Musculoskeletal Chapter 31

7/27/2019 Musculoskeletal Chapter 31

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C H A P T E R 3 1

Musculoskeletal


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Pediatric Differences

Ossification nearly complete at birth Posterior fontanel closes 2-3 months of age Anterior fontanel closes approx. 18-24 months of age Most skull growth by 2 years of age

Long bones of children porous and less dense than adults Muscles increase in length and circumference, not in

number Until puberty, ligaments & tendons are stronger than

bone Cartilage replaced by bone & skeletal

maturation by approximately 20 yearsof age


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Who am I?


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Immobilized Child

Once thought to be restorative for patients withillness and injury

We now know that immobilization has serious

consequences Especially on growth & development of the child

Inactivity leads to decrease in functional capacity of the entirebody

Can delay age appropriate milestones

Decreased muscle mass & strength

Decreased metabolism

Decreased bone mineralization


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Immobilization

Muscular system Decreased muscle strength and endurance

Disuse atrophy

Loss of joint mobility

Skeletal system Bone demineralization

Daily stresses on bone by motion & weight

bearing maintain balance between bone

formation (osteoblastic activity) and bone

resorption (osteoclastic activity).During immobil-

ization INCREASED calcium leaves the bone

causing osteopenia (demineralization)

Negative calcium balance


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Immobilizationpsychologically

Movement is critical : immobility deprives child ofnatural outlet for feelings

Physical growth and development depend onmovement

instrument of communication, expression andlearning

Respond to anxiety with

increased activity


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Not Happy!


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Traumatic Injury

Soft Tissue Injury

Muscles

LigamentsTendons

Sports injuries

Mishaps during play


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Contusions

Damage to soft tissue, subcutaneous tissue andmuscle

Escape of blood into tissue-ecchymosis-black and

blue Swelling, pain disability

Crush injuries


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Contusions


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Dislocations

Occur when force of stress on ligament is sufficient todisplace normal position of opposing bone ends or boneends to socket Pain increased with active or passive movement of extremity May be an obvious deformity & inability to move joint

Most common type : Phalanges elbow

Hip dislocation: (< 5 yrs old) potential loss of bloodsupply to head of femur

Shoulder dislocation: (adolescents) sports related Reduce ASAP Unreduced dislocations: increased swelling, reduction is difficult,

increased risk neurovascular problems


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Dislocations


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Sprains

Trauma to a joint fromligament partially orcompletely torn orstretched byforce

May have associated

damage tobloodvessels, muscles,tendons, and nerves

Presence of joint laxity

is indicator of severity Rapid onset of diffuse

swelling withdisability


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Strains

Microscopic tear tomusculotendinousunit

Similar to sprain Swollen, painful to

touch

Generally incurredover time


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Soft Tissue Injury

TherapeuticManagement RICES and ICESRest the injured partIce immediately (max

30 min at a time)Compression with

elastic bandagesElevation of extremity

Immobilize andsupportCrutches (proper

size and height)

f


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Soft Tissue Injurytreatment


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Fractures

Common injury in children (rare in infants, except with aMVA)

Clavicle the most frequently broken bone, especiallyunder 10 years. (Neonates if they are too large for moms

small pelvis) School aged: bicycle/vehicle or skate board injuries

Adolescents: bicycles, ATVs, skateboards, motorcyclesports

Patterns of fractures, problems of diagnosis& methods oftreatment are different in pediatrics than in adultpopulation


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Epiphyseal(physeal) Injuries

Weakest point of long bones: cartilage growth plate(epiphyseal plate)

Frequent site of damage during trauma

May affect future bone growth Treatment may include ORIF to prevent growth

disturbances


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Epiphyseal plate


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Types of Fractures

Simple or closed (no breakin the skin) Compound or open:

fractured bone protrudesthrough the skin

Complicated: bonefragments have damagedother organs or tissue (lungor bladder)

Comminuted: smallfragments of bone are

broken from fracturedshaft and lie insurrounding tissue (rare inchildren)


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Types of fractures in children

Bend: Bone is bent but notbroken Buckle or torus:

Compression of porousbone, bulging projection atfracture site (more

common in young children) Greenstick: compressed

side of bone bends, buttension side of bone

breaks, causing incomplete

fracture Complete: divides the bone

fragments


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Clinical Manifestations of Fractures

Generalized swelling

Pain or tenderness

Deformity

Diminished functional use May have bruising, severe muscular rigidity, crepitus


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Bone healing and remodeling

Typically rapid healing inchildren (femoral shaft)

Neonatal period:2-3weeks

Early childhood:4 weeks Later childhood: 6-8

weeks

Adolescence: 8-12 weeks


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Remember..


