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PEDIATRICS > Orthopedics > Flashcards

Orthopedics Flashcards

1
Q

Scoliosis

A

a spinal deformity in which there is a lateral curvature in the spine greater than 10 degrees

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2
Q

Types of Scoliosis

A

Congenital: anomalous vertebral development
Infantile: onset before 3 years old
Juvenile: detected between ages 3-10
Neuromuscular: associated with neuro or muscular diseases
AIS = most common; onset between 10 years old and after

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3
Q

AIS

A

Present in 2 to 4 percent of children between 10 to 16-years old
Possible genetic link because it is often seen in multiple family members
More common in girls*
Of adolescents diagnosed with AIS, only 10% have curve progression requiring medical attention
Referred to orthopedist

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4
Q

Curve Progression

A

♣ Double curves progress more than a single curve (almost looks like an S)
♣ Larger curves (30-40 degrees) progress more than smaller curves (20-30 degrees)
♣ Females progress more than males

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5
Q

Curve Progression: Peak High Velocity

A

Increase risk of curve progression during PEAK HEIGHT VELOCITY (most rapid, maximum growth in short period of time) during adolescent growth spurt
• Girls Tanner 2-3
• Boys Tanner 3-5

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6
Q

Symptoms of Scoliosis

A 
One shoulder higher
One shoulder blade sticks out more
More than one dimensional
One side of rib cage appears larger than the other
One hip higher and more prominent
Waist appears uneven
Body tilts to one side
One leg appears shorter than the other
Head is not centered over body
- PAIN NOT TYPICAL --> spinal tumor?
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7
Q

Screening for Scoliosis

A

• American Academy of Orthopedics
Girls 11-13 years (screened at 11 and again at 13)
Boys once at 13 years

• American Academy of Pediatrics
Routine health visits at ages 10, 12, 14 and 16 for both girls and boys

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8
Q

History r/t Scoliosis

A

Primarily diagnosis of exclusion
Family history
Menstrual onset
Development of secondary sexual characteristics and recent growth patterns

Presence of pain and neurologic changes; NOT SCOLIOSIS

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9
Q

Physical = Adams bend forward test

A

Bend forward at waist until spine becomes parallel to the floor while holding palms together with arms extended.
Examine child from behind and side looking for asymmetry in the contour of the back (rib hump)
Flexibility should also be evaluated by stabilizing the spine and asking the child to twist to both sides
Ninety percent of curves are to the right, left thoracic concerning

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10
Q

Curves to right or left side?

A

90% RIGHT SIDE

Concerned if left

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11
Q

Diagnosis: Primary concern

A

possible underlying cause and curve progression

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12
Q

Determinants of Progression

A

Gender
Future growth potential
Curve magnitude at time of dx - larger curve progresses quicker than smaller curve

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13
Q

Evaluation of Growth potential

A

Tanner stage assessment
Risser Scale: Using X-ray evaluates skeletal muscle via fusion of iliac epiphysis?
Bone age: Examination of epiphyseal plates on hand x-ray

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14
Q

COBB ANGLE

A

Determines magnitude of curve

Superior and inferior vertebrae of scoliotic curve

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15
Q

Neuro signs and pain –>

A

NEED MRI

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16
Q

Reasons for Bracing

A

Curve greater than 30 degrees
♣ OR…
Curve which increased from 10->25 degrees at rapid rate

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17
Q

GOAL for bracing

A

Prevent curve progression or until curve progression can be controlled

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18
Q

How long are braces worn?

Under 35 degrees?

A

18-23 hours per day

Night time/part time bracing

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19
Q

Complications with bracing

A

Compliance

Skin breakdown – tight shirts; alcohol for bony prominences

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20
Q

Types of Braces

A 
Milwaukee
TLSO
Boston
Charleston
Providence
Spinecor -- doesnt work
RSC WITH SCHROTH METHOD
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21
Q

RSC

A

• Open pelvis accommodates expansion of lungs which helps in correcting the curve and decreasing curve progression
• Use in conjunction with Schroth method
o Helps in lateral curve and trunk rotation

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22
Q

Schroth method

A

physical therapy for at least an hour a day
Stretching breathing flexibility
Exercises; need to be compliant
Prevent progression AND reduce the curve

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23
Q

Surgery

Objectives of Surgery

A

Indication = cobb angle greater than 45 degrees

o	Objectives of surgery
♣	Arrest progression
♣	Achieve maximum permanent correction
♣	Improve appearance
♣	Keep short and long term complications to a minimum
•	Respiratory and cardiac problems
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24
Q

Surgical Procedure

A

Fuse vertebrae along the curve
Supporting fused bones with instrumentation attached to the spine
Bone grafts from iliac crest fuse vertebrae together
Many surgical variations = instruments, procedures,

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25
Q

Complications of Surgery

A 
Bleeding
Postoperative pain
Infection
Nerve damage
Pseudoarthrosis: incomplete fusion
Disk degeneration and low back pain
Complications that involve lungs and circulation
Flat back syndrome with Harrington rod.
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26
Q

WHY ICU after scoliosis surgery

How old for PCA pump?

