Orthopedic and Musculoskeletal Disorders Flashcards
Normal Development
connective tissue > cartilage > calcifies to bone
long bones increase in diameter by the apposition of new bone tissue around the bone shaft
long bones increase in length due to epiphyses
smaller bones see ossification centers form in the calcified cartilage
Infant Physical Assessment: General
- general muscle movement
- muscle strength
- use of extremities and joints
- observe for head lag
- check for torticollis
Infant Physical Assessment: Hips and Legs
- good ROM
- no restirction of abduction
- equal length (use Galeazzi Test)
- equal thigh and gluteal folds
- firm femoral head in acetabulum (should not be able to move femoral head out)
Barlow and Ortolani Signs
XXX
Toddler and Children Physical Assessment
- Toddler gait: bow leggedness decreases, walking develops, muscles develop in lower back and legs, flat feet (arch to develop after walking for a few years)
- Knock-knees is normal until 7YO
- posture improves and becomes more graceful and balanced
- evaluate muscle strength and joint mobility
- monitor spine for curvature *thoracic spine has some kyphosis,
- lumbar spine has some lordosis
Adolescent Physical Assessment
- slumping shoulders and poor posture
- check for scoliosis
How are children’s bones different from adult bones?
- child’s skeleton is still growing
- bones are rapid healing when broken
- periosteum is thicker and more vascular (aids in more rapid bone growth and repair)
- stiffness is unusual
- bones are more porous > absorbs more energy prior to breaking > bending, bowing of bone aka plastic deformation
Types of Fractures
- spinal
- transverse
- oblique
Nursing Care of Child in Cast
- CMS checks
- petal cast edges
- keep clean and dry
- modification of ADL’s
- skin care
- activities for ROM
- recovery can be weeks to months
- inactive muscles lose strength at a rate of 3% a day
Nursing Care of Child in Skin Traction
- correct alignment of shoulders, hips, and knees
- CMS checks
- skin care/ace wraps
- let weight hang freely
Nursing Care of Child in Skeletal Traction
- correct alignment of shoulders, hips, and knees
- CMS checks
- skin care, under sling
- pin care
- monitor for signs of infection
Developmental Hip Dysplasia: Types
Acetabular dysplasia or preluxation: formal head remains in the acetabulum but the acetabulum is shallow and oblique
Subluxation: femoral head remains in contact w/ the acetabulum, but a stretched capsule and ligamentous tears cause the head of femur to be partially displaced; largest %
Dislocation: femoral head loses contact w/ acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim
Developmental Hip Dysplasia: Causes
- affects females to males at a ratio of 8:1
- most often in first born
- 1/4 cases have both hips involved
- maternal hormone secretion: increased maternal hormone = increased pelvic laxity
- intrauterine position: breech position = increased incidence
- genetics/heredity
- cultural factors
Developmental Hip Dysplasia in Infants: Clinical Manifestations
- restricted abduction
- Galeazzi Test: unequal knee height
- asymmetric skin folds
- wide perineum
- positive Barlow and Ortolani signs
Developmental Hip Dysplasia in Older Child: Clinical Manifestations
- may not be apparent until child begins to bear weight
- delay in walking, limp or waddling gait
- affected hip has shorter leg
- child may feel femur moving up and down in buttocks
- prominent trochanter
- lordosis
- Trendelenburg’s sign
Developmental Hip Dysplasia: Dx
4 months and younger = u/s
over 4 months = x-ray
Developmental Hip Dysplasia: Management
infants (less than 1YO): full abduction in harness
toddler: gradual reduction by traction followed by plaster casting
older child: operative reduction is last resort
Congenital Club Foot
- may be unilateral or bilateral
- males more frequently affected than females
- increased incidence in families who already have one child w/ clubfoot
Congenital Club Foot: Tx
non-invasive therapy:
- begin immediately
- serial casting weekly (foot is manipulated w/ each cast change)
- need to maintain correction w/ use of bi-valved casts, Denis Browne shoes, or exercises
surgical therapy:
- may be needed for most cases that do not respond to casting
- correct bony deformity