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Fractures

Diagnostic evaluation: x-rayis most useful tool

Therapeutic managementgoals

Nursing considerations

Nurses make initialevaluation (calm quiet voice)

Calm the child and the parent tobetter assess

Good history of what occurredto see if abuse is possible

Spiral fx in young child mayindicate abuse

Multidisciplinary team tofurther assess

Assess Extent of Fractures


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Assess Extent of FracturesThe 5 Ps

Pain and point oftenderness

Pulse distal to fracturesite

Pallor: capillary refill Paresthesia: sensation

distal to fracture site

Paralysis: movement

distal to the fracture site


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Neurovascular Assessment

PULSES COLOR

MOVEMENT ANDSENSATION

TEMPERATURE

SWELLING

PAIN


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The Child in a Cast

Cast application techniques Plaster of paris: drying fiberglass

Nursing Care management First few hours after application: Elevate extremity

assess sizing and monitor for degree of swelling Assess for hot spots Casts of open fracture has window over wound for assessment First few hours after surgical reduction (casted as closed fracture)

bleeding may soak through the cast. Outline area to monitor Educate parent on time to dry of plaster cast S/S that cast too tight If cast too loose Home environment

Car seats Protecting the cast transparent dressing or diaper


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Nursing Considerations

Swelling may continue thus cast becomes atourniquet, circulation diminished, neurovascularcomplications

Elevate extremity If swelling is severe: casts are bivalved

Permanent tissue damage can occur within 6 to 8 hrs

COMPARTMENT SYNDROME


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Compartment Syndrome

Pain

Swelling

Discoloration

Decreased pulses Decreased temperature

Inability to move distal exposed part

CALL PHYSICIAN IMMEDIETLY


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Compartment Syndrome


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Casting


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Child in Traction

Traction: Extended pulling force

Purposes:

Fatigue muscle involved and reduce muscle spasm so bonescan be realigned

Position distal and proximal bone ends in desired alignment

Immobilize until healing has taken place to permit casting orsplinting

Help prevent or improve contracture deformity

Promote immobilization

Reduce muscle spasms


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Traction: Essential Components

Traction: Forward force Attaching weight to distal bone fragment

Counter traction: backward force

Body weight provides this ( for free)

Frictional force: provided by patients contact withthe bed


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Types of Traction

Manual Traction: applied by the hand distal tofracture site

Skin Traction: Directly to skin surface and indirectly

to skeletal structures Skeletal traction: directly to skeletal structure with a

pin (ouch)


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Skeletal Traction Pins


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Types of Traction

Upper Extremity Traction: Humerus

Overhead suspension: arm bent at elbow andsuspended vertically & traction applied to distal

end of the humerus.Dunlop traction: Lower arm is flexed and

suspended vertically with traction, while upperarm maintains longitudinal direction and pull


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Lower Extremity Traction

Bryant: running traction, pull in 1 direction

Bucks Extension: legs in an extended position

Russell Traction: skin traction with a padded sling

90-90 traction: most common skeletal traction Steinmann pin or Kirschner wire distal in femur at 90 angle

both at hip and knee

Balance suspension traction with

Thomas splint


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Types of Traction


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Cervical Traction

Halo Brace (vest) attached to head with 4 screws inouter skull: bars connected to vest> greater mobilityof rest of the body


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Cervical Traction

Crutchfield tongs (Barton, Gardner-Wells) burr holesin the skull & weights attached to the head


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Nursing Care Management

Know the reason WHY traction is applied Assess patient

Assess pulses bilaterally

Alteration in sensation or increased pain

Assess any change in color of skin or nail bed

Skin breakdown/ massage pressure areas to stimulate circulation

Position changes

Wash and dry skin daily

Any neurovascular changes: record and call MD

Assess traction apparatus

Check line of pull/ weights

Bandages in place/ excessive tightness

Do not remove unless under supervision of physician

Diet

Balanced diet with fruits and vegetables (fiber)

calcium

Encouraging fluids

Offering laxatives

Encourage deep breathing and Incentive Spirometry

Prevent foot drop

Encourage socialization/ discourage isolation


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Pain management: increased initially as traction pullis fatiguing the muscle

