Pedi Quiz 3: Musculoskeletal Disorders and Fractures

Clubfoot

A complex deformity of one or both feet Occurs from intrauterine crowding (positional), cerebral palsy and spina bifida Diagnosed via prenatal US Perform neurovascular checks (and skin integrity checks)

More on Pavlik harness

Maintain harness for 3 mos, check straps for skin integrity every 1-2 hours, perform neurovascular checks *do not adjust straps*, teach skin care, use an undershirt, assess and massage skin under straps, avoid lotions under straps, place diaper under straps. Put on loose fitting clothing over straps

Why do you want to be sure wrench is attached?

So you can perform CPR if needed!!!!

DDH Nursing Care

Start treatment as soon as diagnosed-Hips are checked upon newborn assessment. Newborn-6mos= Pavlik harness

Clubfoot risk factors

Usually presence of other syndromes

Crepitus

grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone.

Legg Calve Perthes disease

Aseptic necrosis of the femoral head (can be unilateral of bilateral) Risk factors-trauma or inflammation to femoral head Affects children 2-12 but most often 4-8 More common in boys X-ray of hip and pelvis to diagnose Administer NSAIDs. Non weight bearing while resting May need abduction brace, cast, harness sling or traction depending on the severity

Fracture overview

Bones heal faster in kids bc thicker periosteum and good blood supply Growth plate (epiphyseal) injuries are biggest concern in kids and may result in altered growth X=rays must be done to diagnose X-rays sometimes show previous breaks in various stages of healing or in infants (who should not have broken bones easily) may be concern for physical abuse. Also, fractures that happen unexpectedly may be concern for Osteogenesis Imperfecta The infant and young child's bones are more flexible and porous...they have lower mineral content than the adult...so, allow for greater shock absorbtion, so the bones will often bend than break! The strong periosteum of the childs bones allows for more absorption, so sometimes it will buckle or bend instead of breaking. Growth plate- the ends of the bones in young children are composed of the epiphysis, the end of a long bone, and the physis- all in combo known as the growth plate. The epiphyseal region is pretty vulnerable and somewhat weak. Epiphyseal injury may result in early, incomplete, or partial closure of the growth plate- leading to deformity or shortening of the bone. Epiphyseal growth continues till adolescence, and then growth plates fuse and long bone growth is complete.

DDH adduction fracture

Bryant traction- skin traction, hips flexed at 90 degrees with buttocks raised off of the bed. Hip spica cast-change as grows, assess skin especially in diaper area, perform frequent neurovascular checks, perform ROM w/ unaffected extremities, assess pain level, Reinforce teaching about positioning-on pillows, keep cast elevated and dry, check color and CSM (circulation, sensory and movement) of toes, waterproof barrier around genitals

Nursing care fractures

Emergency care if more of a trauma situation- check airway, VS, other organ issue Assess neurovascular status of extremity affected- Is there any numbness or tingling, loss of sensation Check CSM Check to see if warm to touch-should not be cool! Stabilize injured area- wrap with ace wrap ELEVATE Apply ice packs Administer analgesics-preferably NSAID b/c of anti-inflammatory effects

Nursing care continued

Move child in halo traction as a unit to prevent loosening of pins and increase in pain Use overhead trapeze as ordered by MD to help child move in bed Provide ROM exercises to non-immobilized extremities Encourage TCDB, blow bubbles, use IS Change positions but keep traction in mind at all times Provide distraction and age-appropriate activities (music/art therapy, pictures, drawings from friends)

NCLEX q 1

Nursing care of a child with a fractured extremity in whom there is compartment syndrome includes which of the following? Select all that apply. a.) assess pain b.) assess pulses c.)elevate extremity above level of heart d.)monitor cap refill e.) provide pain med as needed ABDE

Fracture risk factors

Obesity Poor nutrition Developmental-the ways kids play put them at risk for injury , sports, climb trees, trampolines etc....

