NP619 Module 7 & 8 Flashcards
Treatment of club feet
More common in boys
The cause is unknown
Serial casting is the treatment for 6-8 weeks with cast changes weekly
surgery possible between 3-18 months
OUR ROLE is to make sure that baby is growing and that someone is doing weight checks
Metatarsus Adductus
can affect one or both feet from position in utero Ankle has full plantar and dorsiflexion Do not x-ray do not worry unless no resolution by 6 months
Torticollis-Contracture of the sternocleidomastoid muscle
occur from position in birth canal, etc
Crook in the neck
What we consider after meningitis
TX: ROM, motrin, older children can maybe use some flexeril
Subluxation of the elbow-Most common at ages 1-3
entrapment of the annular ligament
Dx by Hx: partial dislocation of the head of radius, arises from the sudden jerk or pull of a toddlers arm
Arm=motionless, slight flextion, pronation, adduction, radial head is tender
Tx of the nursemaids elbow
Cup elbow appl pressure over the radial head thumb in the antecubital fossa apply slight longitudinal traction by grasping the wrist supinate (palm up) and flex (to 90 degrees) forearm palpable click felt with reduction child uses arm within 15 minutes can use sling 1-2 days if it does not work-do x-ray
Scoliosis=lateral curve of 11 degrees or greater of spine
Long term consequences: unpleasant deformities back pain social and psychological problems limited job opportunities Screening: inconclusive. some states mandate! TX=bracing has limited effect. maybe exercise, electrical stimulation and surgery if really severe
Cobb angle
Used for scoliosis
Angle of 10 is minimum angulation to define scoliosis
Significant = 25-30 degrees
Severe=45-50 degrees
Sport physicals
Who can participate
Used to meet legal and insurance requirements
counsel on health related issues
Do 6 weeks before pre-season
leading reasons for disqualifying from participation:rhythm and conduction abnormalities
systemic hypertension
valvular heart disease
Sports
Red flags=asthma, mono, SOB w/exercise palpitations seizures family hx of early heart disease LOC hx of fx. Strains, sprains, spec equipment
Sports
ABSOLUTE NO=carditis
leading causes of sudden cardiac death are
hypertrophic cardiomyopathy, coronary artery anomalies, myocarditis, and aortic stenosis
Pectus carinatum
The sternum is bowed
Usually does not present with problems
Cosmetic issues-may be fixed with surgery
Pectus Excavatum
Funnel chest
1 in 500-1000
when moderate or severe it can cause abnormalities of the heart or lungs
can correct with surgery
Osgood-Schlatter syndrome
Common in adolescents
(especially in athletes during growth spurts)
inflammation of anterior proximal tibial tuberosity PULL OF THE LARGE POWERFUL MUSCLWS IN THE FRONT OF THE THIGH
resolves in 6-12 months
knee looks normal but pain over patellar grooves no instability of the knee
Genus varus-persistant bowing may be sign of underlying disruption of growth centers of the knee
Bowlegs
common in children under 2
By 2 they become knock kneed
be concerned if area between the knee is greater than 5-6 inches
Can be associated with Rickettes or Blount dx (early walking or obesity)
Genus valgum (knock knees)
lateral angulation of the tibia relative to the femur in the coronal plane, persisting into adulthood
Normal in 30 month old and will generally show spontaneous correction
Excessive (5-6 inches between ankles) persisting in the older child 6-8 years old is abnormal
Tx = bracing
Septic Arthritis=usually involves hip joint
source of infection can be anywhere
joint is hot, swollen, impaired mobility
complication=necrosis of femoral head
Dx features=younger than 3, HIGH fevers, ill appearing, refusing to walk
Toxic or transient synovitis
limp associated with Upper respiratory dx
low grade fever
child refuses to walk, appears well, decreased internal rotation, normal WBC, ESR <25, blood culture, hip aspiration =neg, x-rays nge, ultrasound of hip = neg (more reliable in detecting fluid)
Tx: resolves in 3-7 days, give ibuprofen
complications 2% will develop Legg-Calve Perthes Disease
position for less pain
Legg-Calve Perthes Disease
Develops over time
Usually 4-8 years old (white males)
DX= limp without hip pain, knee pain is referred, loss of internal rotation, loss of abduction, over all decreased ROM
x-ray shows flattening or deformity of femoral head leads to avascular necrosis
