Exam 1: Orthopedics Flashcards
Definition of Scoliosis
A spinal deformity in which there is a lateral curvature in the spine greater than 10 degrees.
Congenital Scoliosis
Anomolous vertebral development
Infantile Scoliosis
onset before 3yrs old
Juvenile Scoliosis
detected between ages 3-10
Neuromuscular scoliosis
Associated with neurological or muscular diseases
Adolescent Idiopathic
Most common form, onset between 10 yrs old and after.
- Present in 2 to 4 percent of children between 10 to 16 yrs. old
- Possible genetic link because it is often seen in multiple family members.
- More common in girls
- Of adolescents diagnosed with AIS, only 10% have curve progression requiring medical attention.
Curve Progression (with degrees)
- Double curves progress more than single curves
- Can have a curve that looks like an “S”
- Larger curves (30-40°) progress more than smaller curves (20-30°)
- Females progress more than males
- Increase risk of curve progression during Peak Height Velocity during adolescent growth spurt (girls Tanner 2-3, boys Tanner 3-5)
AIS Symptoms (9)
- One shoulder higher than other
- One shoulder blade sticks out more than other
- One side of rib cage appears larger than the other
- One hip higher and more prominent
- Parents usually notice this the most, may have difficulty hemming clothing
- Waist appears uneven (but it actually isn’t)
- Body tilts to one side
- One leg appears shorter than other
- Head not centered over body
- PAIN IS NOT A TYPICAL SYMPTOM
- There may be pain in other places but not in the spine
- Pain in spine could indicate tumor, end for further eval
Screening for Orthopedics (American Academy of orthopedics)
Girls- @ 11 and 13 yrs.
Boys-Once at 13Yrs.
Screening for orthopedics: american academy of pediatrics
Routine health visits at ages 10, 12, 14 and 16 for both girls and boys
*This mostly occurs at nurses offices in schools but that isn’t sufficient because a lot of time scoliosis gets missed; need to do further screening
History Taking of AIS (5)
- Primarily diagnosis of exclusion (ensure nothing else is causing it)
- Family history of scoliosis or other musculoskeletal disorders (inquire about family hx)
- Menstrual onset
- *VERY IMP. because you want to know how much more they are going to grow because that will impact their treatment (have they already experienced peak height velocity?)
- Development of secondary sexual characteristics and recent growth patterns
- Presence of pain and neurologic changes including bowel and bladder dysfunction because this is atypical for AIS
Adams Bend Forward Test
1st: Bend forward at waist until spine becomes parallel to the floor while holding palms together with arms extended.
*Examine child from behind and side LOOKING FOR ASYMMETRY in the contour of the back (rib hump)
~If you see asymmetry, need to get an idea of the degree using a scoliometer (measure in cervical, thoracic, and lumbar)
~Refer anything above 7-10 degrees to orthopedics
2nd: Flexibility should also be evaluated by stabilizing the spine and asking the child to twist to both sides
Ninety percent of curves are to the right, LEFT THORACIC IS CONCERNING!!!
Diagnosing Scoliosis (primary concerns and determinants of progression)
Primary concerns: possible underlying cause and curve progression
Determinants of progression: gender, future growth potential and curve magnitude at time of diagnosis.
- Females progress more than males
- Look at tanner stages to see if they have had their peak height velocity (if not, progression will increase)
- Larger curves at onset progress quicker than smaller curves at onset
Evaluation of Potential Growth (4)
- Tanner Stage assessment
- Increased risk of progression @ peak height velocity
- Risser scale: evaluates skeletal maturity; using x-ray, looks at bony fusion of apothesis of the ileac crest
* The higher the number, the more fusion has occurred - Bone Age: also evaluates skeletal maturity; compares growth plates in hand to growth plate in book to look at growth & their potential level of curve progression
- Cobb Angle
Cobb Angle
Determines magnitude of curve
Superior and inferior vertebrae of scoliotic curve (looking at top of curve and bottom of curve on X-RAY)
Gives definitive angle
*Use this and evaluation of growth potential to tell you how aggressive treatment should be
Treatment: Bracing (use for, goal, and when it’s worn)
Use for: Skeletally immature child, with curve > 30° -Or- Curve which increased from 10°- >25° in a short amount of time
*may brace a child that is at a later time in development if need be
Goal: prevent curve progression or until curve progression can’t be controlled
Worn: 18 – 23 hours/day (makes adherence an issue)
~Braces should be continued until growth stops
Types of Braces (7)
- Milwaukee
- TLSO
- Boston
- Charleston
- Providence
- Spine-Core (least effective)
- RSC (mos effective)
Treatment: Surgery (indications and 4 objectives)
Indication: Cobb Angle >45 degrees
Objectives:
- Arrest progression
- Achieve maximum permanent correction
- Improve appearance
- Keep short and long term complications to a minimum
- Surgery will for the most part correct the curve, whereas bracing only prevents progression
- May do surgery and bracing to keep short and long term complications to a minimum, but bracing isn’t required after surgery
Surgical Procedure
- Fusing the vertebrae along the curve
- Supporting fused bones with instrumentation attached to spine
- Bone grafts fuse the vertebrae together
- *Fuse the vertebrae together with bone graft made ileac crest and then support the fused bones with an instrument attached to spine
- Many surgical variation exist using different instruments, procedures and surgical approaches.