Nursing assessment

PAIN-upon bearing weight, ROM exercises Swelling Bruising-echymosis Tender to touch Visible deformity Edema Crepitus Warmth or redness

**Types of fractures

Plastic deformation-the bone bends no more than 45 degrees Buckle-common, compression of bone results in a bulge or raised area Greenstick- incomplete fracture Transverse- break is straight across bone Oblique- break is diagonal across the bone Spiral- break spirals around the bone Growth plate- injury to end of the long bones/ epiphyseal plate Stress- very tiny "crack" Complete-fragments separated Incomplete-fragments still attached Closed or simple-no break in skin Open or compound- open wound and bone potrudes-OUCH! Complicated-injury to other organs

DDH Diagnostic Procedure

Ultrasound-at 2 weeks old X-ray dx in infants > 4 months

Skeletal traction

Uses a continuous pulling force that is applied directly to the skeletal structure/bone. Used when more pulling force is needed than skin traction can withstand. A pin or rod is inserted through or into bone...force is applied through the use of weights attached by rope (nurses do not ever remove weights!) Halo traction (cervical)=uses a halo type bar that encircles the head. Screws are inserted into the outer skull...the halo is attached to either bed traction or rods that are secured to a vest worn by client.

Skin traction

Uses pulling force that is applied by weights. Using tape and straps applied to the skin along with boots and/or cuffs- weights are attached by a rope to the extremity. (Buck, Russel, Bryant traction)

NCLEX q 2

What is the best explanation by the nurse to parents of a toddler who asks what a greenstick fracture is? a.) it is a fx located in the growth plate b.) because a children's bone is not fully developed any fracture in a young child is called a greenstick c.)it is fracture in which complete break occur in bone and small pieces break off. d.)It is a fracture that does not go all the way through the bone D

NCLEX question 1

A 12 year-old is diagnosed with scoliosis and has to wear a brace is to wear a brace for 23 hours a day. What is the most likely reason the child will not wear it for that long? A.) pain from the brace B.) difficulty in putting the brace on C.) self-consciousness about appearance D.) Not understanding what the brace is for Answer is C

Important points on therapeutic procedures

*Casting- long-leg, short-leg, bilateral long-leg, long-arm, short-arm, full spica and single spica *Assess skin and area around break prior to casting-clean and dry, pad bony prominences *Elevate cast first 24 hours, apply ice, reposition every 2 hours after application to allow air to dry cast *DO NOT USE HAIR DRYER to speed up drying *Assess for warmth on cast surface (infxn) *Monitor for drainage on cast-outline with marker *Monitor edges of cast and contact w/skin *Use moleskin over any rough areas of cast *Cover areas of cast with plastic to prevent soiling *Assist with crutch training Don't want to speed drying up as the dry air circulating around and under the cast will prevent pressure from changing the shape of the cast. Keep affected area with sling or elevated when sitting (support)

NCLEX question 2

2. A 9 year-old is in a spica cast and complains of pain 1 hour after receiving intravenous opioid analgesia. What should the nurse do first? A.) give more pain meds B.) Perform neuromuscular assessment C.) call the surgeon for orders D.) tell the child to wait another hour for the meds to work Answer is B

Scoliosis

COMPLEX DEFORMITY OF THE SPINE A lateral curvature of spine, rib asymmetry At least 10 degrees to diagnose-monitor curves <25 degrees Idiopathic-common cause Risk factors-genetics Assess for asymmetry of the scapula, ribs, flank, shoulder and hips One leg looks shorter than the other Often hits at puberty, start looking around 5th grade

More on nursing care of fractures

CSM-circulation, sensory and movement Some other things to think of nursing care... Remove jewelry or objects that can cause constriction Keep client warm Assess pain frequently Promote ROM of fingers/toes/unaffected extremities

Overview

Clubfoot Legg-calve-Perthes Developmental dysplasia of the hip Osteogenesis Imperfecta Scoliosis

Surgical needs

Depending on the type of fracture surgery may be required. Closed (no incision) or open (w/incision) reduction and with or without pins If open reduction monitor site for ssx infxn Ensure proper cast care and pin care Watch for complications of compartment syndrome which is compression of muscle, blood vessels and nerves inside a confined space. Watch for sx of pain, numbness, pulselessness distal to the fracture, inability to move digits, warm digits, pallor, shiny skin

Developmental Dysplasia of Hip (DDH)

Disorders that result in the abnormal development of the hip structures that can affect infants and children Different degrees: Acetabular dysplasia-delay in development, Subluxation-incomplete dislocation Dislocation Risk factors- birth/intrauterine position(breech), joint stability, delivery type Assessment-INFANT- asymmetry of the gluteal & thigh folds, limited hip abduction, shortening of the femur, +ortolani test, positive barlow test CHILD- one leg shorter, walking on toes, walk with limp, +Trendelenburg sign-pelvis tilts