- lengthen or transplant tendons
- release tight ligaments
Metatarsus Adductus
- medial adduction of toes and forefoot
- very common
- often related to intrauterine position
- frequently associated w/ inversion and convexity of the lateral border of the foot
- often causes pigeon toed gait
Metatarsus Adductus: Tx
- depends on the rigidity of the foot
- PT and exercises: holding heel and stretching foot out
- casting for severe adduction or those who do not respond to exercise
Duchenne Muscular Dystrophy (MD)
- one of nine types of MD
- characterized by progressive muscle weakness and wasting of symmetrical groups of skeletal muscles
- symptom onset is early in childhood
- more common in males (typically X linked)
- Dystrophin (protein product in skeletal muscle) is absent
Duchenne Muscular Dystrophy: Dx
evaluated creatinine phosphokinase (CPK) levels
muscle biopsy
electromyography
prenatal testing
Duchenne Muscular Dystrophy: Clinical Manifestations
- early onset: start seeing symptoms 3-5 YO
- delay in walking and motor development, progresses to abnormal gait on a level surface, difficulty running, riding a bike, climbing stairs
- frequent falls
- lordosis
- Gower’s sign
- muscles become enlarged from fatty infiltration and feel unusually firm or woody on palpatation
- ultimately involves all voluntary muscles
- loss of independent ambulation usually by 9-12YO
- slowly progression until death from respiratory or cardiac failure usually between 15-25 yrs old
Duchenne Muscular Dystrophy: Complications
- contracture deformities
- passive ROM, brace torso, frequent rest periods - Atrophy of disuse:
- occurs quickly from inactivity
- PT even if limited for a few days
- 3 hours of ambulation a day to maintain muscle strength - Respiratory Infections
- prompt and vigorous antibiotics tx
- PD&C, turning every 2 hours or as needed
- obesity contributes to premature loss of ambulation (restricted physical activity can lead to boredom and eating)
- cardiac manifestations: can lead to cardiac failure, medications may be helpful in early stages (Digoxin, diuretics)
Duchenne Muscular Dystrophy: Nursing Considerations
- community resources for housing
- mobility (wheelchairs, vans)
- PT/OT (educating parents)
- social aspects: school is important for this child, respite care for parents
- assistance w/ independence (modifying clothes)
- genetic counseling
Osteogenesis Imperfecta
- majority of cases caused by a dominant mutation to type 1 collagen genesis
- eight types (from very mild to very severe)
Osteogenesis Imperfecta: Sx
- fragile bones that break easily
- muscle weakness
- hearing loss
- fatigue
- joint laxity
- curved bones
- scoliosis
- blue sclera
- short stature
Osteogenesis Imperfecta: Dx
-blood or skin biopsy to check amount of type 1 collagen
Osteogenesis Imperfecta: Tx
- surgical insertion of rods to strengthen bones
- meds to strengthen bones: biphosphate therapy
- minimize fractures
- maximize mobility and independence
- promote general health
Osteogenesis Imperfecta: Nursing Care
- safe exercise
- adequate wheelchair/walker/braces
- safe handling and protective positioning (do not change diapers by holding onto ankles)
- skin care
- nutrition and healthy eating
- no smoking
Legg-Calve-Perthes Disease
- aseptic necrosis of the femoral head as a result of insufficient blood supply
- self limiting disease, but has the potential for structural abnormality of the hip
- unknown etiology
- affects males more
- most often occurs in children age 2-12YO w/ most cases occurring between 4-8YO
Legg-Calve-Perthes Disease: Clinical Manifestations
- limping on affected side
- pain is increased w/ activity, decreased w/ rest
- joint dysfunction-limited abduction and internal rotation o fhip
- hx of pain, limb and joint dysfunction - suspect dx
Legg-Calve-Perthes Disease: Dx
- x-ray
- bone scans
- CT and MRI
Legg-Calve-Perthes Disease: Tx
- prognosis best when younger child/early onset (earlier treatment, less invasive tx)
- initial therapy: rest/activity restrictions
- use of casts/braces (keeps femoral head abducted in acetabulum)
- surgery if conservative methods don’t work or to shorten duration of immobilization
Legg-Calve-Perthes Disease: Nursing Care
- family teaching: care and management of casts, braces, and post-op needs