- Cause of scoliosis usually determines type of procedure
Complications of Surgery (8)
- Bleeding
- Postoperative pain
- Infection
- Nerve damage
- Pseudoarthrosis
- Disk degeneration and low back pain
- Complications that involve lungs and circulation
- Flat back syndrome with Harrington rod.
Clubfoot
- Involves bone deformities and malposition with soft tissue contractures
- TEV most frequently occurring clubfoot (95%)
- Early evaluation and treatment for optimum correction; you will get maximum correction and is least invasive
*Can be diagnosed in utero or immediately after birth
Incidence of Clubfoot
1-2/1,000 live births
- Affects boys nearly twice as often as girls
- Bilateral in 50% of the cases
- A positive family history is associated with an increased incidence
Clubfoot: Talipes Equinovarus
A complex deformity of the ankle and foot with:
- forefoot adduction- toes point in - midfoot supination-turns upward - hindfoot varus-heel turns inward - ankle equinus-toes point downward
Etiology of Clubfoot (6)
Exact cause is unknown
* intrauterine positioning * neuromuscular or muscle abnormality * genetic predisposition * arrested fetal development of skeletal and soft tissue * seen with congenital abnormalities * amniotic banding (premature rupture of amniotic sac causing amnions to float around in fluid and can wrap around extremities of fetus)
IDIOPATHIC CLUBFOOT: no reason why you would expect it
Positional Clubfoot
occur primarily from intrauterine crowding. Responds to simple stretching and casting
Syndromic (tetralogic) Clubfoot
associated with other congenital abnormalities. More severe form.
Congenital (idiopathic or true clubfoot)
occur in otherwise healthy infants. It is the most common form.
*No other congenital anomalies, just born with clubfoot
Other Symptoms of Clubfoot (6)
- Small foot
- Shortened Achilles tendon
- Underdeveloped calf muscle
- Empty heel bed (if you press on it, you can’t feel the bone, but the bone is there)
- Transverse plantar crease
- Normal leg lengths (even if it is unilateral, the leg length is normal, there is just a shortening of the achilles tendon that may make it seem abnormal)
Diagnosing Clubfoot (4)
- May be detected antenatally
- Diagnosis at birth – visual inspection
- Radiographs to confirm degree and severity of deformity
- MRI may also be used
Treatment of Clubfoot
Early treatment is essential to achieve successful correction and reduce chance of complications (want treatment before bones begin to ossify)
Ponseti method: Serial casting is begun immediately or shortly after birth.
**Successive casting allows for gradual stretching of skin and tight structures on medial side of foot.
Casting for Clubfoot
1st: Every few days for first 1 to 2 weeks (come in for casting and stretching)
2nd: Then every 1 to 2 weeks until maximum correction is achieved (this usually takes about 8-12 weeks)
**Avoid overcorrection: can cause rocker bottom foot.
3rd: If corrected, child wears splint (Denis Browne Splint) or corrective shoes for 23 hours a day for first 3 months
4th: Then wear it at night time only until about 4 years old
**If deformity has not been corrected, surgical intervention is required between 3 – 12 months.
Prognosis of Clubfoot
- Parents should realize that outcomes are not always predictable and depend on severity of deformity, age of child at initial intervention, compliance with treatment, and development of bones, muscles and nerves
- Surgical intervention does not restore the ankle to an entirely normal state with the affected foot & leg remaining smaller & thinner than unaffected side.
- Most children after surgical repair are able to walk with out a limp and run or play.
- 25% chance of reoccurrence
- With severe deformities, need repeated surgeries.
* Much of the outcome depends on how early the treatment was done and the adherence of the treatment
Percent Chance of Clubfoot Reoccurence
25%, especially with non-adherence
Nursing Dx for Clubfoot (5)
- Impaired physical mobility
- Risk for impaired skin integrity
- Risk for impaired parenting
- Risk for delayed motor development
- Risk for altered parent/infant relationship
Sports Injuries: Contusions
damage to soft tissue, subcutaneous structure and muscle
Sports Injuries: Sprains
severe trauma to a joint causing a ligament to be partially or completely torn.
