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

2. Orthopedic Disorders  Congenital  Acquired / trauma  Infectious

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

4. 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.

5. 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.

6. 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.

7. Metatarsus Adductus

8. 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

9. Developmental Dysplasia of Hip

10. 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.

11. Asymmetry of skin fold

12. Hip Exam

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

14. Pavlik Harness Bowden & Greenberg

15. Harness JB Chandler

16. Osteogenesis Imperfecta

17.  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.

18. 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

19. 3-month-old with OI Old fractures/demineralization Old rib fractures

20. New Born with OI

21. 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

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

23. 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

24. 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

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

26. 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 (2 - 12 years)

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

28. Right hip - LCP

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

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

31. 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

32. 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.

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

34. 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

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

36. Clinical Manifestations

37. Management  Surgery – fix with a pin  Crutch walking

38. Scoliosis Lateral curvature of spine Medline.com

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

40. 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.

41. Screening

42. Bowden & Greenberg

43. Mild Scoliosis Mild forms Strengthening and stretching

44. Severe Scoliosis

45. Bracing

46. Milwaukee Brace

47. Scoliosis Spinal Fusion

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