Pediatric Orthopedics

In the Risser Scale, we would be more concerned with a child of what score?

0-1, because they have a greater potential for curve progression

What might a sprain be accompanied by?

Contusion, damage to the nerves, blood vessels, muscles, and tendons.

What is the biggest concern regarding a dislocated hip?

Cutting off blood supply to the femur may lead to necrosis of the bone, it's important to be relocated within an hour.

What is a contusion?

Damage to soft tissue, subcutaneous structure, and muscle.

What should you watch out for with dislocation of a large joint?

Damage to the nerves or vasculature; important to get to the hospital right away, do NOT attempt to put back in place.

What is the most common type of splint, for post-casting?

Denis Browne Splint

What question is appropriate to ask if you suspect a sprain of the ACL?

Did you hear a "pop"?

What is exogenous osteomyelitis?

Direct inoculation from outside bone

What is dislocation?

Displacement of the bones that form a joint, most often resulting from trauma that causes adjoining bones to no longer align with each other.

Which type of curve progresses more: single or double?

Double curves

What is it most important to have adequate calcium intake?

During puberty, for bone formation, it is when the maximum amount of bone is laid down.

How does the Risser Scale evaluate growth potential?

Evaluates skeletal maturity, via x-ray to determine the degree of bony fusion of the apophysis/hip bone

What is the approximate time frame for casting?

Every few days for the first 1-2 weeks, then every 1-2 weeks until max correction achieved, total between 8-12 weeks.

What additional injury might you be concerned with following a fracture?

Fat embolism, from the bone marrow of the fractured/crushed bone, particularly long bones.

In which gender do curves progress more?

Females

What is the most common dislocation in children?

Fingers; may also a include small fracture at the site.

What might be the cause of exogenous osteomyelitis?

Fracture, open-reduction surgery, infection introduced into the bone, possibly even from a mosquito bite.

What makes up the "compartment"?

Group of muscles, surrounded by a tough, inelastic/not stretchy fascia connective tissue causing increased pressure in an enclosed space.

What are other organisms that may cause osteomyelitis?

Haemophilus influenza, streptococcus pneumonia, salmonella -- Don't see from influenza as much now due to vaccination rates.

What is an open reduction?

Hardware placed, or an internally-placed device.

Why wouldn't you use heat on a sport injury?

Heat helps with stretching, it keeps the ligaments stretched out and scarring can develop.

What are the stages of bone healing?

Hematoma, within first 24hr, cellular proliferation, callous formation, ossification, consolidation and remodeling.

What does long term IV antibiotics for osteomyelitis indicate?

High doses of several types of antibiotics

What is an appropriate elevation for the injury?

Higher than the heart.

What does ice do for a sports injury?

Ice inhibits the swelling process.

For curve progression, the __ curve has more chance of curve progression.

Larger

Which type of curve progresses more: larger curves (30-40*) or smaller curves (20-30*)?

Larger curves: 30-40*

In infancy, fractures are a ___ finding, and might indicate ___.

Rare, abuse; especially spiral fractures may be indicative of twisting.

What does R.I.C.E. stand for?

Rest - Ice - Compression - Elevation

90% of curves are to which direction?

Right thoracic curves

What is the scoliosis screening recommendation for the American Academy of Pediatrics?

Routine health visits at ages 10, 12, 14 & 16 for both girls & boys.

What organisms causing osteomyelitis are most common in patients with sickle cell disease?

Salmonella and staph aureus - Staph is more common

What system of classifications is used to characterize types of fractures?

Salter-Harris; Type I - V

What is an early treatment for clubfoot, right after birth?

Serial casting to gradually stretch the skin and tight structures on the medial side of the foot, which is begun immediately or shortly after birth.

What is a sprain?

Severe trauma to a joint causing a ligament to be partially or completely torn.

What is the level of pain with compartment syndrome?

Severe, unrelieved by analgesics, and more intense than what would be expected from a fracture.

