ortho Flashcards
Microcephaly - primary - how many weeks
Intrauterine exposure to toxins (weeks 4 to 20)
Microcephaly - secondary
Third-trimester exposure
Perinatal exposure
Exposure in early infancy
Microcephaly - Effects
(micro is twitchy)
Mild hyperkinesis (twitchy), mild motor impairment
Decerebration (apart from brain stem), complete unresponsiveness
Autistic behavior
CRANIOSTENOSIS - Therapeutic Management
(think crane)
Surgical excision of bone (strip craniectomy)
Along or parallel to suture
Releases fused suture
Directs new growth
PLAGIOCEPHALY
(plagerism is flat)
Skull progressively flattened
Not associated with brain malformation
Treatment
Helmets, bands, time
DEVELOPMENTAL DYSPLASIA of the HIP (DDH)
Formerly called “congenital hip dysplasia” and “congenital dislocation of the hip”
Incidence 1-10/1000 live births
More common in females (60%)
More common in Caucasians than any other group
Etiology of DDH - classifications
(DDH is ASD)
Acetabular (shallow)
Subluxation (partial)
Dislocation
(look at photo in slides)
Clinical Manifestations of DDH - what test?
(dds ortega)
Positive Ortolani test (when laying baby on back and open hips)
Audible click when abducting and externally rotating hip
Therapeutic Management of DDH - deepen what?
Directed toward enlarging and deepening acetabulum
Place head of femur within acetabulum
Congenital Clubfoot
(soft club)
Bone deformity and malposition of foot
Soft tissue contracture
Foot twisted out of alignment
May be misshaped
CLUB FOOT - rigid or flexible?
Deformity apparent at birth
Classification
Rigid or flexible
Physiologic Effects of Immobility - Muscular system
Decreased muscle strength and endurance
Atrophy
Loss of joint mobility
Skeletal system
Bone demineralization
Negative calcium balance
Physiologic Effects of Immobility - Metabolism - what about nitrogen?
Decreased metabolic rate
Negative nitrogen balance
Physiologic Effects of Immobility - Cardiovascular system - what about vasopressor?
Decreased efficiency of orthostatic neurovascular reflexes
Diminished vasopressor mechanism
Altered distribution of blood volume
Venous stasis
Dependent edema
Physiologic Effects of Immobility - Respiratory system
Decreased need for oxygen
Diminished vital capacity
Poor abdominal tone and distention
Mechanical or biochemical secretion retention
Loss of respiratory muscle strength
Physiologic Effects of Immobility - gI - difficulty feeding in what position?
Distention caused by poor abdominal muscle tone
Difficulty feeding in prone position
Gravitation effect on feces
Anorexia
Physiologic Effects of Immobility - Urinary system
Alteration of gravitational force
Difficulty voiding in supine position
Urinary retention
Impaired ureteral peristalsis
Physiologic Effects of Immobility - Loss of innervation
If nerve tissue is damaged by pressure
If circulation to nerve tissue is interrupted
Effects of improper positioning
Sensory and perceptual deprivation
EPIPHYSEAL INJURIES- what is special about it?
Epiphysis
Growth end of long bones
Growing cartilage
Growth plate located in the epiphysis
Weakest point of long bones
Frequent site of damage during trauma
May affect future bone growth
Treatment may include open reduction and internal fixation to prevent growth disturbances
FRACTURES - from what for school age kids?
Common injury in children
Clavicle most frequently broken bone in child, especially younger than age 10
School age—bike, sports injuries
Methods of treatment different in pediatrics than in older adult population
Types of Fractures - compound
(compounded to the outside)
Compound or open
fractured bone protrudes through the skin
Immediate Interventions - fracture
Immobilize
Assess circulation
Apply cool/cold compress
Elevate limb ( keep in alignment)
Sterile/clean dressing over open wound
External Fixation
Ilizarov external fixator
The induction of new bone between bone surfaces that are pulled apart in a gradual, controlled manner
Permits limb lengthening by manual distraction
Stimulates new bone formation
Bone Healing - how long for the 4 different groups?