*ACL is most common, will report hearing a popping sound
Sports Injuries: Strains
Injury to the muscle near the musculotendinous junction, as a result of a forceful contraction of the muscle.
Sports Injuries: Dislocation and Subluxation
dislocation and subluxation refer to the displacement of bones that form a joint. These conditions affecting the joint most often result from trauma that causes adjoining bones to no longer align with each other.
*A partial or incomplete dislocation is called a subluxation
Most common under 5: dislocation of hip
Most common in younger children: finger dislocation
Therapeutic Management of Sports Injuries
- RICE= Rest, Ice, Compression, Elevation – NO HEAT
* 20 minutes ice on, 40 minutes off. Don’t put ice directly on skin
* IMP TO DECREASE SWELLING IN ORDER TO PREVENT SCARRING - Immobilization (may need brace or sling)
Fractures
In children, they are result of increased mobility and/or immature motor and cognitive skills
- Infancy – RARE; be concerned about abuse if infant comes in with fracture, especially fracture of femur
- Traumatic musculoskeletal injuries most frequent
- Clavicle most frequent bone broken
- Also worry about epiphyseal injuries – use Salter-Harris classifications; epiphyseal plate is the weakest at this point
Most frequent broken bone
Clavicle (trying to prevent fall by putting out arms but then end up putting too much pressure on clavicle)
Stress Fracture
An overuse injury
- Can be a combination of overuse and not taking in enough calcium
- Becoming more common in adolescents who limit intake of calories and calcium to remain lean for sports
Stress Fracture Symptoms
chronic pain that changes with intensity and focal tenderness in a singular site on the bone.
Bone Healing (with 5 stages)
Rapid in child due to thick periosteum
Stages
1. Hematoma – within first 24 hrs. 2. Cellular proliferation 3. Callus formation 4. Ossification 5. Consolidation and remodeling
Diagnosing Stress Fractures
Look at symptoms
1. pain or tenderness @ site 2. immobility or decreased ROM 3. deformity of extremity 4. edema @ site, crepitis, ecchymosis or muscle spasms
X-rays – sometimes of both extremities
Therapeutic Management of Stress Fractures (2)
- Closed (Simple) reduction: reduce it and put cast on
2. Open reduction: have to go in surgically then put immobilization device on
Compartment Syndrome
Results from swelling caused by trauma and immobilizing device
- Severe pain unrelieved by analgesics/pain more intense than would be expected from a fracture
- Occurs most frequently in tibia, fibia, radius, ulna
- Needs immediate medical treatment or could result in need of skin graft due to loss of circulation and compression on nerve
Compartment Syndrome Signs and Symptoms
- Severe pain unrelieved by analgesics
- Pain more intense than what would be expected from fracture
- Pallor, paresthesia, lack of pulse distal to the trauma
- Pain with extending fingers or toes
Complications of Fractures
- Infection
- Neurovascular injury
- Vascular injury
- Mal-union or delayed
- Leg length discrepancy
Osteomyelitis
Infection of bone; inflammation that involves bone AND THE BONE MARROW due to an infection
Occurs in metaphyseal region of long bones (above femur)
*Most frequent between 5 to 14 years
Exogenous osteomyelitis
Direct inoculation from outside bone
*Where skin is broken - compound fracture/open reduction
For example, could be a wound such as infected mosquito bite
Hematogenous Osteomyelitis
Spread of organism from pre-existing infection (acute and subacute)
Acute: most common cause of osteomyelitis in children because they have such a good blood supply to bone; usually occurs within first few days of infection, the CUT OFF is TWO WEEKS from initial infection
Subacute: after two weeks from initial infection; may even have been treated with antibiotics but still get it
Ex: occurring secondary to an underlying infection such as otitis media
Organisms of Osteomyelitis (know all 7 with details)
- Staphloccus aureus – most common over 5 years
- Haemophilus influenzae ,Strep pneumonia,
- Salmonella and Staph aureus – Sickle Cell Disease
- E coli and B strep – most common in neonates
- Pseudomonas - puncture wounds over 6 years.
