Orthopedic Disorders

Jan Bazner-Chandler
CPNP, RN, MSN

Alterations in Musculoskeletal Status

Bowden & Greenberg

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

Pain

Where is it?
Is it reduced by narcotics?
Does the pain become worse when fingers or toes
are flexed?

Neurovascular Assessment

Sensation

Motion

Can the child feel touch on the affected extremity

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

Color

Sluggish capillary refill may signals poor

circulation
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 do not work pain described as
deep

Interventions

Assess area distal to injury, cast, splint,

traction for adequate circulation

Release pressure by splitting the cast or

loosening restrictive bandage.

Notify physician

Compartment Syndrome

Pain is the hallmark sign, pain out of

proportion to the normal clinical course.

Must be diagnosed immediately or

irreversible neurovascular, muscular,
vascular damage occurs that can lead to
renal failure and death.

Clinical Manifestations

A combination of signs and symptoms characterize compartment

syndrome. 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

Frequent pain assessment

If pain med does not work something is wrong
The muscle may feel tight or full.
Measure the affected muscle group and
compare with the unaffected side
Pulses below area of injury

Treatment

Prevention
Dont elevate the affected limb above or
below the level of the heart.
Dressings should be removed if CS is
suspected.
Casts should be bi-valved in high risk
situations.

Assessment

Dont forget the five Ps

Pain
Paresthesia
Passive stretch
Pressure
Pulse-less-ness

Surgical Management

Siumed.edu

Fasciotomy to relieve pressure. The fascia is divided along

the length of the compartment to release pressure within.

Nerve Assessment

Important to due on admission from ER or to

the unit
Repeat after cast, traction, or surgery done
on the extremity

Radius and ulna nerve

assessment

Ulnar Nerve Injury

Medial Nerve Injury

Radial Nerve Injury

Peroneal Nerve Distribution

Treatment Modalities

Goals of fracture care:

To regain alignment and length of the bony

fragments

To retain alignment and length

To restore function of the injured part

Traction

Realign bone fragments

Provide rest
Prevent or improve deformity
Pre or post operative positioning
Reduce muscle spasm
immobilization

Fractures

Treatment determined
by type of fracture

Fractures

RW Chandler MD

Salter Fracture I and II

Salter Fracture III, IV and V

Salter-Harris Classification
If injury involves growth plate in an immature
bone, growth disturbance may follow.

Classification system describes the injury and

the potential for growth disturbance.

Bucks Traction

Ball & Bindler

Principles of Traction

Counter traction with weights

Make sure all ropes and pulleys are aligned and

weights are hanging freely

Do not remove weights unless instructed to do so

Traction must be applied at all times

Bryants Traction

Bryants Traction

Used for child under 3 yrs

Hip dysplasia / fractured femur
Buttocks do not rest on mattress
Assess neurovascular and restriction by ace
bandages compartment syndrome

Skeletal Traction
Pull directly
applied
to bone by pin
Pin care

Increased risk of
infection

Ball & Bindler

External Fixator

External Fixation

RWChandler

External Fixator

Ball & Bindler

Pin Care

Provide pin care as ordered. Cleanse area

around pin with normal saline or half-strength
hydrogen peroxide.
Have parent / caretaker demonstrate pin care
before discharge

External Fixator

RW Chandler MD

External Fixator

RW Chandler MD

Plates and Pins

Plates, screws, and

wires are used to align
bone fragments.

R.Chandler MD

Post-operative Care

Assess color, sensation, cap refill, movement,

pain, and pulses
Circle any drainage noted on cast or
dressing.
Pain control
Edema = ice to area
Pulmonary function = C&DB

Pulmonary Embolism

A complication of a fractured leg is a

pulmonary embolism. Fat escapes the
marrow when the bone is fractured and can
travel through the blood stream and become
lodged in small vessels like the arterioles and
capillaries of the lung.
Primary symptom is shortness of breath and
chest pain.