Analgesics

Muscle relaxants

Pin care: according to hospital policy or physicianorder

Frequently assessed and cleaned to prevent infection

After first 48 to 72 hours assessment needed less frequently


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Developmental Dysplasia of Hip


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Developmental Dysplasia of HipDDH

Spectrum of disorders describing abnormaldevelopment of hip that can occur

Infancy

childhood

Fetal life

Cause unknown

Gender, birth order, family history,

positioning, delivery type, joint laxity

& post natal positioning

Developmental Dysplasia of Hip


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Developmental Dysplasia of HipDDH

Diagnostic Evaluation Not detected at initial exam after

birth Most often found in pediatrician

office for well baby check up Exhibits as hip joint laxity and

NOT out right dislocation

Shortening of the limb on affectedside

Asymmetric thigh and gluteal fold Broadening of the perineum Ortolani and Barlow tests most

reliable from birth to 3 months Barlow: thighs are adducted

Ortolani: abducting the thighs totest for hip subluxation ordislocation


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DDH

Ortolani Test


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limited hip abduction in flexion

Barlow Test


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thighs adducted

Signs of DDH


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gasymmetry of gluteal and thigh folds


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Therapeutic Management

Treatment initiated as soon as recognized

GOAL: obtain and maintain a safe and congruentposition of hip joint to promote normal development

Early intervention more favorable in restoration of normalbony architecture and function.


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Newborn to 6 months Pavlik Harnace

Hip joint in dynamic splint

Proximal femur centered in acetabulum

Worn continuously until proven

stable on exam and with x-ray


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Ages 6 to 18 monthsGradual reduction by traction for 3 weeks

Closed reduction of hip under general

anesthesia

If not successful then open reduction

Then placed in hip spica cast for 2 to 4

monthsOnce hip is stable a flexion abduction brace

is applied


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Hip Spica cast


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Older Child Increasingly difficult after age 4

Impossible or inadvisable > 6 yrs

Contractures of muscles Deformity of femoral and acetabular structures

Correction is challenging as most likely is secondary toarthritis or CP

Operative reduction with or without presurgical traction

Contracted muscles

Osteotomy procedures


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Nursing Management

Nurses can detect DDH on initial assessment

Ambulatory child who displays limp or unusual gateis referred

Primary Nursing Goal: Teaching ParentWHY DEVICE BEING USED!! Application of device

Maintenance of device

Keep in mind rapid growth of the infant/child(check straps)/check for rubbing/ red marks


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Nursing Management

Normalcy is the goal Involve the child in all activities of any other child in

same age group

Maintain active role in family and activities


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Congenital Clubfoot

Deformity of ankle and foot which includesforefoot adduction

Midfoot supination

Hindfoot varusAnkle equinus

Most common talipes equinovarus

Foot is pointed downward and inward invarying degrees


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Congenital Clubfoot

Cause unknown Some attribute to abnormal positioning and

restricted movement in utero

Arrested or abnormal embryonic development Increased risk of hip dysplasia

l l bf


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Congenital Clubfoot

Classification Positional: intrauterine crowding

Responds to simple stretching and casting

Syndromic (teratologic): associated with other congenital

anomalies More severe form/ often resistant to tx

Surgical intervention may or may not be effective

Congenital/idiopathic: can occur in otherwise normal child

Always requires surgical intervention because there is a bonyabnormality

i i l i


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Diagnostic Evaluation

Detectable prenatally through U/S Noted at birth

h i


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Goal: achieve a painless, plantigrade and stable foot Serial casting before discharge

Successive casts encourage gradual stretching and accommodate rapidgrowth

Maximum correction achieved within 8 to 12 weeks

If no positive result after 3 months= surgical intervention

Three stages

Correction of deformity

Maintenance of correction until normal muscle balance is regained

Follow up observation to prevent possible recurrence

P i


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Ponseti

N i C M


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Casted child:observation of skin and circulation

Rapid growth

Educate the parentSigns of skin breakdown

Signs new cast needed

Help the child to live as normally as possible

M Add (V )


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Metatarsus Adductus (Varus)

Most common congenital foot deformity Result of abnormal intrauterine positioning

Type I: foot flexible and corrects easily

Type II: partial flexibility in forefoot Type III: foot rigid and will not stretch