Osteogenesis Imperfecta

Heterogenous autosomal dominant disorder of the bones= fractures and deformities of bones. Often mistaken for child abuse. Bones break very easily and often. Broken bones put them at risk for osteomyelitis (infxn) Classic signs- multiple bone fractures, blue sclera, early hearing loss, bowed legs and arms, kyphosis and scoliosis-if severe Bone biopsy to diagnose Treatment- supportive MEDS- Aredia+Pamidronate increase bone density Assist with braces and splints Complication- disuse osteoporosis b/c of time in casts and limited activity

Osteomyelitis

Infection w/in the bone secondary to a bacterial infection from an outside source such as an open fracture Child appears ill, irritable, fever, edema, pain, not using affected extremity, site of infxn warm+tender Obtain skin/blood/bone culture is necessary Must receive IV abx-usually long-term Administer pain med PRN Avoid weight bearing until ok by PT or provider

Findings Legg Calve Perthes disease

Intermittent painless limp, hip stiffness, limited ROM, hip, thigh, knee pain, shortening of the affected leg, muscle wasting.

Nursing care while in traction

Maintain body alignment Pharm and nonpharm treatment to prevent muscle spasms Assess and monitor neuro status, monitor skin integrity especially around pins-assess for redness, drainage, odor-PROVIDE PIN CARE Ensure that all hardware is tight and that the bed is in correct position Assess and maintain weights so that they *hang freely-do not lift or remove weights unless prescribed. Assure wrench to release rods is attached to the vest when using halo traction

Slipped Capital Femoral Epiphysis

SCFE ("skiffy)-is when the top of the thigh bone slips out of place-top or cap of the ball slips off the femoral head through the growth plate Almost all children with SCFE need surgery One foot might point outward or one leg may be slightly longer Children may be stiff and possibly develop arthritis Preadolescence- overweight, family history, endocrine disorders Limp, hip stiffness, mild pain in hips, groin and knees, difficulty walking XRAY & MRI to diagnose ALMOST IMMEDIATELY-SURGERY IS NEEDED! When the femoral head dislocates from the neck and shaft of the femur at the level of the epiphyseal plate. The epiphysis slips downward and backward. More often in obese males, 11-16 years old. More often the left hip. Exact cause unkown- may be due to the teenage growth spurt. Immediate surgery reduces chance of deformity.

Scoliosis Screening

Screen in school starting in 5th grade to see where child's spine is at before and after growth spurts. Have the child bend over at the waist with arms hanging loose and look for asymmetry of ribs and flank. Look from all angles. Use scoliometer if a curvature or sway XRAY- may be needed if school nurse or doctor refers child to orthopedic doctor.

Neurovascular assessment

Sensation, skin temp, skin color, cap refill (should be within 3 sec) Pulses (should be palpable and strong) Movement- should be able to move joints distal to the injury (fingers or toes)

Clubfoot treatment

Series of casting starting after birth until max correction, think about skin break down and compartment syndrome with this Weekly manipulation of the foot to stretch the muscles with subsequent placement of new cast. Surgical intervention-osteotomy, fusion, tendon lengthening

Types of traction

Skin(Bucks, Russell, Bryant) Skeletal traction- a pin or rod inserted into bone, balanced suspension-suspends leg in flexed position Halo-attached to skull via pins

Traction

Traction, countertraction, and friction are used to align, immobilize and reduce a muscle spasm associated w/ fractures. A forward pulling force and a backward force, must use weights-add or remove to control the degree of force applied to maintain traction. The type depends on age, fracture, and nature of injury. Traction involves the use of pulling force to reduce a fracture, maintain alignment, and provide muscle rest...

Scoliosis Treatment

Treatment all depends on the severity, degree, location and type of curve Bracing-custom made and slows the progression of curve, compliance is a major issue w/ kids Assist with fitting of brace and reinforce skin assessment Inform child/parent about how often to wear brace-some only wear at night while other wear daily. Surgery may be needed- spinal fusion with rod placement. Tough recovery, initially in ICU Post-op-pain control (need lots of pain meds, PCA), PT very important!