Children and Orthopedic Nursing
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Pain
o Location
o Nature
o Frequency
o Remember child may deny pain
Pallor (skin color)
o Warm Skin With Blue Tinge
 Possible Venous Status
o Cool Pale Skin
 Possible Arterial Insufficiency
Paralysis (movement)
o Compare Bilaterally
o Wiggling Fingers Or Toes Does Not Always Assess Motor Damage
o Hard For A Young Child To Describe
o Numb, Tingling
 “Bugs Crawling”
 “Pins And Needles”
 “Burning”
 “Asleep”
o Loss Of Sensation
Pulse
o Assess Uninjured Limb First To Establish Baseline
o Don’t Forget To Assess Capillary Refill
Orthopedic Appliance
o Clothing Between Appliance And Skin
o No Lotion Under Appliance
 Can lead to yeast build up
o No Powder Under Appliance
 Can be abrasive and cause skin breakdown
o Toughen Skin In Contact With Metal
 Alcohol Or Tannic Acid
o What About Balance?
Legg-Calve-Perthes Disease
o Info
 Avascular Necrosis of the femoral head which occurs in four stages
o Patho
 Blood Flow To Femoral Head Is Interrupted Resulting In Bone Necrosis
 Blood Supply Returns To Femoral Head
 New Bone
 Remodeling Of New Bone
 Bone is taking the proper shape, very important
 Process Takes 18 Months to Several Years
o Assessment
 Usually A Boy 2- To 12-Years-Old
 Slow Onset
 Limp
 Pain In Thigh, Hip, And/Or Knee
o Worse With Activity, Relieved By Rest
o Limited Motion
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o Eventually Muscle Atrophy
 Definitive Test Is MRI
o Treatment
 Keep Head Of Femur In The Acetabulum (main concept in this disease process)
 Treatment Plan Is Influenced By
 Child’s Age
o The younger the child the better the outcome because there is more time for that bone
to remodel
 Condition Of The Femoral Head
 Position Within the Acetabulum
o Overview Treatment
 Initial Therapy Is
 Rest
 Non-Weight Bearing
 Activity Can Cause Microfractures
 Conservative Versus Surgical Containment
 Later, Active Motion Is Encouraged
o Nonsurgical Containment
 Non-Weight Bearing Devices
 Abduction Brace
 Leg Casts
 Leather Harness Sling
 Weight Bearing Devices
 Abduction-Ambulation Braces
 Casts After A Period Of Bed Rest And Traction
 Can Take 2 – 4 Years
o Surgical Intervention
 Osteotomy
 Screws And Plates
 Spica Cast
 Frequently From Chest To Toes
 6 – 8 Weeks
 Physical Therapy
 Partial-Weight Bearing
o Prognosis
 Excellent In Most Cases
 Outcome Is Influenced By
 Child’s Age
 Early Treatment
 Possibilities
 Osteoarthritis
 Leg Length Discrepancy
Osteomyelitis
o Info
 Infection of a bone, primarily a long bone in children
 In Children: Most Common Between 1 – 12 Years
 Boys Affected More Often Than Girls
 Hematogenous Spread
 Organism Reaches The Bone Through The Blood
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There is an infection somewhere else in the body and the bug gets into the blood and then
reaches the bone
Open Fracture Or Wound
Staphylococcus aureus
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Patho
 Bacteria adheres to bone
 Purulent exudates in bone tissue (pus)
 Exudates moves beneath the periosteum, abscess formation
 Necrosis of the bone
Assessment
 Fever
 Irritability
 Pain with movement
 Swelling and warmth
Labs
 Leukocytosis
 Elevated Erythrocyte Sedimentation Rate (ESR)
 Tests for inflammation. Not where in the body that it’s located, just that there is inflammation
somewhere
 Cultures
 Blood culture looking for bugs in the blood, may also culture the joint nearest the infection
 Blood And Nearest Joint
 X-Ray, MRI, CT Scan, Bone Scan
Medications
 Antibiotics 4 – 6 Weeks
 Important To Monitor Hematological, Renal, Hepatic, Ototoxic And Other Potential Side Effects
 Common Medications
 Nafcillin
 Clindamycin
 Vancomycin
Interventions
 Assess And Document 5 P’s
 Pain
 Handle With Extreme Care
 On Bed Rest Or Wheelchair (Maybe)
 Immobilization (Probably)
 High Protein Diet
Surgical Interventions