A

PAIN
Blood transfusions
PCA pumps – 6 years old

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27
Q

Opioids given after surgery
Opioids not given
Itching
Nausea

A

Morphine and Dilaudid
Demoral
Benadryl
Zofran

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28
Q

Post-surgery –> assessing for

A

Constipation, LOC, urine output

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29
Q

Progression post scoliosis surgery

AVOID WHAT MEDS?

A 
1 day = sitting
1 week = walking
0-3 months no sports
3-4 fusion substantial
6 mo no restrictions
1-2 year = complete fusion

NSAIDS AND STEROIDS

30
Q

CLUBFOOT – initial info

A
  • Involves bone deformities (bone AND soft tissue) and malposition with soft tissue contractures
  • TEV (Talipes Equinovarus) most frequently occurring clubfoot (95%)
  • Early evaluation and treatment for optimum correction and least invasive treatment
31
Q

Clubfoot
Dx
Incidence

A 
Dx in utero or right away after they are born
1-2 per 1000 live births
Affects boys 2x girls
Bilateral 50%
positive family history
32
Q

TEV - forefoot adduction

o Talipes Equinovarus

A

TOES POINT IN

33
Q

TEV - midfoot supination

A

TURNS UPWARDS – high arch

34
Q

TEV - Hindfoot varus

A

heel turns inwards

35
Q

TEV - ankle equinos

A

Toes point downwards

36
Q

Talipus Calcaneovarus

A

Foot looks like J

37
Q

Etiology of Clubfoot

A
  • intrauterine positioning
    • neuromuscular or muscle abnormality
    • genetic predisposition
    • arrested fetal development of skeletal and soft tissue
    • seen with congenital abnormalities
    • amniotic banding
38
Q

Categories of Clubfoot

A
  1. Positional: occur primarily from intrauterine crowding. Responds to simple stretching and casting
    1. Syndromic (tetralogic): associated with other congenital abnormalities. More severe form.
    2. Congenital (idiopathic or true clubfoot): occur in otherwise healthy infants. It is the most common form.
39
Q

Other symptoms of Clubfoot

A 
Small foot
Shortened Achilles tendon
Underdeveloped calf muscle
Empty heel bed
Transverse plantar crease
Normal leg lengths
40
Q

Dx of clubfoot

A

May be detected antenatally
Diagnosis at birth – visual inspection
Radiographs to confirm degree and severity of deformity
MRI may also be used

41
Q

Tx of Clubfoot

A

Early treatment is essential to achieve successful correction and reduce chance of complications
Serial casting is begun immediately or shortly after birth.
Successive casting allows for gradual stretching of skin and tight structures on medial side of foot.

42
Q

Casting

A

Every few day for first 1 to 2 weeks
Then every 1 to 2 weeks until maximum correction is achieved.
Avoid overcorrection can cause rocker bottom foot.
If corrected, child wears splint (Denis Browne Splint) or corrective shoes.
If deformity has not been corrected, surgical intervention is required between 3 – 12 months.

43
Q

Prognosis for CF

A

Parents should realize that outcomes are not always predictable and depend on severity of deformity, age of child at initial intervention, compliance with treatment, and development of bones, muscles & nerves

Surgical intervention does not restore the ankle to an entirely normal state with the affected foot & leg remaining smaller & thinner than unaffected side.

Most children after surgical repair are able to walk with out a limp and run or play.

25% chance of reoccurrence

With severe deformities, repeated surgeries.

44
Q

Nursing Dx for CLUBFOOT

A 
Impaired physical mobility
Risk for impaired skin integrity
Risk for impaired parenting
Risk for delayed motor development
Risk for altered parent/infant relationship
45
Q

Contusions

A

o Damage to soft tissue, subcutaneous structure and muscle
♣ Initial symptom is pain and swelling
♣ Should be taken out of game and not put back in until function of limb is back to normal

46
Q

Sprains

A

o Severe trauma to join causing a ligament to be partially or completely torn
♣ ACL sprain is most common in adolescent female
• Anterior crucial ligament
• Report popping sound
• May not have pain at time of popping sound
♣ Patients usually report pain, swelling, and inability to use joint

47
Q

Strains

A

o Injury to the muscle near the musculo-tendinous junction, as a result of a forceful contraction of the muscle