What factors dictate the outcomes of clubfoot treatment?

Severity of deformity, age of child at first intervention, compliance with treatment, and development of bones, muscles, and nerves.

Why might a child be susceptible to a fracture?

They are the result of increased mobility, and/or immature motor and cognitive skills -- uncoordinated.

In what adolescents might stress fractures be more common?

Those who limit the intake of calories and calcium to remain lean for sports.

Where is compartment syndrome most common?

Tibia/fibula area, and the radius/ulnar area; therefore fractures in these areas are most concerning.

What kind of injuries occur most frequently in pediatrics?

Traumatic musculoskeletal injuries.

How many hours per day might a brace need to be worn?

18-23 hours/day

If the deformity has not been corrected by what age would a surgical intervention be necessary?

3-12 months

About how long does it take for the vertebrae to fuse substantially, and about how long until it's complete?

3-months; 1-2 years

In what percentage of cases does TEV occur?

95%

What is a closed/simple reduction?

Aligned and casted; splint and ACE-bandage.

What is syndromic/tetralogic clubfoot?

Associated with other congenital abnormalities, it is considered the more severe form. Can stretch and cast, but may need surgery or hardware.

Where does osteomyelitis occur?

At the metaphyseal (primary area) region of long bones.

What other diagnostic imaging might be good to run if osteomyelitis is suspected

CT Scan & MRI, specifically to rule out a tumor b/c most common site of osteosarcomas are the osteomyelitis

What is a good method to ensure that the extremity is getting adequate perfusion?

Capillary refill, temperature, pain, color, swelling, odor -- if wound within cast to indicate infection

What should the initial nursing assessment include?

Cause of the fracture, and examination of the fracture site

Which type of scoliosis is an anomalous vertebral development?

Congenital

What are the types of scoliosis?

Congenital, infantile, juvenile, neuromuscular, adolescent idiopathic

At what stage is weight bearing activity okay?

Consolidation and remodeling of the bone.

What else might you assess for when managing a fat embolism?

Dyspnea, restlessness, fever over 103, petechia, rash, tachycardia, tachypnea, hypoxia.

What organisms are the most common causes of osteomyelitis in neonates specifically?

E. coli, and B. strep

For optimum correction, it is best to evaluate and treat for club foot ___.

Early, may even be diagnosed in utero.

In TEV, talipes equinovarus, how can the ankle be described?

Equinus, toes are pointing downward

What are the two types of osteomyelitis?

Exogenous, hematogenous

How does compartment syndrome result?

From swelling caused by trauma and immobilizing device.

What are the determinants of curve progression?

Gender, future growth potential, and curve magnitude at time of diagnosis

What is the scoliosis screening recommendation for the American Academy of Orthopedics?

Girls: 11 & 13 Boys: Once at 13

Why are we concerned about the menses of a female with scoliosis?

Gives you an idea of approximately when their growth spurt occurred.

For possible curve progression, females have a ___ chance than males.

Greater

What is therapeutic management for sports injuries?

R.I.C.E., and immobilization

What is the rate of bone healing in children?

Rapid, due to thick periosteum in children, which makes for really very good bone healing

Bracing, a scoliosis treatment, is most effective for a __.

Skeletally immature child, one with a curve >30*, or one whose curve increased from 10* to >25*.

What would you be additionally concerned with in a patient needing a brace?

Skin breakdown

What other symptoms might be seen in a patient with clubfoot?

Small foot, shortened Achilles tendon, underdeveloped calf muscle on the affected side(s), empty heel bed, bone is not as prominent, transverse plantar crease, normal leg lengths, but it may appear as a discrepancy.

Which brace uses bands instead of a hard brace to re-align the spine?

SpineCor Brace

What is the goal with bracing?

To prevent curve progression

What is acute hematogenous osteomyelitis?

When the infection of the bone develops within 2 weeks of the initial infection.

With a sports injury-related contusion, when is it okay to return to activity?

