Cryptorchidism/ DDH/ Fractures

Care for child in Pavlik harness Assess

(can't be removed or adjusted w/o order, sponge baths only, keep T-shirt on and do skin care to prevent skin breakdown) • Adjust feeding for child in hip spica cast • Cast care Assessment of CMS (circulation/motion/sensation) Prevent complications of immobility

Fractures in infants

, bones don't easily break, so think abuse

Fractures in Children

-Bone fractures occur when the resistance of a bone against the stress being exerted yields to the stress force.

Cryptorchidism

-failure of one or both testes to descend through the inguinal canal into the scrotum.

Tx- begin immediately for best results. Longer delay = more serious deformity.

.

• Mechanical-

Breech presentation Multiple fetuses Oligohydramnios Large infant size Use of swaddling/cradle boards

Clinical manifestations-

Dx should be made in newborn period b/c tx started before age 2 mos yields best success

Dx- •

Imp to differentiate b/t retractile testes and true cryptorchidism • Dx of retractile testes not made at single examination. • Ultrasound, CT or MRI to differentiate b/t anorchia and cryptorchidism

Etiology- Unknown. Some risk factors increase the incidence of DDH: • Physiologic-

Intrauterine positioning Maternal hormone (estrogen) secretion

Incidence-

More common among cultures/societies that tightly swaddle their infants [Native Americans; Laplanders].

Joint laxity as demonstrated by

Ortolani or Barlow maneuver (until age 2-3 mos)

• Genetic-

Runs in families

Patho-

The femoral head is in a very weak joint remains in contact with the acetabulum until stress (e.g., walking) moves it away, thus the necessity for early detection and treatment.

Tx- Children's bones have an amazing capacity for healing.

The younger the child the more true this fact becomes b/c of thickened periosteum and generous blood supply.

Developmental Dysplasia of the Hip (DDH)

a spectrum of disorders that involve abnormal development of the hip. May begin during fetal life, infancy or childhood . The spectrum ranges from preluxation to full dislocation of the femoral head within the acetabulum.

Wolff's Law:

bone will grow in the direction in which stress is placed on it; e.g., hip spica cast for DDH.

Trendelenburg sign:

if, when standing on one leg, the pelvis drops on the side opposite to the stance leg. o The weakness is present on the side of the stance leg. o The body is not able to maintain the center of gravity on the side of the stance leg.

Retractile testes

may be palpated anywhere along the natural course of the testis, although most are inguinal.

• Skeletal traction

o 90-90 traction  often used for fractured femur  involves casted lower leg and pin in distal fragment of femur  Provides good immobilization of fracture site

contd

o Abx ointment o assess for s/s infection or bleeding at pin site • Prevent skin breakdown • Pain meds • Muscle relaxants • Overhead trapeze (facilitates hygiene and positioning) • Diversionary activities • Monitor for s/s comps of immobility • Never release skeletal traction

Examples of types of traction • Skin

o Bucks extension traction o Russell traction

• Monitor CMS

o Circulation: color, cap refill, perfusion, local pulses o Motion: can child wiggle toes/fingers depending on where child is casted o Sensation: does child have feeling in that area distal to the cast. Ask about numbness • Circle, date and time any drainage noted on cast. Monitor for progression of drainage

• For itching:

o Cool fan o Ice pack o No powder or lotion down cast

exam

o Examiner strokes or pinches medial thigh o Stimulus usually causes cremasteric muscle contraction o Observe for rise of the testicle on same side (normal) o activates w/ exposure to cool temp o active during infancy o peaks ~ 4-5 yrs/age

• Call ortho MD for:

o Intractable pain o Numbness o Cast breaks o Extremity red, swollen, blue, pale, cold o Child febrile o Cast underneath smells purulent

• Children -

o MVCs [most freq cause all ages] o falls from heights o fx of forearm when extending arm to break a fall o clavicle fx usu in children < 10 ur/age o pedestrian vs. auto [usu femoral neck fx] age 4-7 yrs most common o bike, skateboard, sports injuries -school age/teens

serious complication

o Monitor for compartment syndrome- pain that is uncontrolled or gets worse! Edema/swelling has nowhere to go • Pain that doesn't respond to analgesics may indicate compartment syndrome. Always notify ortho MD • Check rough edges of cast. Cut off and petal edges of cast

• Cryptorchidism [true undescended testes] surgery. when done?

o Mostly: Surgery preferred tx in US  done b/t 6-24 mos/age  if testes do not spontaneously descend, surgery must be done before age 2 years (since higher rate of cancer, if higher than 2 and not had surgery)  recently, procedure done closer to age 6 mos based on

Bones going to grow in placement aligned in, Goals:

o Re-establish alignment of bone [reduction] o retain alignment [immobilization] o restore function o prevent further injury

normal? puberty? surgery?