- pre-operative: CMS checks, non-weight bearing and bed rest
- post operative: CMS checks, observe dressing/surgical site, teaching and reinforcing post surgical limitations
Slipped Capital Femoral Epiphysis (SCFE)
- head of femur displaces from neck of femur
- prior to displacement the epiphyseal plate widens then weakens
- often seen before/during accelerated growth and onset of puberty
- more commonly seen in obese children and boys
- idiopathic
SCFE: Clinical Manifestations
- constant or intermittent pain in hip or groin (radiates to knee or thigh, limp, loss of hip motion)
- onset: acute, chronic, or acute-on-chronic
- lower extremity is held in a flexed, abducted, and externally rotated position b/c of pain
- attempts to move the limb are met w/ resistance
SCFE: Tx
- immediate non-weight bearing (NWB), no sitting, may ambulate w/ crutches
- surgical stabilization and correction (pinning w/ screws)
- more severe
- 6 months or more for immobilization
SCFE: Nursing Considerations
pre-op:
- NWB
- no sitting
- immediate eval w/ ortho
- quick surgery
- CMS checks
post op:
- pain control
- CMS checks
- NWB for a while, touch down weight bearing (TDWB) afterwards
- may return to all contact activities
- teach proper use of crutches and importance of avoiding any weight bearing on affected hip
Osteomyelitis
- infectious process in the bone which can occur at any age
- most frequently in children less than 10YO
- 2x as common in boys than girls
Osteomyelitis: Etiology
many organisms can cause osteomyelitis - some relationship between age and organisms exists
- neonates: Group B strep
- older child: S. Aureus
- since advent of HIB vaccine in the late 1980s, this has become a less common causative pathogen
Osteomyelitis: Pathophysiology
- infected emboli from a focus of infection travels to the small arteries in the bone metaphysis where they set up infectious process leads to local bone destruction and abscess formation and bone necrosis
- infants: more likely to have infection invade joint as blood vessels cross the growth into the epiphysis and joint space
- children: infection usually contained by the growth plate
Osteomyelitis: Dx
- increased SED rate or ESR
- increased WBC
- positive blood cultures
- X-ray (signs only evident after 2-3 weeks of infection)
- bone biopsy may be needed if blood cultures and x-rays are not consistent w/ osteomyelitis
Osteomyelitis: Care Management
- position for comfort
- pain meds
- monitor VS
- antibiotics (IV/PO)
- antibiotic irrigations
- possible surgical drainage w/ wound care
Osgood Schlatter’s Disease
- pain and inflammation where patellar tendon attaches to tibia
- avulsion fractures can occur at distal portion of patellar tendon; partial separation of tibial tubercle
- separation caused by sudden or continuous stress on patellar tendon during periods of rapid growth
- most common in males that are active in sports
Osgood Schlatter’s Disease: Clinical Manifestations
- pain which increases w/ activities and subsides w/ rest
- may see temporary or permanent swelling at the area of tibial tuberosity
Osgood Schlatter’s Disease: Tx
- rest
- analgesics
- self limiting
- resolved w/ closure of the growth plate
Scoliosis
- lateral curvature of the spine
- idiopathic, genetic, or spontaneous
- eventually causes cosmetic and physiologic alterations of the spine, chest, pelvis
- occurs at any age (usually adolescent females)
Scoliosis: Management
-observation w/ regular clinical evaluation and x-rays
-orthotic intervention w/ bracing
-bracing and exercise: goal is to slow the progression of the curve
(Boston brace, Wilmington brace)
-exercises in and out of the brace
Scoliosis: Tx
-surgical fusion may be required for correction of severe curves (45 degrees or more)
Scoliosis: Preop Needs
X-Rays
Blood work
Blood donation
Urine
Scoliosis: Post-Op Care
assessments:
- surgical site
- CMS
- neuro
- pain
- VS
- C&DB
- pain control
- progression to ambulation (lay flat, log-rolling, up to chair, ambulation)
- advance diet after POD 0
- may have additional lines/drains (IV, arterial lines, foley, JP drains, chest tube, NG tube)
Scoliosis: Surgery Discharge Teaching
- pain control
- ambulation and limitations
- surgical site skin care
- brace use
- follow up visits