(heal in 2 - 12 weeks)
Typically rapid healing in children
Neonatal period—2 to 3 weeks
Early childhood—4 weeks
Later childhood—6 to 8 weeks
Adolescence—8 to 12 weeks
THE CHILD in TRACTION
Traction—extended pulling force may be used to
Provide rest for an extremity
Help prevent or improve contracture deformity
Correct a deformity
Treat a dislocation
Allow position and alignment
Provide immobilization
Reduce muscle spasms (rare in children)
Traction- Essential Components
Traction—forward force produced by attaching weight to distal bone fragment
Adjust by adding or subtracting weights
Countertraction—backward force provided by body weight
Increase by elevating foot of bed
Frictional force—provided by patient’s contact with the bed
Types of Traction
Manual traction
applied to the body part by the hand placed distally to the fracture site
Skin traction
pulling mechanisms are attached to the skin with adhesive material or elastic bandage
Skeletal traction
applied directly to skeletal structure by pin, wire, or tongs Inserted into or through the diameter of the bone distal to the fracture
Cervical Traction
Crutchfield or Barton tongs
Inserted through burr holes in skull with weights attached to the hyperextended head
As neck muscles fatigue, vertebral bodies gradually separate so the spinal cord is no longer pinched between vertebrae
Halo traction can be applied in some cases
Therapeutic Management of Soft Tissue Injuries - what type of elastic bandage?
RICE
Rest the injured part
Ice immediately (max 30 minutes at a time)
Compression with wet elastic bandage
Elevation of the extremity
ICES- Ice, Compression, Elevation, Support
Immobilization and support (casts or splints as appropriate to injury)
MUSCULOSKELETAL COMPLICATIONS
Circulatory impairment
Nerve compression syndromes
Compartment syndromes
Volkmann contracture (a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm)
Epiphyseal damage
Nonunion/malunion
Infection
Kidney stones
Pulmonary emboli
COMPARTMENT SYNDROME
Pressure within the muscles builds to dangerous levels (from swelling or bleeding)
Decreases blood flow
Prevents nourishment and oxygen from reaching nerve and muscle cells
Causes cell damage and death
Acute or chronic
More painful than would be expected
Not relieved by pain meds
Clinical Manifestations of Osteomyelitis - where is the pain?
Localized Pain - pain will be in a specific spot
Swelling at site
Warm at site
Redness at site
Pain upon weight bearing
Osteomyelitis Diagnosis - is it slow or fast onset?
Signs and symptoms begin abruptly; resemble symptoms of arthritis and leukemia
Therapeutic Management of Osteomyelitis - and how long?
May have subacute presentation with walled-off abscess rather than a spreading infection
Prompt, vigorous IV antibiotics for extended period (3 to 4 weeks or up to several months)
Monitor hematologic, renal, hepatic responses to treatment
SCOLIOSIS
The most common spinal deformity
SCOLIOSIS - Clinical Manifestations - when does pain occur? (2 times)
(scoly active)
Insidious onset
May have history of limp
Soreness or stiffness
Limited ROM
Vague history of trauma
Pain and limp most evident on arising and at end of activity
Diagnosed by x-ray
SCOLIOSIS - Therapeutic Management - how many hours a day to wear the brace?
Team approach to treatment
Bracing
Must be worn 23 hrs/day
Exercise
Surgical intervention for severe curvature (various systems of instrumentation and fusion)
SCOLIOSIS - Nursing Interventions
Maintain spinal alignment per protocol
Provide care when wearing brace
Examine skin surfaces where contact with brace
Implement corrective action for skin breakdown
Help select appropriate apparel to wear over brace to minimize altered appearance
Encourage wearing low-heeled shoes for balance
Reinforce instructions regarding plan of care
Use of appliance
Activities
Prepare for surgery when appropriate
JUVENILE IDIOPATHIC ARTHRITIS (JIA) - what type of disease is it?
Formerly called JRA (juvenile rheumatoid arthritis)
Chronic autoimmune inflammatory disease
JUVENILE IDIOPATHIC ARTHRITIS - what about RA factor?
90% children have negative rheumatoid factor
Symptoms of JIA
Pain
Stiffness
Swelling
Loss of motion in affected joints
Diagnostic Evaluation of JIA - what is elevated?
(JIA has ESP)
No specific diagnostic tests
Elevated ESR and CRP
Rheumatoid factor and Antinuclear antibodies may be +
Leukocytosis during exacerbations
American College of Rheumatology Diagnostic Criteria - JIA (4 things)
(JIA is 16 and 6)
Age of onset younger than 16 years
One or more affected joints
Duration of arthritis more than 6 weeks
Exclusion of other forms of arthritis
Therapeutic Management of JIA
No specific cure
Goals of therapy
Preserve function
Prevent deformities
Relieve symptoms
Iridocyclitis/uveitis
Inflammation of iris and ciliary body
Unique to JRA
Requires treatment by ophthalmologist
Pharmacology for JIA
(Sarry for JIA)
NSAIDs (Nonsteroidal anti-inflammatory drug)
SAARDs (Slow-acting anti-rheumatic drug)
Used when first-line therapy (NSAIDs), fails to control disease
Corticosteroids
Cytotoxic agents - methotrexate
Immunomodulators
Management of JIA
Therapy individualized to child
PT, OT
Nutrition
Exercise
Splinting devices
Pain management
Prognosis
injuries at 12
(knee at 12)
overuse injuries, knee
injuries at 17
MVA,
what age for a craniectomy
Before 6 mo old
Best cosmetic and neurodevelopmental results
nursing interventions - JIA - warm or cold compresses?