o Testicles will descend at puberty o This condition is considered a variant of normal o Once a testicle has been discovered in the scrotum, it is generally considered descended even if it is temporarily pulled back (retracted) on a later examination o Surgical correction is not needed; no tx required

• Retractile testes can be manipulated into the scrotum, where they remain without tension.

o This occurs because of the strength of the muscle reflex (cremasteric reflex) that retracts the testicles and the small size of the testicles before puberty

• Three major types

o Upper extremity o Lower extremity o Spica [immobilizes hip and knee

ask parents difference b/w retractile/undec.

o ask parents if they have ever seen both testes in scrotum o retractile testes can be "milked" into scrotum; truly undescended testes cannot

Etiology- • Infancy-

o birth trauma [clavicle] o motor vehicle injury o abuse

1] Closed reduction 2) Casting

o can be done in ER w/ conscious sedation 2] Casting • Indications o completeness of fx o type of bone involved o joints above and below fx have to be immobilized

o categorized o classification

o categorized according to the involvement of the physis, metaphysis, and epiphysis (how far it goes through bone) o classification of the injuries is important, because it affects patient treatment and provides clues to possible long-term complications

 Nerve Compression Syndromes

o circulatory impairment o nerve compression o check CMS to assess for these

• Materials

o gauze impregnated w/ plaster o synthetic lighter weight materials o plaster casts usu used for fx that need to be held more tightly

weakest point of long bones>

o growth plate frequent site of fx

• Nurse often assists w/ cast application

o hold extremity in alignment o age-appropriate psychosocial support o clean wound any areas first

• may have 5 Ps in affected extremity d/t vascular injury at site:

o pain o pallor o pulselessness o parasthesia o paralysis

Tx- • Retractile testes

o parental reassurance o retractile testes that can be successfully manipulated into scrotum require no tx o by 1 yr/age, testes will spontaneously descend in 75% of cases [pre-and full-term infants

• 3 main types: o manual [done in ER; temporary]

o skin  pull applied directly to skin, indirectly to bone  pulling mechanism attached to skin with adhesive or elastic bandage  contraindicated w break in skin integrity

Trendelenburg gait (in walking child):

pelvis tilts down on unaffected side when bearing weight on affected hip causing a waddling gait and toe-walking

Predispose

prematurity, low birth weight, small size for gestational age, twinning, and maternal exposure to estrogen during the first trimester. Also runs in families. Anorchism is associated with chromosomal anomalies.

The advantage of Russell traction is

that some movement in bed is permissible. The patient can turn slightly toward the side in traction for back care, bedpan placement, or linen change.  pressure in popliteal area can cause foot drop

Patho-in children,

the bones are more easily fractured, even w/ minor injury as compared to adults

Incidence-

the most common genital problem encountered in pediatrics. • The prevalence of cryptorchidism is 45% in premature male neonates

how to tell

• Although not truly undescended, these testes may be suprascrotal secondary to an active cremasteric reflex: (if can get them to come back down are retractile, not undescended)

palpable nonpalpable

• Approximately 80% of undescended testes are palpable and 20% are nonpalpable. • Nonpalpable testes may be intra-abdominal or absent. • Palpable testes may be undescended, ectopic, or retractile.

all are factors during the physical examination

• Body habitus, testicular position, and compliance of the child

Associated anomalies and conditions may include the following:

• Cerebral palsy • Chromosomal anomalies • Wilms tumor • Abdominal wall defects (eg, gastroschisis, omphalocele, prune belly syndrome) • Hypospadias

contd

• Complicated-bone fx causes injury to another organ • Comminuted- bone is broken into more than two pieces or crushed (shatter) • Salter-Harris (fracture through growth plate of bone) o fractures through a growth plate; therefore, they are unique to pediatric patients

Older child:

• Disorder very difficult to correct if child > 4 yrs/age d/t severe shortening and contracture of muscles • Surgery w/ internal fixation • Casting (usually hip spica) • ROM exercises pre-op

Nursing care:

• Early detection in newborn period • Assessment of hips in early infancy-Ortolani maneuver in nursery • Assessment of gluteal folds; gait in older children • note wide perineum

• Nursing Care of Child in Cast:

• Ensure that cast dries without indentations • Handle cast w/ palms of hands, not fingertips • Leave cast uncovered and open to air to dry. No plastic sheeting-prevents drying • Keep cast dry after initial casting (cant get wet!)