T t t


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Treatment

Type I & IIOften times corrected with gentlemanipulation

Passive stretching of foot

Parent teaching performed

Continue for 6 weeks

Type III

Serial manipulation and casting

N i M t


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Nursing Management

Teaching the parent

hold heal firmly and to stretch ONLY theforefoot

Cast teaching

Signs of skin breakdown

Signs new cast needed

Help the child to live as normally aspossible

Sk l t l Li b D fi i


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Skeletal Limb Deficiency

Underdevelopment of skeletal elements ofextremities

Can range from minor defects (missing digit) toserious abnormalities

Amelia: loss of entire extremity

Meromelia: partial absence of an extremity

Phocomelia: seal limbs

Most are primary defects of development of limb Prenatal destruction can occur due to constriction of

amniotic band


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Meromeliati l b f t it


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partial absence of extremity

Sk l t l Li b D fi i


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Skeletal Limb Deficiency

Therapeutic Management Prosthetic devices

Applied at earliest possible stage


Teaching parent about prosthetic application

Occupational therapist

Encourage parent to assist the child in making age appropriateadvancements

Do not OVERPROTECT child

L C l P th Di


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Legg- Calve-Perthes Disease

Self limiting disorder withfemoral head aseptic

necrosis

Affects ages 2 to 12

Most commonly in boysages 4 to 8

Cause unknown

Can take place over 18

monthsor as long as several years


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Camerons Personal Story

Legg Calve Perthes Disease


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Insidious onset History may reveal intermittent limp or persistent

ache or stiffness

Diagnosed with x-ray and confirmed with MRI Revealing osteonecrosis



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Therapeutic Management Goal: Keep head of femur in acetabulum Treatment varies based on: Age

Appearance of femoral head vasculature and position within acetabulum Rest and non weight bearing

At times traction applied to stretch tight adductor muscles

Non weight bearing devices:

Abduction brace Leg casts

Leather harness sling

Surgery in some cases


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Self limiting Younger children have better prognosis for complete

recovery Epiphysis are more cartilaginous

Children 10 and older have high risk for degenerativearthritis

The later the diagnosis, the more damage to femoral

head



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Nursing Care Management Identify the affected child and refer

Educate the parent

Why device being orderedManagement and application of corrective

device

Signs of skin breakdownSigns that a new size needed

Help the child to live as normally as possible


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Skeletal deformity


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Skeletal deformity

Kyphosis: increased convex angulation in curvatureof the thoracic spine

Secondary to

TB

Arthritis Osteodystrophy

Compression fractures of thoracic spine

Lordosis: accentuation of cervical or lumbar

curvature Trauma

idiopathic

Idiopathic Scoliosis


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Idiopathic Scoliosis

Complex spinal deformity in three plains Lateral curve

Spinal rotation causing rib asymmetry

Thoracic kyphosis

Most common spinal deformity Classified according to age of onset Infantile: birth to 3 yrs

Juvenile: develops during childhood

Adolescent: develops during the growthspurt of early adolescents.

Most noticeable during the pre adolescent growth spurt

Idiopathic Scoliosisdiagnostic evaluation


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diagnostic evaluation

Observation: behind standing child Symmetry of shoulder height

Scapular or flank shape

Hip height and alignment

As child bends forward at the waist (Adams test)with hanging arms

Assymetry of ribs and flanks may be noted

Scoliometer used to measure truncal rotation

Definitive diagnosis made by radiograph

of child in standing position

Idiopathic ScoliosisTherapeutic Management


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Observation with clinical and radiographic evaluation Curve < 10 degrees is postural variation

Curve < 20 degrees is mild

Orthotic intervention (bracing) Boston, Wilmington, TLSO (thoracolumbosacral

orthosis),Milwaukee, Charleston Nighttime Bending Brace

Surgical spinal fusion: realignment and straighteningwith internal fixation and instrumentation combinedwith bony fusion of the realigned spine.

