Orthopedics Disorders Pediatrics Part II Jan Bazner-Chandler RN, MSN, CNS, CPNP

Orthopedic Disorders  Congenital  Acquired / trauma  Infectious

Talipes Equinovarus Talipes equinovarus or Club foot Obvious deformity noted at birth. Surgical correction

Talipus Equinovarus  Club Foot  1 to 2 per 1000  Males more affected  Involves both the bony structures and soft tissue.  The entire foot is pointing downward.

Interventions  Manipulation and serial casting immediately.  The more rigid the foot the more likely surgery will be necessary.  Surgery performed between 4 and 12 months.

Metatarsus Adductus  Most common foot deformity  2 per 1000  Result of intrauterine positioning  Forefoot is adducted and in varus, giving the foot a kidney bean shape.  Most often resolves on own or with simple exercises.

Metatarsus Adductus

Dysplasia of the Hip  Abnormality in the development of the proximal femur, acetabulum, or both.  Girls affected 6:1  Familial history  Breech presentation  Maternal hormones  Other ortho anomalies

Developmental Dysplasia of Hip

Clinical Manifestations  + Ortolani maneuver  Asymmetrical lower extremity skin folds – soft sign not always seen.  In the older infant there would be decreased ROM in the affected hip especially with abduction.  In the child there might be discrepancy in limb length.

Asymmetry of skin fold

Hip Exam

Interventions  Maintain hips in flexed position  Traction to stretch muscles  Pavlik harness  Hip surgery Bowden & Greenberg

Pavlik Harness Bowden & Greenberg

Harness JB Chandler

Osteogenesis Imperfecta

 Genetic disorder  Caused by a genetic defect that affects the body’s production of collagen.  Collagen is the major protein of the body’s connective tissue.  Less than normal or poor collagen leads to weak bones that fracture easily.

Osteogenesis Imperfecta  Often called “brittle bone disease”  Characteristics  Demineralization, cortical thinning  Multiple fractures with pseudoarthrosis  Exuberant callus formation at fracture site  Blue sclera  Wide sutures  Pre-senile deafness

3-month-old with OI Old fractures/demineralization Old rib fractures

New Born with OI

CaReminder  Signs of a fracture, especially in an infant, are important items to teach caregivers. In a baby, these signs are general symptoms, such as fever, irritability, and refusal to eat.  Bowden, 1998

Cerebral Palsy  Group of disorders of movement and posture  Prenatal causes = 44%  Labor and delivery = 19%  Perinatal = 8%  Childhood = 5%

Assessment  Developmental surveillance is key  Diagnosis often made when child is 6 to 12 months of age  Physical exam:  Range of motion  Evaluation of muscle strength and tone  Presence of abnormal movement or contractures

caReminder  Reflexes that persist beyond the expected age of disappearance (e.g., tonic neck reflex) or absence of expected reflexes are highly suggestive of CP.  Bowden, 1998

Clinical Manifestations  Hypotonia or Hypertonia  Contractures  Scoliosis  Seizures  Mental Retardation  Visual, learning and hearing disorders  Osteoporosis – long term due to lack of movement

Legg-Calve-Perthes  Vascular disturbance leads to bone death in hip do to interruption of blood flow.  Four times more common in males  More common in Asians, Eskimos and Caucasians.  Peak age 6 ( years)

Clinical Manifestations  Pain – groin, hip or referred pain to knee.  Limping  Limited hip motion especially internal rotation and abduction is classic sign.

Right hip - LCP

Management  Goal of care is to: Keep femoral head in the hip joint  Traction  Anti-inflammatory  Physical therapy  Surgery if femoral head destroyed

Osgood-Schlatters Painful prominence of the tibial tubercle Gait.udel.ed u

Osgood-Schlatters  Due to repetitive motion  Affects children 10 to 14 years old  Males 3:1  Diagnosis is based on clinical signs and symptoms  Pain, heat, tenderness, and local swelling

Assessment  Tip: Asking the child to squat or extend his or her knee against resistance usually elicits pain and is a good indicator of Osgood-Schlatter Disease.

Management  Reduce activity  Stretching before activity  Anti-inflammatory  Avoid activity that cause pain

Slipped Capital Femoral Epiphysis  Top of femur slips through growth plate in a posterior direction.  Ages 10 to 14 in girls  Ages 10 to 16 in boys  High proportion are obese

Clinical Manifestations  Pain in groin  Limp  Limited abduction  Leg may be shorter

Clinical Manifestations

Management  Surgery – fix with a pin  Crutch walking

Scoliosis Lateral curvature of spine Medline.com

Clinical Manifestations Pain is not a normal finding for idiopathic scoliosis Often present with uneven hemline Unequal scapula Unequal hips

Assessment  Alert: If pain is a reported symptom of the child’s scoliosis, it should be investigated immediately. Pain is not a normal finding for idiopathic scoliosis, and the presence of this symptom could be signaling an underlying condition such as tumor of the spinal cord.

Screening

Bowden & Greenberg

Mild Scoliosis Mild forms Strengthening and stretching

Severe Scoliosis

Bracing

Milwaukee Brace

Scoliosis Spinal Fusion

Post-operative Care  Pain management  Chest tube in many cases  Turn, cough, and deep breathe  Log-roll