When the strength and range of motion is the same bilaterally.

How might a contusion appear?

With bruising/ecchymosis, swelling, edema, etc.

What are the two recommending bodies for scoliosis screening?

American Academy of Orthopedics & American Academy of Pediatrics (*)

What is a stress fracture?

An overuse injury.

What's the best way to administer ice to a sports injury?

Alternating, 40 min on, and 20 min off; not placing directly on skin.

What non-medical, non-surgical therapeutic management could you try for a patient with osteomyelitis?

Complete bed rest, immobilization of the affected limb, or at least non-weight bearing activities

In males or females, what pubertal changes would you be interested in with regard to their medical history?

- Development of secondary sexual characteristics - Recent growth patterns

What are the objectives of scoliosis surgery?

Arrest progression, achieve maximum permanent correction, improve appearance, minimize short/long term complications, such as respiratory compromise from lung compression

If a tumor is suspected of an osteomyelitis, what could you do to differentiate?

Aspirate the area

Describe the "Adams Bend Forward Test":

1) bend forward at waist until spine is parallel to floor, palms together, arms extended 2) examine child from behind and side, looking for asymmetry 3) assess flexibility, stabilize spine and ask patient to twist

What is the approximate incidence of clubfoot in newborns?

1-2 per 1,000 live births

Of adolescents diagnosed with AIS, what percentage have curve progression requiring medical attention?

10%

What is the RDA, recommended daily allowance for calcium in adolescents?

1500 mg/day

What would be a concern with a closed reduction?

Compartment syndrome.

What percentage of children between 10 and 16 years of age present with adolescent idiopathic scoliosis (AIS)?

2-4%

What is the chance of clubfoot re-occurrence, post-surgery?

25%

About when would it be okay to go back to sports/athletic activities after scoliosis surgery?

3 months; and generally NO restrictions after 6 months

If you see a curve during the "Adams Bend Forward Test", what is the likely degree of the curve?

> 10*

What is an indication for a patient needing surgery to correct scoliosis?

A Cobb Angle > 45*

Which is more concerning: a girl who has already had her menses, or one who has NOT?

A girl who has NOT yet had her menses.

What is subluxation?

A partial or incomplete dislocation.

How is scoliosis defined?

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

What might be the cause of hematogenous osteomyelitis?

A systemic infection such as acute otitis media, absessed tooth, etc.

What is the most common sprain in adolescent females?

ACL

In TEV, talipes equinovarus, how can the forefoot be described?

Adduction, toes are pointing inward

Which type of scoliosis is the most common form, and that typically has an onset after 10 years of age?

Adolescent idiopathic

How often does the splint need to be worn, post-casting?

At night and during naps for up to about 3-4 years, their adherence will dictate their probability of reoccurrence.

Why is bleeding a complication of surgery to correct scoliosis?

Because the area is highly vascularized.

What is the most commonly used named technique to correct clubfoot?

Benseti Method

When is osteomyelitis most common?

Between 5-14 years

In about 50% of the cases, the clubfoot is ___.

Bilateral

What are some complication of surgery to correct scoliosis?

Bleeding, post-op pain, infection, nerve damage, pseudoarthrosis, disk degeneration and lower back pain, lung and circulatory complications, flat-back syndrome with Harrington rod.

What other cultures might be good to run if osteomyelitis is suspected?

Blood and bone cultures

How is scoliosis corrected by surgery?

By fusing the vertebrae along the curve together, supported by fusing along with instrumentation, such as a rod. Bone grafts, from iliac crest, may be used to fuse vertebrae.

What are the symptoms of a stress fracture?

Chronic pain that changes with intensity, and focal tenderness in a singular site on the bone.

Which bone is most frequently broken?

Clavicle, because many children fall with their hands stretched out, either forward or backward

What are the two types of therapeutic management?

Closed/simple reduction, and open reduction.

When would part-time or night-time bracing be effective?