Curve >40 degrees Paralytic and Congenital curves generally

-progress

Idiopathic ScoliosisNursing Care Management


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Treatments extends over years Childs identity (physical and psychological) is

formed in adolescents

Nursing care must take into consideration the

adolescents perspective Positive reinforcement

Encouragement

Independence

Selection of clothing Participation of activities

Socialization with peers



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Preoperative Care Educate on complexity of surgery

Teach patient to manage own PCA

How to Log Roll

Prepare for foley catheter Possibility of a chest tube

Possibility of NG tube

Have a favorite toy, stuffed animal, iPad

Meeting with a peer who has undergone similar surgery as well


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Postoperative care Monitored in an acute care setting

Neurological assessments of extremities critical

Delayed paralysis may develop

Most common post op issues Neurological injury

Spinal cord injury

Hypotension from blood loss

Wound infection

Log rolled

Skin care Risk for pressure ulcers

Pain management

Scoliosis


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Scoliosis

Ambulation begins 2 or 3 P.O.D. Discharged after 1 week Adequate urine output Fluid and electrolyte balance ileus

Skin integrity Start PT as soon as patient able Self care always encouraged Teaching of family Body image

Refer family to resources American Association Orthopedic Surgeons Scoliosis Research Society

Osteomyelitis


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Osteomyelitis

Inflammation and infection of bony tissue May be caused by exogenous reasons ( trauma/

puncture wound/ or surgery)

Or hematogenous sources (pre existing infection/tonsillitis/ impetigo where the organism travels)

Osteomyelitis


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Osteomyelitis

Exogenous: infectious agent invades the bone following penetrating

wound, open fracture, contamination in surgery or secondaryextension from abscess or burn.

Hematogenous: Existing infection spreads to bone

Sources may be furuncles, skin infection, URI, abscessed teeth,pyelonephritis

Any organism can cause osteomyelitis

Infective emboli travel to arteries in bone metaphysis, causingabscess formation and bone destruction

Anna


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Anna

Osteomyelitis


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Osteomyelitis

Staphylococcus aureus is most common causativeorganism

Signs and symptoms begin abruptly, resemblesymptoms of arthritis and leukemia

Marked leukocytosis and elevated Sed rate

Early x-ray may appear normal

CT, Bone scan , MRI

Bone culture obtained from biopsy

or aspirate

Osteomyelitistherapeutic management


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therapeutic management

May have sub-acute presentation with walled offabscess rather than spreading infection

Prompt, vigorous IV ABT for extended period (3-4weeks or up to several months)

Monitor hematologic, renal, hepatic

responses to treatment

OsteomyelitisNursing Considerations


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Nursing Considerations

Complete bed rest and immobility of limb Casting at time necessary

Pain management: position and medicate Surgery may be necessary Long term IV access (for ABT administration) Nutritional considerations Child may have vomiting and poor appetite As infection controlled appetite returns

Long term hospitalization/ Physical Therapy to

ensure restoration of optimum functioning Psychosocial needs Diversional and constructive activities

Juvenile Idiopathic Arthritis(juvenile rheumatoid arthritis)


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(juvenile rheumatoid arthritis)

Chronic Autoimmune inflammatory disease causinginflammation of joints and other tissue

Starts before age 16 with peak onset between ages 1 and 3 years

Twice as many girls are affected

13.9 per 100,000 children per year in caucasian children 113 per 100,000 children overall

Unknown cause

Immunogenic susceptibility

Environmental or external trigger such as a virus

Pathophysiology of JIA


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Pathophysiology of JIA

Chronic inflammation of synovium with joint effusioneventual erosion

destruction

fibrosis of the articular cartilageIf inflammatory process continues

adhesions between joint surfaces

ankylosis of joints


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JIA


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Clinical Manifestations


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Variable and unpredictable Not life threatening but can

cause significant disability 70% of cases eventually

becomes inactive However child may have severe

or minimal joint damage bytime disease process abates

30% have progressive diseaseinto adulthood Significant joint deformity and

functional disability Medical evaluations PT

Possible joint replacements Chronic or acute uveitis may

occur

Diagnosis


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g

Diagnosis of exclusion Clinical criteria at age of onset before 16 years

Swelling and pain

Lab tests may or may not provide evidence

Sedimentation rate may or may not be elevated

Leukocytosis usually present with acute exacerbationAntinuclear antibodies common but not specific

Radiology studies

Show soft tissue swelling and joint space widening with increasedsynovial fluid

Uveitis Inflammation of anterior chamber of the eye

Can be sight threatening



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p g

Control pain NSAIDS

Preserve Joint ROM and function

PT: active range of motion

Minimize effects of inflammation/ Joint deformity NSAIDs/PT/OT

Promote normal growth and development

Pool therapy Nighttime splinting reduce flexion deformity

Medications


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NSAIDS

Naproxen, ibuprofen and tolmetin

Take with food

Hydrate

bruising

Methotrexate

Second line tx for children who have failed NSAIDs alone

Used in combination with NSAID

CBC and LFTs

Corticosteroids

Potent immunosuppressives

Incapacitating arthritis/ uveitis/life threatening complications

Etanercept (TNFI) (Enbrel)

Tumor necrosis factor receptor blocker SAARDS

Slow acting anti rheumatic drugs

Work in combination with NSAIDS

Sulfasalazine

Hydroxychloraquine, gold, D-penicillamine.



