Lecture 7.2 - MSK Flashcards
What is scoliosis?
Lateral curvature if the spine, usually involves rotation
What is a structural curve of the spine?
Does not change with movement, fixed
What is non-structural scoliosis?
Caused by issues other than spinal structure: differing leg lengths, muscle spasms, etc.
–> aka functional scoliosis
Does not involve abnormal rotation
What is considered a scoliosis curve?
Cobb angle > 10 degrees
Small curves are considered spinal asymmetry and have no long-term significance
Is scoliosis passed down from families?
yes, 30% increased incidence if a person has an affected family member
What are the two classifications of scoliosis based on timing of onset?
Early onset
–> Before age ten
Late onset
–> onward, grouped by age.
What are the possible etiologies of scoliosis (main three types)?
Congenital, neuromuscular, idiopathic
What is congenital scoliosis? When does it occur in utero?
Failure of vertebral column to form or segment in utero
–> Abnormaility occurs by 6 weeks GA
Is congenital scoliosis diagnosed at birth?
Often not present right away, may take time to develop
–> Might be found of a prenatal US
What are some symptoms of neuromuscular scoliosis?
Spasticity, weakness, hypotonicity
–> Variable Symptoms
What are some syndromes that can cause neuromuscular scoliosis
Caused by muscle imbalance and lack of trunk control. Early detection is important, early intervention can improve function:
Cerebral palsy
Muscular dystrophy
Neurofibromatosis
Myelomeningocele
EDS
Marfan
Osteogenesis imperfecta
Achondroplasia
Most idiopathic scoliosis presents in what age group?
80-85% - adolescent idiopathic scoliosis
What are the 3 subcategories of idiopathic scoliosis?
Infantile - 0-3 years
Juvenile: 4-9 years
Adolescent: >10
Most common in adolescents (80-85%)
What organ systems are affected when a scoliosis angle increases over 70°?
Curve around ribs - heart and lungs are a concern
What is AIS? Do most people with it need treatment?
Adolescent idiopathic scoliosis (AIS)
No, only 3% have Cobb Angle > 10°, and only 10% of that population require observation or intervention
Although both girls and boys can be affected by IAS, they present differently. How so?
Boys - progress more quickly , maybe because it is more challenging to track pubertal development
girls - Risk for larger curves requiring treatment
What is the aim to manage AIS?
Increase screening in primary care - typically found by family member
What kind of curve is most common in IAS?
Right thoracic
What is a double major curve?
presence of both a thoracic and lumbar spinal curvature.
What inspection findings would indicate scoliosis?
Shoulder and hip asymmetry
Head in line with center of sacrum
What is the Adam’s forward-bending test?
Assess degree of rotation and deformity
–> Pt bend forward at wait with knees straight and palms together. Note thoracic and lumbar prominences
What is a scoliometer?
A tool that measures the angle of trunk rotation during a forward bend test
How can cafe au lait spots be associated with scoliosis?
Both are associated with neurofibromatosis type 1
How is scoliosis diagnosed definitively?
3 foot spine x-ray identifies:
–> site of deformity
–> Magnitude of curve
–> Skeletal maturity
–> Spondylolysis/spondylolisthesis
What is spondylolysis/Spondylolithesis?
Degeneration of spinal discs and joints (lysis) leads to segmental instability and displacement over time (lithesis)
What is the Cobb angle?
Degree of curvature of the spine - Draw lines from the most tilted vertebrae above and below the curve’s apex. Measure the angle between two intersecting lines perpendicular to the tilts.
(I cannot describe this, picture slide 20 is great)
Measurement of the cobb angle is essential to determine management of scoliosis an risk progression
What is the Risser Sign?
The degree of ossification of the iliac crest, maturity occurs in a stepwise fashion from lateral to medial - can be used to assess skeletal maturity using an x-ray.
Can correspond to menarche status in females
What patients with idiopathic scoliosis require monitoring and treatment?
Monitoring
–> Angle < 25° & pt still growing
–> Curve > 45° and finished spinal growth
Treat is pt is still growing and
–> Angle > 25° (bracing for Risser 0-2)
–> Cobb angle > 45-50° at time of diagnosis will likely require treatment
What is the purpose of bracing for scoliosis? What Risser stage can it be attempted on?
Does not correct curvature, simply stops it - Reduces the chance of progressing to require surgery
Must be skeletally immature (Risser 0-2)
What are the two kinds of bracing for scoliosis?
TLSO
–> Thoracolumbarsacral orthosis
Providence
–> Night time only
How much time should be spent in a scoliosis brace daily?
18-24 hours daily
–> 72% success rate at preventing surgery
What is the goal of operative interventions for scoliosis?
What are two main types?
To prevent curve progression through spine stabilization
–> Growth modulation techniques
–> Definitive Fusion
MAGEC rods - magnetic growing rod
Vertebral Body Tethering
Posterior spinal fusion - wait until child is not growing to allow lung capacity to develop
What is a MAGEC rod?
A magnetic rod that grows with the child and prevents curve progression with scoliosis
What is vertebral body tethering?
Tension on vertebrae to correct curvature, helpful for patients still growing
What is the gold standard treatment for scoliosis?
Spinal fusion
–> Correction comes from healing phase following 6 months after fusion
What are nursing roles with pre-op patients?
Review day-to-day protocols, expectations for surgery so they know what to expect
Assess mental health
How is mental health of children affected by scoliosis or spine disorders?
Children with ortho conditions are at increased risk of depression
–> may be d/t bracing, poor body image, stress factors related to surgery
What is the ASQ?
Ask suicide-screening questions
–> Tool that can identify adolescents at risk of suicide
What is covered in a HEADS assessment?
Home
Education
Activities/Anxiety
Drugs
Sex/Suicide
What happens if a person has a positive ASQ screen?
