Orthopedics Disorders Pediatrics
Part II
Jan Bazner-Chandler
RN, MSN, CNS, CPNP
Orthopedic Disorders
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Congenital
Acquired / trauma
Infectious
Talipes Equinovarus
Talipes equinovarus or
Club foot
Obvious deformity noted
at birth.
Surgical correction
Talipus Equinovarus
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Club Foot
1 to 2 per 1000
Males more affected
Involves both the bony structures and soft tissue.
The entire foot is pointing downward.
Interventions
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Manipulation and serial casting immediately.
The more rigid the foot the more likely surgery will be
necessary.
Surgery performed between 4 and 12 months.
Metatarsus Adductus
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Most common foot deformity
2 per 1000
Result of intrauterine positioning
Forefoot is adducted and in varus, giving the foot a kidney
bean shape.
Most often resolves on own or with simple exercises.
Metatarsus Adductus
Dysplasia of the Hip
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Abnormality in the development of the proximal femur,
acetabulum, or both.
Girls affected 6:1
Familial history
Breech presentation
Maternal hormones
Other ortho anomalies
Developmental Dysplasia of Hip
Clinical Manifestations
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+ Ortolani maneuver
Asymmetrical lower extremity skin folds – soft sign
not always seen.
In the older infant there would be decreased ROM in
the affected hip especially with abduction.
In the child there might be discrepancy in limb length.
Asymmetry of skin fold
Hip Exam
Interventions
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Maintain hips in flexed position
Traction to stretch muscles
Pavlik harness
Hip surgery
Bowden & Greenberg
Pavlik Harness
Bowden & Greenberg
Harness
JB Chandler
Osteogenesis Imperfecta
Osteogenesis Imperfecta
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Genetic disorder
Caused by a genetic defect that affects the body’s
production of collagen.
Collagen is the major protein of the body’s connective
tissue.
Less than normal or poor collagen leads to weak bones
that fracture easily.
Osteogenesis Imperfecta
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Often called “brittle bone disease”
Characteristics
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Demineralization, cortical thinning
Multiple fractures with pseudoarthrosis
Exuberant callus formation at fracture site
Blue sclera
Wide sutures
Pre-senile deafness
3-month-old with OI
Old rib fractures
Old fractures/demineralization
New Born with OI
CaReminder
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Signs of a fracture, especially in an infant, are important
items to teach caregivers. In a baby, these signs are
general symptoms, such as fever, irritability, and refusal to
eat.
Cerebral Palsy
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Group of disorders of movement and posture
 Prenatal
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causes = 44%
Labor and delivery = 19%
Perinatal = 8%
Childhood = 5%
Assessment
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Developmental surveillance is key
Diagnosis often made when child is 6 to 12 months of age
Physical exam:
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Range of motion
Evaluation of muscle strength and tone
Presence of abnormal movement or contractures
caReminder
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Reflexes that persist beyond the expected age of
disappearance (e.g., tonic neck reflex) or absence of
expected reflexes are highly suggestive of CP.
Clinical Manifestations
Hypotonia or Hypertonia
Contractures
Scoliosis
Seizures
Mental Retardation
Visual, learning and hearing disorders
Osteoporosis – long term due to lack of movement
Legg-Calve-Perthes
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Vascular disturbance leads to bone death in hip do to
interruption of blood flow.
Four times more common in males
More common in Asians, Eskimos and Caucasians.
Peak age 6 (2 - 12 years)
Clinical Manifestations
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Pain – groin, hip or referred pain to knee.
Limping
Limited hip motion especially internal rotation and
abduction is classic sign.
Right hip - LCP
Management
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Goal of care is to: Keep femoral head in the hip joint
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Traction
Anti-inflammatory
Physical therapy
Surgery if femoral head destroyed
Osgood-Schlatters
Painful prominence of the
tibial tubercle
Gait.udel.ed
Osgood-Schlatters
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Due to repetitive motion
Affects children 10 to 14 years old
Males 3:1
Diagnosis is based on clinical signs and symptoms
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Pain, heat, tenderness, and local swelling
Assessment
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Tip: Asking the child to squat or extend his or her knee
against resistance usually elicits pain and is a good
indicator of Osgood-Schlatter Disease.
Management
•Reduce activity
•Stretching before activity
•Anti-inflammatory
•Avoid activity that cause pain
Slipped Capital Femoral Epiphysis
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Top of femur slips through growth plate in a
posterior direction.
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Ages 10 to 14 in girls
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Ages 10 to 16 in boys
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High proportion are obese
Clinical Manifestations
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Pain in groin, hip or knee
Limp (antalgic is limping on affected side)
Limited abduction
Leg may be shorter
Clinical Manifestations
Management
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Surgery – fix with a pin
Crutch walking
Complications
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Avascular necrosis of femoral head is compromise of
circulation of the femoral head leading to ischemia. This may
lead to collapse of the necrotic segment.
Scoliosis
Lateral curvature of spine
Medline.com
Mild Scoliosis
Mild forms
Strengthening and
stretching
Clinical Manifestations
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Pain is not a normal finding
for idiopathic scoliosis
Often present with uneven hemline
Unequal scapula
Unequal hips
Assessment
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Alert: If pain is a reported symptom of the child’s
scoliosis, it should be investigated immediately. Pain is not
a normal finding for idiopathic scoliosis, and the presence
of this symptom could be signaling an underlying
condition such as tumor of the spinal cord.
Screening
Screening
Bowden & Greenberg
Severe Scoliosis
Bracing
Milwaukee
Brace
Scoliosis
Spinal Fusion
Post-operative Care
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Pain management
Chest tube in many cases
Turn, cough, and deep breathe
Log-roll
Muscular Dystrophy
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Group of genetic diseases characterized by progressive
weakness and degeneration of the skeletal muscles that
control movement.
Most common: Duchenne muscular dystrophy (DMD)
Predominately male disease
X-linked recessive inherited disease
Pathophysiology
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DMD is deficiency or absence of the protein dystrophin.
Protein is thought to strengthen the muscle cell
membrane.
Laboratory values: Creatinine kinase levels are high.
Assessment
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Infant may display mild delay in attaining milestone.
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Sitting up, crawling, cruising
Toddler (between ages 2 to 3) may have a clumsy gait and have
difficulty climbing stairs.
Classic physical finding: Gowers’ sign
Gowers’ Sign
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http://www.youtube.com
Type in Gowers’ Sign
Interdisciplinary Interventions
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Team of nursing, physicians, specialists
Pharmacologic Interventions
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Glucocorticosteroids (prednisone and deflazacort): steroids
have been found to increase muscle strength and pulmonary
function.
Long Term Problems
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Cardiomyopathy in 90% over 18 years of age
Respiratory complications
Obesity