If the curve is <35*

What nursing diagnoses might apply to clubfoot?

Impaired physical mobility, risk for... impaired skin integrity, impaired parenting, delayed motor development, altered parent/infant relationship

Where might a fracture be the most problematic?

In the epiphysial, growth, plate, as they are the weakest part of the bone.

What technologies can be used to confirm clubfoot?

In utero: an ultrasound. In an infant, radiographs can be used to confirm the degree of severity, and an MRI can be used to look at soft tissue damage.

What could you do to offset the risks of long term IV antibiotics?

Increase probiotics

Which type of scoliosis has an onset prior to 3 years of age?

Infantile

What is osteomyelitis?

Infection of the bone, either from hardware, or usually from the site of injury introduction.

What are complications of fractures?

Infection, neurovascular injury (compartment syndrome), mal-union or delayed (not common), and leg-length discrepancy, especially if in the epiphysial plate.

What is a strain?

Injury to the muscle near the musculotendinous junction, as a result of a forceful contraction of the muscle.

What are some ideas of what might cause clubfoot in utero?

Intrauterine positioning, neuromuscular abnormality, genetic predisposition, arrested fetal development of skeletal and soft tissue, amniotic banding.

Describe clubfoot:

Involves bone deformities, and malposition with soft tissue contractures.

Clubfoot is most often seen in which gender?

It affects boys nearly twice as often as girls.

Why is greater than 10 years of age associated with the most common type of scoliosis?

It becomes more noticeable after their growth spurt.

Why is the swelling of compartment syndrome concerning?

It causes compression of the blood vessels and nerves, potentially causing significant damage.

When correcting clubfoot, it's important to avoid overcorrection, why?

It could cause rocker bottom foot

Adolescent idiopathic scoliosis is most common in which gender?

It is much more common in girls, it is extremely rare in boys.

How is clubfoot diagnosed?

It may be detected antenatally, or diagnosed at birth during a visual inspection.

Which type of scoliosis is typically detected between the ages of 3 and 10 years?

Juvenile

What about developmental delays...

Kids typically "catch up" in terms of their development.

Which direction of curves are more concerning?

Left thoracic curves

In the Risser Scale, more fusion means...

Less potential for curve progression

What lab data is indicative of osteomyelitis?

Leukocytosis and elevated ESR, erythrocyte sedimentation rate

What is the ONLY treatment for osteomyelitis?

Long term IV antibiotics

What does the "Cobb Angle" measure?

Magnitude of the curve, x-ray image is from the back

In the Risser Scale, a 4-5 means...

May have already been through puberty, and have had their menses

Why might subacute hematogenous osteomyelitis result?

Maybe the initial infection wasn't treated long enough, or with the right antibiotics.

In females specifically, what additional pubertal change would you be interested in with regard to their medical history?

Menstrual onset

What are the 6 types of braces?

Milwaukee, TLSO, Boston, Charleston, Providence, SpineCor

In idiopathic scoliosis, if the patient presents with pain, why type is it most likely?

Musculoskeletal pain, NOT bone pain

What type of pain medications should be avoided with scoliosis surgery? Why?

NSAIDS can interfere with growth

Which type of scoliosis is associated with neurological or muscular diseases?

Neuromuscular

What organism causing osteomyelitis is most common in sexually active adolescents?

Nisseria gonorrhea

Does surgical intervention restore the ankle to an entirely normal state?

No; the affected foot and leg remain smaller and thinner than the unaffected side.

What is congenital/idiopathic clubfoot?

Occurs in otherwise healthy infants, it is the most common form.

What is positional clubfoot?

Occurs primarily from intrauterine crowding, either single, or multiplets, responds to simple stretching and casting.

Generally, at which stage should the cast be taken off?

Ossification stage, it's the calcification point.

What is NOT a common symptom of idiopathic scoliosis?

Pain

What symptoms might you expect from a broken/fractured bone after a Motor Vehicle Accident?