Interventions

Place patient in high fowlers

Administer oxygen
Call MD
Chest x-ray
Outcomes are better for a health person;
poorer for person with pre-existing lung
problems.

Orthopedic Disorders

Congenital
Acquired / trauma
Infectious

Tales Equinovarus
Tales equinovarus or
Club foot

Obvious deformity note

at birth.
Surgical correction
Bowden & Greenberg

Tales 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
Surgery is performed between 4 to 12
months if full correction is not achieved
with casting

Nursing Diagnosis

Impaired physical mobility related to cast

wear
Altered parenting related to emotional
reaction following birth of child with physical
defect
Risk for impaired skin integrity related to
cast wear.
Knowledge deficit: cast care and home care

Metatarsus Adductus

Most common foot deformity

2 per 1000
Result of intrauterine positioning
Forefoot is abducted and in varus,
giving the foot a kidney bean shape.

Metatarsus Adductus
Turning in of foot
Treatment:
Passive manipulation
Soft shoes at night
Serial casts
Bowden & Greenberg

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

Clinical Manifestations

Head of femur lies outside the acetabulum

+ Ortolani maneuver

Asymmetrical lower extremity skin folds

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

Nursing Diagnosis

Knowledge deficit regarding care of harness

or cast
Impaired physical mobility
Risk for impaired skin integrity related to
pressure from casts or braces
Altered skin perfusion due to casts or braces
Risk for altered growth and development due
to limited mobility

Harness

JB Chandler

Osteogenesis Imperfecta

Osteogenesis Imperfecta

Genetic disorder
Caused by a genetic defect that affects
the bodys production of collagen
Collagen is the major protein of the
bodys connective tissue
Less than normal or poor collagen
leads to weak bones that fracture easy

Osteogenesis Imperfecta

Often called brittle bone disease

Characteristics

Demineralization, cortical thinning

Multiple fractures with pseudoarthrosis
Exuberant callus formation
Blue sclera
Wide sutures
Pre-senile deafness

Genetic Defect

Type I: autosomal dominant: age at

presentation 2 6 years.
Common age for child abuse.
Often present as suspected child
abuse

3-month-old with OI

Old rib fractures

Old

Type II

Autosomal Recessive
Pre- or perinatal death
Pulmonary hypoplasia

Fetus with severe OI

Rib fractures / poorly developed spine / limbs & craniu

New Born with OI

Nursing Diagnosis

Risk of injury related to disease

process
Risk for altered growth and
development
Knowledge deficit: disease process
and care of child

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%

Cerebral Palsy

Assessment

Developmental surveillance is key

Diagnoses 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

Team Management

Legg-Calve-Perthes

Self-limiting disease

Femoral head loses blood supply

Four times more common in males

Peak age 4 to 7 years

Clinical Manifestations

Pain

Limping

Limited hip motion especially internal

rotation and abduction is classic sign

Management

Goal of care is to: Keep femoral head in

the hip joint

Traction

Anti-inflammatory

Physical therapy

Osgood-Schlatters
Painful prominence of the
tibial tubercle

Gait.udel.e

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.

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

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
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

Screening

Screening

Bowden & Greenberg

Mild Scoliosis
Mild forms
Strengthening and
stretching

Ball & Bindler

Severe Scoliosis

Assessment

Alert: If pain is a reported symptom of

the childs 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.

Bracing
Custom designed brace
Child wears at night

Bowden & Greenberg

Moderate Scoliosis

Whaley & Wong

Milwaukee brace

Scoliosis

Spinal Fusion

Post-operative Care

Pain management
Chest tube in many cases
Turn, cough, and deep breath
Log-roll

Nursing Diagnoses

Body image disturbance related to

bracing
Risk of injury related to brace
Impaired physical mobility related to
brace wear
Risk for non-compliance with
treatment regimen

Inflammatory Process

Osteomyelitis

Septic arthritis

Juvenile arthritis

Osteomyelitis

Webmd.lycos.com

Osteomyelitis

Infection of bone and tissue around

bone.

