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Pediatric and Neuromuscular Orthopedics

Pediatric and Neuromuscular Orthopedics. Objectives. 11%-self-care-comfort -avoid complications Identify signs and symptoms in selected pediatric and neuromuscular disorders. Outline nursing interventions for medical and surgical protocols.

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Pediatric and Neuromuscular Orthopedics

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  1. Pediatric and Neuromuscular Orthopedics

  2. Objectives • 11%-self-care-comfort -avoid complications • Identify signs and symptoms in selected pediatric and neuromuscular disorders. • Outline nursing interventions for medical and surgical protocols. • List strategies to maximize function in patients and families with neuromuscular disorders

  3. Development • Infancy 0-18 months • Toddler 18 mos – 3 yrs • Pre-school 3-5 yrs • School age 6-12 yrs • Adolescence 13 –19

  4. Pediatric Differences • Visualization • ossification • ultrasound • X-ray • Bone • Thick periosteum • Metaphyseal growth • Re-modeling

  5. Nursing Intervention • Nursing see Table 11-1 from Core Curriculum 4th ed. • Child’s developmental level • Parent and child’s ability to learn • Amount disorder interferes with: • ADLs • Growth • Learning Ability • Social Adjustment

  6. Nursing Intervention Parents • Realistic expectations • Understanding of the disease/disorder • Follow-up with treatment • Response to public inquiry

  7. Nursing Intervention • Team approach • Include child in decisions • Play • Independence, socialization, • Creativity, problem solving

  8. Upper Extremity Disorders • Congenital anomalies • Syndactyly webbing 2+ digits • Polydactyly extra digits • Congenital amputations /deficiencies • Brachial plexus injuries

  9. Lower Extremity Disorders • DDH • Legg-Calvé-Perthes • Intoeing, torsional problems • SCFE (presentations) • Limb length inequality • Osteomyelitis, septic joint • Trauma

  10. Developmental Dislocation of the Hip • DDH • F>M 1:500-1000 births • Breech, 1st born • Family history

  11. Developmental Dislocation of the Hip • Physical Exam - hip clicks and clunks • Barlow’s – push hip out back • Ortolani’s abduct click in • Decreased abduct • Unequal skin folds • Ultrasound - X-ray

  12. DDH Rx • Pavlik, abd. splint • Traction Bryant’s/ mod Bryant's • Surgical reduction closed vs open • Spica cast

  13. DDH Nursing Care • Traction • Neurovascular Exam • Amputation 2° necrosis • Cast syndrome • Can be fatal

  14. Talipes Equinovarus • “Clubbed Foot” 1.24:1000 births • M 2x > F • Inversion adduction and equinus of the forefoot • Fixed rigid deformity • Etiology: controversial • Uterine position • Idiopathic

  15. Talipes Equinovarus • Dx: clinical apparent • Calf smaller, Achilles short • Rx:Stretching • Casting • Surgical releases

  16. Talipes Equinovarus • Nursing, watch toes in cast • Foot will be smaller! • Rocker bottom from push up on metatarsals • Can play sports

  17. Intoeing • Most common complaint! • Metatarsus adductus (foot deformity) • Tibial torsion • Femoral anteversion

  18. Metatarsus Adductus • Foot deformity • 1:1000 births • Dx: exam • Rx: stretching • long leg molded cast • surgery

  19. Tibial Torsion • Physiologic bowing of tibia • 2º intrauterine position • NORMAL for toddler • No treatment unless present at 8 years of age • Nursing - bring grandparent to appointment

  20. Femoral Anteversion • Curvature of the femur • After 3 yrs resolves by 8yrs • Brace not effective • Osteotomy if functional problems after 8 yrs

  21. Va us cubitus valgus cubitus varus coxa vara coxa valga genu valgum genu varum heel valgus hallux valgus heel varus metatarsus varus

  22. Genu Valgus • Knock knees • Joint laxity -medial collateral ligs. • Common: 3 - 5 years • improves by 7 years • normal angulation • girls: 7 - 9° valgus • boys: 4 - 6° valgus

  23. Genu Varus • ^ dist between knees >2.5 cm • W/ ankles together • external torsion of femur • improves spontaneously by 18 - 24 mos •  in early amb & heavy children

  24. Blount’s Disease • X-ray changes medial prox tibia • 50% unilat. tibial bowing • ^Black, ^obese, • Rx: no Δ 6 mos bracing • Surgical >30 mos old w/o Rx or structural / functional deform

  25. Blount’s Disease • Rx: • Corrective prox. osteotomy. • Hemiepiphysiodesis • External fixator • Some with gradual correction