TX=decrease activity, surgery if severe
can lead to degenerative hip disease
Salter-Harris System Criteria
Type I horizontal fracture through the physis
Type II Fx through the physis, extending into the metaphysis
Type III Fx throu the epiphysis, extending into the physis
Type IV Fx through the epiphysis, physis and metaphysis
Type V crush injury of the physis
Salter-Harris
Greenstick=cortex broken on tension side but intact on compression side
Transverse=perpendicular to long axis of the bone
buckle=bone compression causes a buckle or bend rather than break
Spiral=zig-zag course around the bone
oblique=at an angle to long axis of the bone
comminuted=fx with 3 or more fragments
RICEM
Rest ice compression elevation mobility
Cerebral palsy
neurological brain disorder
life long condition
affects communication between brain and the muscles, causing permanent state of uncoordiated movement and posturing
result of an episode that cause lack of oxygen to the brain
CP-establish and diagnose that motor deficits are static and nonprogressing (fine and gross motor skills not devleoping)
Can do an MRI or EEG
prenatal factors
infections, maternal anoxia, ABO incompatibility)
perinatal factors=anoxia, prolonged labor, resp. obstruction, and others stuff
POSTER: posturing, oropharyngeal problems, strabismus, tone, evolutional responses, reflexesCan be tx with BtA for spacisidy
Muscular Dystrophy=genetic, x-linked autosomal recessive degeneration of muscles
babies=diminshed reflexes flat affect floppy later they are clumsy, toe-walking Need to look at their development
MD-Creatinine Kinase is elevated
can do a muscle biopsy
Refer to Neuro
Referr to PT/OT
Refer to First Steps program
Hip dysplasia=more common in girls
breech and familial
not sure when it displaces so must check FOR A FULL YEAR!!!!
If not caught it affects movility and abnormalities of the femoral head and the acetabelum
Get a plain frog leg view or ultrasound
Ortolani= (click of entry) 90 degree hip abduction and feel if hip moves smoothly or do you feel a click or clunk
abduct the hips 90 with index finger palpate hip joint for clicks, clunks = dislocated femoral head reduced
Barlow=(click of exit) push down and see if you can put joint out of socket
one hip at a time-knee flexed and extended
Thigh back and out!!
Hips are adducted
Ortolani and Barlow are used only 6-8 weeks
Galeazzi is noted with the observed discrepancy in knee heights when infant is supine. the sacrum is flat on the table and the knees and hips are bent
Pavlik harness is used on infants
worn 3 mos by children 3 mos and younger
and older children 4 mos or older a period of double their age. Should be worn 23 hours a day
Traction or cast would be next.
Refer to Ortho is clunk!!
Click may just be ligament
Sports
Repetitive motion is the problem
Craniosynostosis
The premature closing of suture lines
2 most common forms:
Scaphocephaly (boat head) long and narrow Sagittal suture fuses,
Most common. 54-58%
Brachycephaly is if the coronal sutures fuse too soon, the head is flattened. 18-29%
Microcephaly - <2 standard deviations below norm for age, gender and gestational Premature closure of suture line hypoxic encephalopathy congenital infection
Macrocephaly>2 standard deviations above normal for age, gender and gestation Hydrocephalis enlarged ventricular system megaencephaly-from metabolic conditions 97th percentile and higher
Plagiocephaly-positional molding
occipital flattening
Ask if it was round at birth
teach parents to turn head
treat torticollis with stretching
orthotic device-helmet
Meningitis- late winter, early spring
viral=summer and fall.
household or
close contacts (individuals who slept and ate in the same household with the
patient) and intimate nonhousehold contacts who have had mucosal exposure
to the patient’s secretions (such as a boyfriend or girlfriend). Individuals
who have had direct exposure to the patient’s secretions through
shared utensils or toothbrushes, kissing, and school/daycare contacts in
the prior seven days should receive chemoprophylaxis.four or more hours with the index case for 5-7 days before the illness
meningitis types- Treat with Rifampin
Cipro or rocephin
rifampin
given in a 600 mg dose for adults, 10 mg/kg every dose for children older
than 1 month, 5 mg/kg every dose for neonates (age less than or equal to
30 days) orally every 12 hours for a total of four doses.