Requires immediate treatment

Can cause massive bone destruction

and life-threatening sepsis

Pathogenesis of Acute Osteo

Under 1 year
the epiphysis is
nourished by
arteries.

In children 1 year
to 15 years the
infection is restrict
to below the
epiphysis.

Osteomyelitis
Most common organism
Staphylococcus areus

Osteomyelitis.com

Clinical Manifestation

Localized pain
Decreased movement of area
With spread of infection

Redness
Swelling
Warm to touch

Diagnostic Tests:

X-ray
CBC
ESR / erythrocyte sedimentation rate
C-reactive protein
Bone scan most definitive test for
osteomyelitis

X-Ray

18-year-old boy with painful right

arm

Osteomyelitis

Management

Culture of the blood

Aspiration at site of infection
Intravenous antibiotics x 4 weeks
PO antibiotics if ESR rate going down
Monitor ESR

Decrease in levels indicates improvement

Goals of Care

To maintain integrity of infected joint /

joints

Septic Arthritis

Infection within a joint or synovial

membrane
Infection transmitted by:

Bloodstream
Penetrating wound
Foreign body in joint

Septic Arthritis of Hip

Difficulty walking and fever

Diagnosis: x-ray, aspirate fluid from
joint, ESR

Septic Hip

Diagnostic Tests
X-ray

Needle aspiration
under fluoroscopy

Erythrocyte Sedimentation Rate

ESR
Used as a gauge for determining the
progress of an inflammatory disease.
Rises within 24 hours after onset of
symptoms.
Men:
0 - 15 mm./hr
Women: 0 20 mm./hr
Children:
0 10 mm./hr

WBC

31,700

bands

4%

segs

85%

monos

6%

lymphs

5%

HgB

12.4

MCT

35.4

Platelets

394,000

C- reactive protein

8.2 mg

ESR /sed rate

39

C-Reactive Protein

During the course of an inflammatory

process an abnormal specific protein, CRP,
appears in the blood.

The presence of the protein can be detected

within 6 hours of triggering stimulus.

More sensitive than ESR / more expensive

Joint Space Fluid

WBC

80,000

Segs

88%

Monos

1%

Lymphs

11%

RBC

16,000

Gram Stain

Gram-positive cocci in
chains

Management

Administration of antibiotics for 4 to 6

weeks.
Oral antibiotics have been found to be
effective if serum bactericidal levels
are adequate.
Fever control
Ibuprofen for anti-inflammatory effect

Goals of Care

Maintain integrity of affected joint

Juvenile Rheumatoid Arthritis

Chronic inflammatory condition of the joints

and surrounding tissues.

Often triggered by a viral illness

1 in 1000 children will develop JRA

Higher incidence in girls

Clinical Manifestations

Swelling or effusion of one or more

joints
Limited ROM
Warmth
Tenderness
Pain with movement

Diagnostic Evaluation

Elevated ESR / erythrocyte

sedimentation rate
+ genetic marker / HLA b27
+ RF 9 antinuclear antibodies
Bone scan
MRI
Arthroscopic exam

Goals of Therapy

To prevent deformities

To keep discomfort to a minimum

To preserve ability to do ADL

Management

ASA
NASAIDS around the clock
Immunosuppressive drugs: azulvadine
Enbrel: new class of drugs to treat
JRA

Attacks a specific aspect of the immune

response

ASA Therapy

Alert: The use of aspirin has been highly

associated with the development of Reyes
syndrome in children who have had
chickenpox or flu. Because aspirin may be
an an ongoing p art of the regimen of the
arthritic child, parents should be warned of
the relationship between viral illnesses an
aspirin, and be taught the symptoms of
Reyes syndrome.

Management

Physical therapy
Exercise program
Monitor ESR levels
Regular eye exams: Iriditis

Iriditis

Intraocular inflammation of iris and

ciliary body

2% to 21% in children with arthritis

Highest incidence in children with multi

joint involvement disease.

Iriditis