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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.

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Orthopedics disorders pediatrics part ii l.jpg

Orthopedics Disorders Pediatrics Part II

Jan Bazner-Chandler

RN, MSN, CNS, CPNP


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Orthopedic Disorders

  • Congenital

  • Acquired / trauma

  • Infectious


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Talipes Equinovarus

Talipes equinovarus or

Club foot

Obvious deformity noted

at birth.

Surgical correction


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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.


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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.


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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.



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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



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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.




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Interventions

  • Maintain hips in flexed position

  • Traction to stretch muscles

  • Pavlik harness

  • Hip surgery

Bowden & Greenberg


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Pavlik Harness

Bowden & Greenberg


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Harness

JB Chandler



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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.


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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


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3-month-old with OI

Old rib fractures

Old fractures/demineralization



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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.


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Cerebral Palsy

  • Group of disorders of movement and posture

    • Prenatal causes = 44%

    • Labor and delivery = 19%

    • Perinatal = 8%

    • Childhood = 5%


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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


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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.


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Clinical Manifestations

  • Hypotonia or Hypertonia

  • Contractures

  • Scoliosis

  • Seizures

  • Mental Retardation

  • Visual, learning and hearing disorders

  • Osteoporosis – long term due to lack of movement


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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)


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Clinical Manifestations

  • Pain – groin, hip or referred pain to knee.

  • Limping

  • Limited hip motion especially internal rotation and abduction is classic sign.



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Management

  • Goal of care is to: Keep femoral head in the hip joint

    • Traction

    • Anti-inflammatory

    • Physical therapy

    • Surgery if femoral head destroyed


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Osgood-Schlatters

Painful prominence of the

tibial tubercle

Gait.udel.edu


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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


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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.


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Management

  • Reduce activity

  • Stretching before activity

  • Anti-inflammatory

  • Avoid activity that cause pain


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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


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Clinical Manifestations

  • Pain in groin, hip or knee

  • Limp (antalgic is limping on affected side)

  • Limited abduction

  • Leg may be shorter



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Management

  • Surgery – fix with a pin

  • Crutch walking

  • Complications

    • Avascular necrosis of femoral head is compromise of circulation of the femoral head leading to ischemia. This may lead to collapse of the necrotic segment.


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Scoliosis

Lateral curvature of spine

Medline.com


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Mild Scoliosis

Mild forms

Strengthening and

stretching


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Clinical Manifestations

  • Pain is not a normal finding

    for idiopathic scoliosis

  • Often present with uneven hemline

  • Unequal scapula

  • Unequal hips


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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.



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Screening

Bowden & Greenberg





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Scoliosis

Spinal Fusion


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Post-operative Care

  • Pain management

  • Chest tube in many cases

  • Turn, cough, and deep breathe

  • Log-roll


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Muscular Dystrophy

  • Group of genetic diseases characterized by progressive weakness and degeneration of the skeletal muscles that control movement.

  • Most common: Duchenne muscular dystrophy (DMD)

  • Predominately male disease

  • X-linked recessive inherited disease


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Pathophysiology

  • DMD is deficiency or absence of the protein dystrophin.

  • Protein is thought to strengthen the muscle cell membrane.

  • Laboratory values: Creatinine kinase levels are high.


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Assessment

  • Infant may display mild delay in attaining milestone.

    • Sitting up, crawling, cruising

    • Toddler (between ages 2 to 3) may have a clumsy gait and have difficulty climbing stairs.

    • Classic physical finding: Gowers’ sign


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Gowers’ Sign

  • http://www.youtube.com

  • Type in Gowers’ Sign


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Interdisciplinary Interventions

  • Team of nursing, physicians, specialists

  • Pharmacologic Interventions

    • Glucocorticosteroids (prednisone and deflazacort): steroids have been found to increase muscle strength and pulmonary function.


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Long Term Problems

  • Cardiomyopathy in 90% over 18 years of age

  • Respiratory complications

  • Obesity