S. pneumoniae (47%), N meningitidis (25%),
The article says
Close contact (for more than
eight hours) with someone with N. meningitidis infection
Contact with oral secretions of someone with N. meningitidis infection
Kernig and Brudzinski signs
poorly sensitive but highly specific for bacterial meningitis.
K=patient supine flex knee and thigh to 90 degrees pain in the hamstring when leg is extended is a + sign
B=flex neck and reflex flexion of the hips is a + sign
Meningitis in children-fever, petechial (nipple line & down) or purpural rash on trunk, legs, mucus membranes, flu-like symptoms, classic signs of HA, vomiting, photophobia, nuchal rigidity, full fontanel, poor feeding
A recent history of upper respiratory tract infection is common in children with bacterial meningitis; children are also more likely than adults to experience a seizure.12 The illness course varies, with progression over hours to several days.
Suture lines close= 2-3 years
Anterior fontanel 15-18 mos
Posterior fontanel= 2 mos
Abuse-call CPS and police
ASK; who, what, where, when
Primitive reflexes
Something wrong in the brain or CNS
Shaken baby syndrome
Lethargy / decreased muscle tone Extreme irritability Decreased appetite, poor feeding or vomiting for no apparent reason Grab-type bruises on arms or chest No smiling or vocalization Poor sucking or swallowing Rigidity or posturing Difficulty breathing Seizures Head or forehead appears larger than usual or soft-spot on head appears to be bulging Inability to lift head Inability of eyes to focus or track movement or unequal size of pupils
`Closed head injuries
No LOC, minor head injury
normal mental status, no abnormal findings or focal findings on exam, including fundoscopic, no evidence of skull fx
THEN YOU CAN OBSERVE WITH NO CT/SKULL FILMS
For LOC<1 minute and neg exam you can still observe or get a cranial CT scan. Skull films and MRI are not recommended
Helmets cut risk for head injury by 80% if worn properly
If worn wrong, then twice as likely to have a head injury
Headaches
Tension-like a band around the head.
Migraine=pain, n/v, visual changes
common vs classic (aura)
Brain tumors-Chronic recurrent headaches
worse on wakening
may improve with vomiting
Variables that predict a presence of a space-occupying lesion include: HA of less than 1 month absence of family hx of migraine abnormal neurological findings on exam gait abnormalities occurrence of seizures
Neuroimaging study on a routine basis is not recommended in children with recurrent headaches and a normal neurologic examination
Should only be considered with an abnormal neurologic exam or other physical findings that suggest CNS disease
Treatment of migraines in children
>5 with features from below lasts 1-72 hours bilateral or uni (frontal or temporal) pulsating moderate to severe intensit aggravated by routine physical activities AND n/v photophobia
Acetaminophen is probably effective
Children <6 ibuprofen is effective and acetaminophen
Work on triggers
Give antiemetic early for nausea
Child must be 12 for migraine triptans
A neurologist can give a triptan earlier if he wants.
You should refer for this if younger than 12
Seizures
chronic that recur without any external disorder
REFER
Order lab tests based on historic or clinical findings such as vomiting dehydration, or failure to return to baseline alertness
Consider toxicology if question of drug use or exposure
In the child with a NONFEBRILE first seizure, LP is of limited value. The EEG is recommended as part of the neurodiagnostic evaluation of the child with an apparent first unprovoked seizure.
If a neuro-imaging study is obtained, MRI is the preferred modality.
Consider MRI with a signficant cognitive or motor impairment
unexplained abnormalities
a seizure of partial onset with or without secondary generalization
an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy
in children under 1 year of age
Seiaures
medication is typically started after 2 unprovoked seizures
Involve neuro and peds
monotherapy is the gold standard
routine blood tests may actually lead to unnecessary changes and more problems in asymptomatic patients, BUT do if suspect toxicity
therapy maintained for two years of seizure free period and then d/c?
Psuedo seizure vs true seizure
Psuedo=The EEG may be normal
Look for in children who have witnessed a seizure in another, who have seizures that occur in the same situations, does not decrease with anticonvulsants, and whose seizures appear “suggestable”
True -Seizure is like epilepsy. Brain activity depolarization of the neurons is widespread
NPs and seizures
Discuss safety issues with the parents. Drowning, machinery, careful of being in high places,