Pain or tenderness at the site, immobility or decreased range of motion, deformity of the extremity, edema at the site, crepitis, ecchymosis, muscle spasms.

What might you see with compartment syndrome?

Pallor, paresthesia/tingling, lack of pulse distal to the trauma, worsening pain with extension, swelling.

During the ___ there is an increased risk of curve progression.

Peak Height Velocity: adolescent growth spurt

What are 3 categories of clubfoot?

Positional, syndromic/tetralogic, congenital/idiopathic or true clubfoot

What areas of nursing would you focus on for a patient with osteomyelitis?

Positioning, careful movement of limb, skin breakdown if on bed rest, pain control, vital signs, antibiotic therapy, casting, nutrition, physical therapy

What are your primary concerns with regard to scoliosis?

Possible underlying cause, and curve progression

Does scoliosis have a genetic link?

Potentially, and family members may have it to varying degrees.

What additional history items may be atypical of AIS?

Presence of pain, neurologic changes, bowel and bladder dysfunction.

What organism causing osteomyelitis is most common with puncture wounds over 6 years of age?

Pseudomonas

If/when corrected, the child will need to wear ___.

Splint or corrective shoes

What is hematogenous osteomyelitis?

Spread of organism from pre-existing infection, acute or subacute -- systemic.

What is the most common organism causing osteomyelitis?

Staphyloccus aureus

What complications might arise from a fracture at the epiphysial growth plate?

Stunting growth in the affected leg, resulting in leg-length discrepency.

What would you be concerned with for a patient on long term IV antibiotics?

Superinfections, i.e. C. diff; decreased liver and kidney function as many are nephrotoxic

When considering the Cobb Angle, what is it assessing?

Superior and inferior vertebrae of scoliotic curve.

In TEV, talipes equinovarus, how can the midfoot be described?

Supination, arch of the foot is turning upward, much like a high arch

With severe deformities, what might be necessary?

Surgery may need to be completed in steps.

If a patient with osteomyelitis does require a surgical intervention, it would most likely be ___.

Surgical drainage

Which type of clubfoot is most common?

TEV: Talipes Equinovarus

Which brace allows for more movement, and is easier to hide under clothing?

TLSO

What are two assessments used to evaluate growth potential?

Tanner Stage Assessment, and the Risser Scale

What is the typical adolescent growth spurt for girls?

Tanner stage 2-3

What is the typical adolescent growth spurt for boys?

Tanner stage 3-5

Why is early treatment of clubfoot essential?

The bones at this age are primarily cartilage, it's easier to correct before they ossify.

Why are we more concerned with scoliosis progression in females who have not yet had their menses?

The chance of curve progression is greater, prior to growth spurt.

What is the etiology of clubfoot?

The exact cause is unknown.

What is lordosis?

The natural inward curvature of a portion of the lumbar and cervical vertebral column.

If a patient presents with scoliosis and IS experiencing pain, what is your concern?

Tumor (NOT idiopathic)

What are symptoms of scoliosis?

Uneven appearance of shoulders, shoulder blades, rib cage, hips, waist, leg length, body tilt, and head appears not centered over the body.

How long should bracing be continued?

Until growth has stopped: for females, about 2 years after menses

What causes the deformity?

Usually muscle spasms, trying to form a physiological splint.

What symptoms are common with osteomyelitis?

Vague and non-specific symptoms. Infant: fever, irritability, poor feeding Child: pain, warmth & tenderness over site of infection, lethargy, decreased ROM

In TEV, talipes equinovarus, how can the hindfoot be described?

Varus, heels are turning inward

What is pseudoarthrosis?

When the fusion fails to heal, at any level along the curve; may need to have a cat-scan to see if the rod has slipped.

What is subacute hematogenous osteomyelitis?

When the infection of the bone develops more than 2 weeks after the initial infection.

Is there a genetic predisposition for clubfoot?

Yes, a positive family history is associated with increased incidence.