

Old fractures/demineralization

Old rib fractures

New Born with OI

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.

Cerebral Palsy Group of disorders of movement and posture

Prenatal causes = 44% Labor and delivery = 19% Perinatal = 8% Childhood = 5%

Assessment Developmental surveillance is key Diagnosis 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.

Clinical ManifestationsHypotonia or HypertoniaContracturesScoliosisSeizuresMental Retardation Visual, learning and hearing disordersOsteoporosis – long term due to lack of

movement

Legg-Calve-Perthes Vascular disturbance leads to bone death in

hip do to interruption of blood flow. Four times more common in males More common in Asians, Eskimos and

Caucasians. Peak age 6 (2 - 12 years)

Clinical Manifestations Pain – groin, hip or referred pain to knee. Limping Limited hip motion especially internal rotation

and abduction is classic sign.

Right hip - LCP

Management Goal of care is to: Keep femoral head in the

hip joint Traction Anti-inflammatory Physical therapy Surgery if femoral head destroyed

Osgood-Schlatters

Painful prominence of the

tibial tubercle

Gait.udel.edu

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

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.

Management

•Reduce activity

•Stretching before activity

•Anti-inflammatory

•Avoid activity that cause pain

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, hip or knee Limp (antalgic is limping on affected side) Limited abduction Leg may be shorter

Clinical Manifestations

Management Surgery – fix with a pin Crutch walking Complications

Avascular necrosis of femoral head is compromise of circulation of the femoral head leading to ischemia. This may lead to collapse of the necrotic segment.

Scoliosis

Lateral curvature of spine

Medline.com

Mild Scoliosis

Mild forms

Strengthening and

stretching

Clinical Manifestations• Pain is not a normal finding

for idiopathic scoliosis• Often present with uneven hemline• Unequal scapula• Unequal hips

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.

Screening

Screening

Bowden & Greenberg

Severe Scoliosis

Bracing

Milwaukee Brace

Scoliosis

Spinal Fusion

Post-operative Care Pain management Chest tube in many cases Turn, cough, and deep breathe Log-roll

Muscular Dystrophy Group of genetic diseases characterized by

progressive weakness and degeneration of the skeletal muscles that control movement.

Most common: Duchenne muscular dystrophy (DMD)

Predominately male disease X-linked recessive inherited disease

Pathophysiology DMD is deficiency or absence of the protein

dystrophin. Protein is thought to strengthen the muscle

cell membrane. Laboratory values: Creatinine kinase levels

are high.

Assessment Infant may display mild delay in attaining

milestone. Sitting up, crawling, cruising Toddler (between ages 2 to 3) may have a clumsy

gait and have difficulty climbing stairs. Classic physical finding: Gowers’ sign

Gowers’ Sign http://www.youtube.com Type in Gowers’ Sign

Interdisciplinary Interventions Team of nursing, physicians, specialists Pharmacologic Interventions

Glucocorticosteroids (prednisone and deflazacort): steroids have been found to increase muscle strength and pulmonary function.

Long Term Problems Cardiomyopathy in 90% over 18 years of age Respiratory complications Obesity