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g g

Assessment of all aspects of the child General health

Status of involved joints

Emotional response

Support of the parents Parental concerns of prognosis

Financial concerns

Spouse and sibling relationships

Job and schedule conflicts

Referral to social worker, counselors and support groups



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g g

Relieve Pain Provide as much relief as possible Medications

Opioids avoided Non pharmacologic

Behavior therapy

Relaxation techniques Promote general health Well balanced diet with sufficient caloric intake Sufficient rest Communication between family/PCP/rheumatology team is critical

Normalcy Encourage independence!!! Attending school important

Communicate with school and school nurse



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g g

Educate the patient and family on Medications Therapeutic levels r/t schedules Signs and symptoms of toxicity

splints and appliances Proper placement and reason for device

available resources

Benefits of heat application Moist heat Bathtub Electric blankets

Exercise Pools : range of motion

Prevent isolation and foster independence Encourage child to perform ADLs independently Encourage family to pursue normal activities

Osteosarcoma


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Most common bonecancer in children

Peak incidence between10 and 25 years of age

Primary tumor sites inmetaphysis of long bones(most likely in lowerextremities)

>50% femur

Humerus, tibia pelvis, jawand phalanges



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Surgery and chemotherapy Biopsy followed by limb salvage or amputation



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Education for family and child Salvage vs amputation

Prosthesis fitting promotes early functioning

Chemotherapy and side effects

Anger and depression are normal and expected

Honesty and straightforward answers Be in the room when physician explains

Everyone grieves and learns differently

Phantom limb pain Sensations such as tingling itching and pain in amputated limb

Elavil



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Promote normalcy and resumption of preamputation activities

Pick clothing that does not draw attention to amputation

Body image critical to adolescents

Ewing Sarcoma


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Primitive neuroectodermal tumor Second most common malignant bone tumor in

childhood

Under age 30 majority being between ages 4 and 25

Originates in the shaft of long and trunk bones

Femur tibia fibula humerus ulna vertebrae scapula ribs pelvicbone and skull


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Intensive irradiation of the bone combined withchemotherapy

Amputation last resort



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Less traumatic for family related to likelihood that noamputation will be necessary Need education r/t Diagnostic testing (BMT, biopsy) Radiation and chemotherapy

Intense radiotherapy causes skin reaction Dry or moist desquamation then hyperpigmentation

Increased sensitivity of area Child should wear loose fitted clothing over the area to minimize

additional skin irritation

Chemotherapy

Hair loss, n/v, peripheral neuropathy and possible cardiotoxicity

Encourage resumption of normal lifestyle and activities


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Systemic Lupus Erythematosus(SLE)


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Autoimmune disease of connective tissues and bloodvessels

Chronic

Multisystem Result of genetics as well as a trigger

Exposure to ultraviolet light

Estrogen/pregnancy

Infections

drugs

Multisystem


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SLE


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Clinical Manifestations

Malar rash

Discoid rash

Photosensitivity

Oro nasal ulcers

Arthritis

Serositis

Renal disorder

Neurological disorders

Hematologic disorders



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Balance medications needed to avoid exacerbation andcomplications

While preventing or minimizing treatment associatedmorbidity Corticosteroids

Antimalarial: rash and arthritis

NSAIDS

Immunosuppressive: cyclophosphamide

Nutrition

Sleep Exercise

Limited exposure to sun & UV light



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Goal: assist family to positively adjust to disease & therapy Recognize exacerbation Recognize complications of medications Discuss with health care provider

Body Image Problems Rash/hair loss/ steroid therapy

Support Groups Lupus Foundation of America Arthritis Foundation

Teaching Regular medical supervision Seek attention QUICKLY during illness or prior to elective surgical procedures

Avoid sun and AVB exposure Wear sunscreen and sun resistant clothing Limiting outdoor activities


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Documents

Musculoskeletal Chapter 31