Emphasize medication protocol
Promote functional alignment
Encourage warm baths or warm moist compresses
Offer nutritious diet
Promote adequate rest and sleep
Provide emotional support
DDH - another test
(Dentist Barlow)
Barlow maneuver (guiding the hips into mild adduction and applying a slight forward pressure with the thumb)
DDH - limbs?
Shortening of limb (femur) on affected side
DDH - what about the thighs?
Asymmetric gluteal, popliteal, and thigh folds
Broadening of the perineum
DDH - limited what?
(DDH gets abducted)
Limited abduction of hip on affected side
Waddling gait and lordosis
DDH - in older infant and children
(older children are pistols)
Affected leg shorter than the other
Telescoping or piston mobility of joint
DDH - in older infant and children - trendeleburg?
Positive trendelenburg sign- when hip swings down when walking (weak gluteal muscles)
Greater trochanter is prominent and appears above a line from anterior superior iliac spine to tuberosity of ischium
Marked lordosis if bilateral dislocations
Waddling gait if bilateral dislocations
DDH - management - pressure?
Apply constant pressure
Legs slightly flexed and abducted
Splinting
Spica cast
Pavlik harness
Surgical intervention
ORIF with casting
Age variations
Newborn to 6 months
6 to 18 months
Older child
club foot - Talipes equinovarus (TEV)
(horse pointing down)
Talipes equinovarus (TEV)
Toes pointed downward and inward
club foot - more common in who?
(men club)
More common in males
Bilateral clubfeet in 50% of cases
Familial tendency
club foot - mild
(mild position)
Mild (positional)
club foot - Syndromic
(the syndrome is elsewhere)
Syndromic (associated with other congenital abnormalities)
Congenital
Wide range of prognosis
Usually requires surgical intervention
immobility and metabolism - what about calcium?
(calcium builds up)
Hypercalcemia
immobility and metabolism - what about hormones? what type of hormones?
Decreased production of stress hormones
compartment syndrome - what is a sign?
when pain is so bad it won’t go away
Osteomyelitis - will prob need
a pic line. will be immobile on that leg.
scoliosis - what age?
7th (girl) or 8th grade (boy)
fracture - Complicated
(complicated bone fragments)
Complicated
bone fragments have damaged other organs or tissues
fracture - Comminuted
(comminuted not commuting)
Comminuted
small fragments of bone are broken from the fractured shaft and lie in surrounding tissue
fracture -Greenstick
(incomplete greenstick)
Greenstick
compressed side of bone bends, but tension side of bone breaks, causing incomplete fracture
osteomylitis - what blood marker is elevated?
Marked leukocytosis
Bone cultures obtained from biopsy or aspirate
Early x-rays may appear normal
Bone scans for diagnosis
scoleosis - Complex spinal deformity in three planes
(lst complex scoleosis)
Lateral curvature
Spinal rotation causing rib asymmetry
Thoracic hypokyphosis
May be congenital or develop during childhood
Lordosis
Accentuation of the cervical or lumbar curvature beyond physiologic limits (swayback)
Kyphosis
Abnormally increased convex angulation in the curvature of the thoracic spine (round shoulders or hunched shoulders)
JIA - peak ages
Affects joints and other tissue
Peak ages: 1-3 years and 8-10 years
JIA - which gender?
(Ja female)
Female predominance 2:1
Often undiagnosed
Actually a heterogeneous group of diseases
JIA - Pauciarticular onset
(particular at 4)
involves ≤4 joints
JIA - Polyarticular onset
(Poly is 5)
involves ≥5 joints
JIA - systemic symptoms - serious
Systemic onset (high fever, rash, hepatosplenomegaly, pericarditis, pleuritis, lymphadenopathy)
JIA - are they active?
Symptoms may “burn out” and become inactive
\
JIA - inflammation of what?
Chronic inflammation of synovium with joint effusion
Destruction of cartilage
Scar tissue
Limits range of motion
JIA - does it affect growth?
Alters growth
JIA - when is the pain most common?
(Ja can’t exercise)
Most common in morning and after inactivity
JIA - is there erythema?
Warm to touch, usually without erythema
Tender to touch in some cases
JIA - does stress make it worse?
Symptoms increase with stressors