48
Q

Dislocation and Subluxation

A

o Dislocation and subluxation refer to the displacement of bones that form a joint. These conditions affecting the joint most often result from trauma that causes adjoining bones to no longer align with each other.
♣ Dislocation = total nonalignment
o A partial or incomplete dislocation is called a subluxation

49
Q

Adolescent dislocation
Toddler
Below 5 years old

A

Shoulder
Fingers
Hip

50
Q

Therapeutic Management

A 
RICE
Immobilzation
Nursing Interventions -- 
Neurovascular impairment
Elevating at level of heart
51
Q

Fractures = general info

A

In children, they are result of increased mobility &/or immature motor & cognitive skills
Infancy – RARE
Traumatic musculoskeletal injuries most frequent
Clavicle most frequent bone broken
Epiphyseal injuries – Salter-Harris classifications

52
Q

Stress fractures

A

Overuse injury
Becoming more common in adolescents who limit intake of calories and calcium to remain lean for sports
Symptoms - chronic pain that changes with intensity and focal tenderness in a singular site on the bone.
RDA – calcium 1500 mg/day for adolescents

53
Q

Bone Healing

STAGES??

A 
Rapid in child due to thick periosteum
Stages
     * hematoma – within first 24 hrs.
     * cellular proliferation 
     * callus formation 
     * ossification
     * consolidation & remodeling
54
Q

Dx of Fractures

A 
Pain or tenderness at site
Immobility or decreased ROM
Deformity of extremity
Edema at side
Crepitus (fractured clavicle)
Ecchymosis/muscle spasms
Over fracture = hard = muscle is trying to compensate for the loss of bone function -- physiological splint
55
Q

Nursing
Initial assessment
Assess and manage fat embolism

A 
Initial Assessment
    * cause of fracture
    * examine fracture site
    * neurovascular evaluation
Asses & manage fat embolism
    * after crush injury of long bones
    * dyspnea, restless, fever over 103, petechie      rash, tachycardia, tachypnea, hypoxia
Cast care
56
Q

Patient teaching - cast care

A 
keep elevated
monitor skin breakdown
Itching - use blowdryer with cool air
Drainage -- infection
Peddling
Do not get wet
57
Q

Compartment Syndrome

A

Results from swelling caused by trauma & immobilizing device
Severe pain unrelieved by analgesics
Pain more intense than what would be expected from fracture
Pallor, paresthesia, lack of pulse distal to the trauma
Pain with extending fingers or toes

58
Q

Complications of fractures

A 
Infection
Neurovascular injury
Vascular injury
Mal-union or delayed
Leg length discrepancy
59
Q

Osteomyelitis

Exogenous vs. Hematogenous

A

Infection of bone
Occurs in metaphyseal region of long bones
Most frequent between 5 to 14 years
Exogenous – direct inoculation from outside bone
Hematogenous – spread of organism from pre-existing infection (acute & subacute)
Acute = first few days of infection – cut off 2 weeks

60
Q

Staphloccus aureus

A

most common over 5 years

61
Q

Haemophilus influenza

A

strep, pneumonia

62
Q

Salmonella and staph aureus

A

sickle cell disease

63
Q

MRSA

A

difficult tx and improvement

Community acquired

64
Q

E. Coli and B Strep

A

most common in neonates and infants

65
Q

Pseudomonas

A

Puncture wounds over 6 years

Osteomyelitis secondary to puncture would

66
Q

Nisseria gonorrhea

A

Sexually active adolescents

67
Q

Dx of osteomyelitis

A

Symptoms – vague & son-specific

  • infant: fever, irritability, poor feeding
  • older child: pain, warmth & tenderness over site of infection, fever, lethargy, decreased ROM
68
Q

Lab data and osteomyelitis

A 
Lab Data
   * leukocytosis & elevated ESR
Erythrocyte sedimentation rate -- goes up with inflammation and infection
   * blood cultures 
   * bone cultures -- aspiration
CT scan & MRI
Tumor
Best way to see where infection is*
Xray sometimes does not show until 2-3 weeks after
69
Q

Therapeutic Management

A 
Long term IV antibiotics -- community acquired
aspiration to see what organism is
     * monitor for side effects
Complete bed rest
Immobilization of affected limb
May require surgical drainage

Antibiotics
Napcilin, clindamycin, vanco, 1st generation cephalosporin

Watch BUN and creatinine 
Secondary infections
Resistance
Trush
Peak and trough
70
Q

Time of IV–Oral for osteomyelitis antibiotics

A

♣ Normally takes about 7-14 days to transition from IV to oral antibiotics (4-6 weeks)

71
Q

Nursing Care for osteomyelitis

A 
Positioning
Careful & gentle moving of limb
Pain control
Monitor vital signs
Antibiotic therapy
May require isolation
May require casting
Nutrition
Non-weight bearing
Physical therapy

PEDIATRICS (5 decks)

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