Nursing Care of child in traction

• Ensure weights hanging freely; not resting on bed or floor • Ropes must be inside pulley • Check CMS • Make sure child and traction are in alignment • Pin care (skeletal traction) o 1/2 str peroxide

 Compartment Syndrome

• Fascia compressing muscles and vessels • Suspect when you assess diminished CMS and pain out of proportion to injury or severe pain that persists even after you give pain meds

Types-

• Greenstick- when the bone cracks on one side only, not all the way through • Complete- bone has broken into two pieces • Incomplete-fracture fragments remain attached • Transverse-crosswise at right angles to long axis of the bone (directly across bone) • Oblique-slanting but straight, b/t a horizontal and perpendicular direction • Spiral-slanting and circular, twisting around the bone shaft. Often assoc w/ abuse • Simple-fracture does not break through skin; same as closed fracture • Compound-bone is sticking through the skin; same as open fx

6-18 months:

• If not discovered until now, the discovery occurred when the child began pulling his/herself to stand/walk • Limb shortening apparent • Traction used for ~ 3 weeks, then: • Closed reduction under anesthesia • If dislocation not reducible, hip spica cast for 2-4 months until hip stable • Then flexion-abduction brace applied

Complications-

• If one or both testicles do not descend, a man may be infertile later in life • Males with undescended testis are 40 times as likely to develop testicular cancer as males without undescended testis

Physical exam- position

• Inspection first • The patient should be placed in the frog-leg position for examination-this diminishes cremasteric reflex (normal for testes to go back up but should not come back down on own) • assess whether the testes are palpable upon physical examination • it is occasionally difficult to accurately determine the exact location of the testis

contd

• Joint laxity in newborn period • Asymmetry of gluteal and thigh folds (extra folds on affected side) • Shortening of limb on affected side (Allis or Galleazi Sign) • Older infant and child: affected leg is shorter • Limited hip abduction • Broadening of perineum (w/ bilateral dislocation) • Weight bearing precipitates • Limp or toe-walking

position elevate

• Maintain body and cast alignment • Elevate extremity to decrease swelling. Continue to monitor CMS locally. May need bi-valving (allows for exantion of cast if swelling, cut sides of cast for a little) • Position to avoid skin breakdown • Assess and medicate for pain

Dx- • Not always dx at birth • Need assessment at well-child visits thru 1st YOL

• Ortolani's and Barlow maneuver • Inspect thigh/gluteal folds • If not diagnosed in infancy-X-ray of hip. X-ray not useful in newborn until 3-6 months • Ultrasound-high rate of false positives • CT scan-usu used after closed reduction or casting to assess posn of femoral head

Nursing Care-

• Pain medication is used as needed • Keep the surgical area dry for 1-2 days o keep op site clean of urine and stool to prevent infection o observe wound for bleeding or s/s infection • Absorbable sutures are used during closure; therefore, removal is not necessary

Birth - 6 months: harness- does what

• Pavlik harness o for 3-5 months. o 95% successful. o Causes hip dislocation to reduce itself. o needs to be readjusted q 1-2 mos to accommodate infant's growth

importance

• Teach importance of TSE (testicular self-exam) at age > 15 yrs

Teach home cast care to parents:

• Teach parents about CMS checks • Skin care • Activity restrictions • Follow-up care

position if orchiopexy

• The patient should avoid using straddle toys or participating in physical education for 2-3 weeks • If orchiopexy delayed until after age 10-11 yrs, these boys need close follow up for testicular Ca; they are 6 times more likely to develop it

traction used

• Traction used w/ adduction contracture • Double/triple diapering no longer used • Tx lasts usually < 1 year • If ineffective, hip spica cast, changed prn to accommodate infant's growth

Dx-

• be sure to get good hx; often difficult w/ childhood injuries; necess to r/o abuse • Xray • may not be as reliable in very young children d/t bones that are not fully ossified

Dx in infants

• bone trauma in infants d/t twisting will cause periosteal bleeding; no radiographic evidence until 3-6 weeks after (b/c bones aren't ossified) • fx various stages of healing = abuse

 Epiphyseal [Growth Plate] Damage

• caused by fx of diaphysis

 surgery also done to:

• decrease chance of torsion • close processus vaginalis • cosmetic [having an empty scrotum]  a same day surgery procedure surgery done to prevent damage to testicle by increased body heat • infertility • increased chance of malignancy

Categories:

• fully undescended testes [cryptorchidism] • retractile testes • fully absent testes [anorchism]

Clinical manifestations- parents may report

• scrotum appears lopsided or empty • with retractile testis, parents may report intermittently being able to see testicle, then it cannot be seen or palpated • parents often will say w/ retractile testis, the testicle can be observed in scrotum when child is being bathed in warm water • parents may notice and tell HCP

Clinical Manifestations- of any kind of break

• swelling • pain/tenderness • diminished use; refuses to walk • crepitus [grating sensation at site]

 procedure: orchiopexy

• testes are brought down to scrotum and secured • usually done laparoscopically

3] Traction

• used when bone fragments can't be reduced w/ simple casting to achieve and maintain bone alignment • used to immobilize fx site until realignment achieved and sufficient healing has taken place to permit casting or splinting

o skeletal

 pull applied directly to bone  pull achieved w pin, wire or tongs inserted through diameter of bone

Observe for fracture complications: o Circulatory Impairment

 trauma of injury or immobilizing device can impair circulation  important to assess CMS • check local pulses