  26. Osteogenesis Imperfecta “OI” • Brittle bone disease fracture with minimal stress • Multiple types some fatal • Etiology: autosomal dominant vs. recessive • Defect collagen synthesis • 1:20,000 births

  27. Osteogenesis Imperfecta “OI” • Dx: Clinical deformities • Blue sclera, shepherds crook deformity • Dentinogenesis, deafness • Radiographs • Biopsy • Bone density

  28. Osteogenesis Imperfecta “OI” • Rx brief Light wt. immob • I-M rods “Bailey” grows with child • Pamidronate treatment • Pain meds. • “Brittle baby” NO BP’s signs Don’t pull limbs, • Physical NOT mental handicap • Encourage independence

  29. Legg Calvé Perthes • Aseptic necrosis femoral head • Idiopathic vs heredity • M 4x >F 1:2000 births • Age 3-12 years

  30. Legg Calvé Perthes • Sx: Knee, hip, thigh pain • Limp • Decreased ROM • Dx: exam / X-ray

  31. Slipped Capital Femoral Epiphysis Endocrine/ obesity/ growth / trauma • F 8-15yrs. M 10-17yrs • 1 : 10,000 adolescents • Sx: Hip, knee, pain (long duration) • Limp, decreased ROM • Dx: Hallmark sign- lack of internal rotation • X-ray -“Ice cream falling off the cone

  32. Slipped Capital Femoral Epiphysis • Rx: bedrest, • N W B, crutches • Surgical pinning • Teach S&S for other hip - >50%

  33. Limb Length Inequality • Congenital vs acquired • Sx: short limb, limp, back pain • Dx: X-ray, CT, bone age

  34. Limb Length Inequality Rx: • < 2cm no treatment • 2-6 cm lifts epiphysiodesis • >6 - 15cm shorten opposite limb • Limb lengthening, external fixation

  35. Limb Length Inequality • Nursing • Pain management • Pin care • Compartment syndrome • Emotional support

  36. Osgood-Schlatter’s Disease • F 8-13 yrs M 11-15 yrs • Sx: painful swelling tibial tubercle • cosmetic deformity

  37. Osgood-Schlatter’s Disease • Dx: exam • X-ray traction apophysitis • Rx: rest, ice, stretch hamstrings • Casting

  38. Trauma • Leading cause of death in children • Common injuries (see table 11-3 ) • Child abuse – Battered Child Syndrome

  39. Trauma: Child Abuse • 3.14 million children reported abused • Physical abuse • Greatest < 3 years (66-78%) • 30% under 6 mos

  40. Salter-Harris Classification 1 2 4 5 3

  41. Child Abuse - Fractures • Most common presentation! • >30% under 3 mos. • 70% under 6 mos.(1yr) are inflicted

  42. Common Fractures Inflicted • Metaphyseal • Rib Fxs seen in 5-20% of abused • Scapular/distal clavicle/ night stick • Vertebral fx. or subluxation

  43. Common Fractures Inflicted • Finger Fx. In non-ambulating child • Humerus Fx. (X supracondylar) < 3 Yrs. • Bilateral, multiple, or Fxs in different stages of healing • Complex skull Fx

  44. Fracture treatment

  45. Questions Linsey, 5 months old presents with knee swelling which of the following would prompt you to file for suspected child abuse: A. Septic joint with staph on aspiration B. Mongolian spots about the lower back C. Metaphyseal fractures of the distal femur D. Parent are obviously worried and seem really nice.

  46. Questions Three year old Stephanie has a history on limping and refusing to put weight on her left leg. She is lying with her leg externally rotated. You are admitting her for: A. Traction to treat her Perthes disease and high fever. B. Observation for bracing of her septic hip. C. fever, high white count Perthes treatment. D. Severe malaise, fever, pre-op for septic hip aspiration.

  47. Questions An 18 month old infant is admitted to your unit with a fractured femur. You notice blue sclera and shepherd crook deformities of his arms. You would: A. Hang “Brittle Baby” sign on his crib B. Change his diapers lifting him by the feet C. Keep his medication strictly by weight even if ineffective to prevent overdosing. D. Use real plasters for casting.

  48. Achondroplasia • Most common dwarfing syndrome • 1 of every 26,000 live births M>F • Etiology: abnormal endochondral ossification • genetic defect autosomal dominant • 90% spontaneous mutations

  49. Achondroplasia • Hypotonia resulting in slow motor development • C-spine injuries secondary to poor head control • Low back pain 2° to spinal stenosis • Thoracolumbar kyphosis hyperlordosis • longitudinal growth most affected • difficulty performing ADL’s

  50. Scoliosis • Lateral curvature of the spine • Congenital • Paralytic • Neuromuscular • Idiopathic = most common

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