Referral to mental health team before d/c
What is the correlation between HEADS assessments and a positive ASQ screen?
Patients with a positive HEADS assessments are more likely to have a positive ASQ screen
Psychosocial risk factors –> Increased risk of suicidal ideation
What are the main goals of post-op recovery following spinal surgery?
Pain management, early mobilization, fluid balance and regulation, diet tolerance
same as usual
What assessments must nurses perform regularly following spinal surgery?
VS, neurovascular, ankle dorsiflexion
What restrictions are in place for someone who has gone through spinal surgery?
Keep in mind this will be teaching bc d/c is usually day 3.
–> No shower 5-7 days, no soaking for 6 weeks
–> Return to school 1 month post op
–> No contact sports 6 months
What is a common finding immediately post-op for spinal surgery?
Numbness - often resolves
What non-pharmacologic pain management can be helpful for spinal post-op?
Warm compresses, frequent position changes
Early hip development progresses until what age?
Progresses until 6-8 and continues into adolescence
How does the hip differ in children and adults?
Acetabulum and femoral head are cartilaginous in children
What is developmental dysplasia of the hip (DDH)?
Refers to a spectrum of abnormality in the developing hip
What is the most common MSK abnormality in the NB period?
DDH
Mild dysplasia with mild instability for the first few weeks of life generally has a benign course. When should we begin to worry about DDH?
Frank dislocation often leads to progressive dysplasia - spontaneous resolution in baby over 6 months is not likely (intervention is needed)
What are the 5 Fs of risk factors for DDH?
Family Hx
Fetal breech position
Fluid - oligohydramnios
First born infant
Females
“packaging disorder”
What is club foot?
Inward deviation of metatarsals - associated with DDH
What is dysraphism?
An umbrella term for a number of conditions where the spine and spinal cord do not develop normally
–> Such as spina bifida
What is congenital torticollis?
A condition where the infant neck muscles contract and cause head tilt to one side
–> Indicative of spinal abnormalities
Asymmetrical creases or decreased ROM of hips can indicate what?
Hip dysplasia/dislocation
What are the Barlow and Ortolani Maneuvers?
Tests hip stability.
Barlow
–> Flex + adduct hip joint. Positive test results is palpable posterior dislocation
Ortolani
–> Flex + abduct hip, femoral head will reduce into acetabulum and audible clunk will be heard and felt.
What is the Galeazzi sign?
Asymmetrical knees when supine and soles of feet brought flat to surface
How does swaddling affect the hips?
Cultures that keep hips and legs together in extended knee position have higher rather of hip dysplasia
Keeping baby’s hips in M position is better
How can we treat hip dysplasia under 6 months?
Pavlik harness
–> 12 weeks treatment (6 full/6 nights only)
Goal is to obtain and maintain concentric reduction of the hip and allow for healthy development of the acetabulum and hip joint
When is a fixed harness (Rhino) or spica cast indicated for hip dysplasia?
Pavlik harness has failed, or the child is over 6-12 months
Up to what age can a spica cast be used to treat hip dysplasia?
Up to 2 years it can be tried with closed reduction
What are some procedures that would result in a spica cast being needed?
Femur fracture
DDH
Pelvic osteotomies
Some treatments for cerebral palsy
What positioning is important for a child in a spica cast?
Well supported, prevent pressure sores
–> Consider bean bag or spica table
What position should a child who had a osteotomy be in post-op? Why?
Head above legs (reverse Trendelenburg)
–> anticipate edema, especially genital swelling
What is important parent teaching is a child had a spica cast?
Diaper care
–> Must keep case clean, it cannot be removed and if it is soiled there will be skin breakdown
–> On similar vein, keep food off of it
Clothing on upper body only
Watch skin for sores
What assessments are used to detect (not Dx) scoliosis?
Inspect for asymmetry
Adam’s forward-bending test (AFBT)
Scoliometer (optional)
What are the two kinds of growth modulation techniques for scoliosis?
MAGEC rods - magnetic growing rod
Vertebral Body Tethering
What is definitive fusion?
The Gold Standard for scoliosis treatment
–> Posterior spinal fusion
Must wait until child is not growing to allow lung capacity to develop
What is plagiocephaly?
Development of a flat spot of part of the skull
What is arthrogryposis? What causes it? How it is diagnosed and managed?
A number of congenital conditions characterized by stiff joint or abnormal muscle development. This condition is not progressive.
Etiology - might be obstruction to uterine movement, early viral infection in utero.
Diagnosis - Hx, examination. Imaging may also be used
Management - OT, orthopedic surgery.
What are the three degrees of DDH?
- Acetabular dysplasia
- Subluxation
- Dislocation
How is club foot diagnosed and managed?
Dx: Deformity readily apparent prenatally through ultrasound or at birth
Management: Goal is to achieve painless, plantigrade, stable foot through correction of deformity, maintenance of correction, and follow-up observation
What is osteogenesis imperfecta? How is it managed?
Genetic disorder characterized by bones that fracture easily
Managed supportively - bisphosphates + Ca + Vit D
Cobb curves of less than ____ degrees are considered mild and require observation during growth.
25°
Bracing for scoliosis is ineffective in managing curves greater than what?
50°
–> But might be used to delay surgical interventions by slowing the curve progression
Curves at this size require surgical intervention
What diet and bowel protocols are put in place following a spinal fusion?
Diet progresses over 3 days
Bowel protocol - PEG daily
What activity is necessary for recovery following spinal fusion? Why?
POD#1: Standing at bedside BID
POD#2: Walking BID
Necessary to prevent complications
What medications is someone discharged with following a spinal fusion?
Narcotics PRN, PEG.
Tylenol x3D then PRN
Celebrex and Baclofen x7D