- Nisseria gonorrhea – sexually active adolescents
- MRSA - very difficult to treat
Diagnosing Osteomyelitis (Symptoms)
- Symptoms – vague and non-specific
- infant: fever, irritability, poor feeding
- older child: pain, warmth and tenderness over site of infection, fever, lethargy, decreased ROM
*Warmth and tenderness usually doesn’t occur until osteomyelitis has progressed
Therapeutic Management of Osteomyelitis (with what you need to monitor)
- Long term IV antibiotics
- monitor for side effects (C. diff, thrush, follow kidney and liver function)
- Probably will use medications such as Vancomycin or first generation cephalosporin
- Complete bed rest due to fracture risk
* teach crutch walking for when out of hospital - Immobilization of affected limb
- May require surgical drainage
Nursing Care for Osteomyelitis
- Positioning - can be uncomfortable for patient; careful and gentle moving of the limb
- Pain control
- Monitor vital signs (ESPECIALLY TEMPERATURE)
- Antibiotic therapy
- May require isolation
- May require casting
- Nutrition
- Non-weight bearing
- Physical therapy
When is the age of onset for scoliosis?
10 years and older
When does curve progression risk increase?
During peak height velocity
Girls: tanner stages 2-3
Boys: tanner stages 3-5
What should braces be worn with?
Tight fitting T-shirts with no wrinkles!
NUMBER ONE CONCERN WITH WEARING A BRACE IS RISK FOR IMPAIRED SKIN INTEGRITY; tight shirts help prevent skin breakdown
*Patient should be inspecting for skin breakdowns; may rub alcohol on ribs to toughen skin
Spine Core Brace
Teenagers like this because it’s not bulky but research has shown that it doesn’t prevent curve progression, so don’t use it!
RSC Brace
Most effective in helping lateral curve and in trunk rotation
*Frequently used in conjunction with Schroth method
Schroth Method
Physical therapy that incorporates stretching, breathing, flexibility
- Used with RSC brace; helps prevent progression AND reduces the curve!
- Helps with lateral curve and trunk rotation
- MUST BE VERY DEDICATED TO DOING THIS AT LEAST ONE HOUR PER DAY and wear a brace!
Post scoliosis procedure
- Sit up one day post surgery & out and ambulating by 1 week post-op
- Patient will be in extreme pain after surgery and usually go to ICU for first 24 hours due to pain and extreme blood loss
* Use PCA pump with children above 6, may also have basal and bolus dose on top of the PCA
* Also give blood during surgery and may require it post surgery
* Avoid NSAIDs because that may interfere with healing - Restrictions with sports in first 3 months but no restrictions after 6 months
Things to Monitor in Children on Pain Medications (7)
- Vital signs
- Constipation (px using Colace, ask about last bowel)
- Urinary output (ask about voiding frequency)
- Pain Scale
- Ask about ITCHING (may use Benadryl to help)
- N/V (give Zofran to px it)
- Assess LOC to see if they are getting too much pain meds
Pain meds contraindicated and indicated with children
Contraindicated: Demerol
Indicated: Morphine and Diluadid
How long does it take for vertebra to fuse post scoliosis surgery
3 months for vertebra to fuse substantially, 1-2 years before fusion is complete
Pseudoarthrosis
When fusion after scoliosis surgery fails to heal
*Patient will be in significant pain, may have dislodgment of rod which is causing the pain
Signs and Symptoms of ACL sprain
- Reports hearing popping sounds
- Not as much pain as you think they would have
- Won’t be able to use joint
- More prevalent in females
- Swelling, pain, echymosis, reluctance to use join
RDA For Calcium
1500 mg/day for adolescents
Nursing Care for Stress Fractures
- Initial assessment: cause of fracture, examination, neurovascular evaluation
- Assess and manage fat embolism
- Cast Care Directions
Cast Care Directions (5)
- Can’t Shower or get it wet (even with fiber glass)
- Monitor swelling and color (check for perfusion)
- Keep it elevated as much as possible
- Check for skin breakdown around the edges of the cast (may use peddling, a soft material to put at edges)
- If child had significant wound before casting, parent should check for infection (fever, fowl odor, drainage on cast)
Compartment
Group of muscles that is surrounded by tough, inelastic fascia (connective tissue) that when there is an increased pressure in a closed space, it doesn’t expand
- Ends up compressing on vessels as well as nerves in that area
- May have swelling, and compartment doesn’t allow for expansion
Diagnosing Osteomyelitis: Lab Data (6)
- Leukocytosis
- Elevated ESR (erythrocyte sedimentation rate): goes up with inflammation and infection)
- C-Reactive Protein (CRP): also goes up with inflammation
- Blood cultures - culture and sensitivity
- bone cultures - aspiration –> trying to locate osteomyelitis
- CT scan and MRI –> best thing to see where infection is; also want to see if there is a tumor (osteocarcoma)
- X-ray isn’t good because nothing will show until 2-3 weeks after it occurs
IV Antibiotics Course for Osteomyelitis
IV antibiotics for 7-14 days, then look at all the lab count and physical symptoms again, if they have improved then change to oral antibiotics for 4-6 weeks
*Unless it’s community acquired MRS, then they will be on long-term IV antibiotics
