Orthopedic Assessment Jan Bazner-Chandler CPNP, CNS, MSN, RN

Musculoskeletal Differences in Children  Epiphyseal growth plate present  Bones are growing / heal faster  Bones are more pliable  Periosteum thicker and more active  Abundant blood supply to the bone  The younger the child the faster the healing.

Focused Physical Assessment  Inspect child undressed  Observe child walking  Spinal alignment  ROM  Muscle strength  Reflexes

Assessment Concerns:  Pain or tenderness  Muscle spasm  Masses  Soft tissue swelling

CoREminder  If an injury has occurred, examine that area last and be gentle when palpating the injury site.

Nursing Alert  A child younger than 1 year who presents with a fracture should be evaluated for possible physical abuse or an underlying musculoskeletal disorder that would cause spontaneous bone injury.

Neurovascular Assessment  Circulation  Nerve function

Neurovascular Assessment  Sensation  Can the child feel touch on the affected extremity  Motion  Can the child move fingers or toes below area of injury / nerve injury  Temperature  Is the extremity warm or cool to touch

Neurovascular Assessment  Capillary refill  Sluggish capillary refill may signal poor circulation  Color  Note color of extremity and compare with unaffected limb  Pulses  Assess distal to injury or cast

Neurovascular Impairment  Restriction of circulation and nerve function from injury or immobilizing device.

Clinical Manifestations  Increased pain  Edema  Decreased movement or sensation  Diminished or absent pulses distal to injury  Patient often described as restless – pain medication does not work – pain described as deep

Interventions  Assess area distal to injury, surgical site, cast, splint, or traction  Notify physician  Release pressure by splitting the cast or loosening restrictive bandage per physician order.

Compartment Syndrome  A painful condition that results when pressure within the muscles builds to dangerous levels. This prevents nourishment from reaching nerve and muscle cells.  Muscle groups in legs, arms, hands, feet and buttocks can be affected.

Clinical Manifestations  The classic sign of acute compartment syndrome is pain, especially when the muscle is stretched.  There may also be a tingling or burning sensation (paresthesias) in the muscle.  A child may report that the foot / hand is “a sleep”  If the area becomes numb or paralysis sets in, cell death has begun and efforts to lower the pressure in the compartment may not be successful in restoring function.

Physical Assessment Assess pain and if pain medication is working. The muscle may feel tight or full. Measure the affected muscle group and compare with the unaffected side. Check pulses below area of injury

Treatment  Prevention!!!!  Don’t elevate the affected limb above or below the level of the heart.  Dressings should be removed or loosened if CS is suspected.  Current standards: a split is applied for the first 48 hours until swelling from injury / surgery has gone down.

Surgical Management Fasciotomy to relieve pressure. The fascia is divided along the length of the compartment to release pressure within. Siumed.edu

Nerve Assessment  Important to do on admission from ER or to the unit and pre and post surgical procedure

Radius and ulna nerve assessment

Ulnar Nerve Injury

Medial Nerve Injury

Radial Nerve Injury

Peroneal Nerve Distribution