 Surgical Drain (Maybe)
 Two Tubes Are Placed In Wound
 One Tube Instills An Antibiotic Solution Directly Into Infected Area
 One Tube Provides Drainage
 Surgical Removal Of Dead Bone (Sequestrectomy) (Maybe)
Scoliosis
o Info
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Curvature of the spine associated with vertebral rotation causing rib asymmetry, potentially effecting
heart/lung function
Structural
 Has to do with the spine itself
 The most common type we see is idiopathic and we see it during the growth spurts
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 Adolescent Growth Spurt (is when you usually notice this)
 >10°
 Functional
 Factors Outside Spinal Column
 Like a leg length discrepancy, so when they stand up the spine is crooked, but when they sit
down the spine is straight
o Assessment
 Forward Bending Test
 Assess Standing And Bending
 Assess Symmetry
o Shoulders
o Scapulas
o Waist
o Hips
 Scoliometer
 Protractor Used To Measure Curvature
 Assess For Leg Length Discrepancy
o Treatment
 Serial Observation (10° to 20°)
 Bracing (20° to 40°)
 Purpose Is To Prevent Further Curvature
 Usually Worn 16 – 23 Hours A Day
 Gradually Weaned Off Brace After Spinal Growth Has Stopped
o May Wear At Night For 1 – 2 Years
o Braces
 Braces do not correct the curve that is already there, but only prevents further curvature
 Boston Brace
 Standard, kind of off the rack, generic style for everyone
 TLSO Brace (Thoracolumbosacral Orthotic)
 Custom Fit, you get your own one of a kind brace
 Milwaukee Brace
 Kyphosis
o Surgical Intervention
 > 40˚ Curve
 Realignment And Straightening
 Instrumentation
Developmental Dysplasia of the hip
o Info
 Separation of the femoral head from the acetabulum
o Types
 Dysplasia
 Mildest Form
 Femoral Head Remains In Acetabulum
 Subluxation
 Greatest Percentage Of Cases
 Incomplete Dislocation
 Dislocation
 Femoral Head Not In Contact With Acetabulum
o Infant Assessment
 Shortened Limb On Affected Side
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Asymmetry Of Gluteal Folds
Ortolani Click
 Into Place
 When you move the leg and you hear a click, meaning the leg is in place
 Positive Barlow Sign
 Passive Dislocation
 Nursing Alert  Ortolani and Barlow tests must be performed by an experienced clinician to prevent
damage to the hip. If these tests are performed too vigorously in the first 2 days of life, persistent
dislocation may occur
o Child Assessment
 Level Of Knees
 Limp
 Leg Length Discrepancy
 Positive Trendelenburg Sign
 Stand On One Foot (Affected Side). Pelvis Tilts Downward On Normal Side
o Treatment
 Newborn to 6 Months (treatment is crucial for the infant! Don’t want them to have a limp or whatever for
the rest of their life)
 Pavlik Harness
o Legs Abducted, Knees And Hips Are Flexed
 Holds the femoral head high in the acetabulum
o Worn Continually 3 – 6 Months
o Position Chest Halter At Nipple Line
 Fasten With Velcro
o Position Legs And Feet In The Stirrups
 Hips Are Flexed And Abducted
o Connect The Chest Halter And Leg Straps
 In Front
 Then In Back
o Skin Is Marked With Indelible Ink At Strap Lines
 6 to 8 months old
 Traction (but we don’t see this much anymore)
 Closed Reduction Under Anesthesia
 Spica Cast For ~ 2 – 4 Months
 Brace after the spica cast is taken off
 Older child
 Tenotomy Of Contracted Muscles
o The muscles grow and tighten around the retarded hip joint, before we can fix the hip
we have to address the muscles
 Reconstruction Of Acetabulum
 Cast (Spica)
 Rehab
o May never have a perfect leg or walk, will have some degree of impairment, limp etc.
Fractures
o Types
 Bend
 Bent But Not Broken
o May Bend 45° Or More Before Breaking
 Most Common In Ulna And Fibula
o Often Associated With Fractures Of Radius And Tibia
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Casts
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Greenstick
 Bent beyond edurance
 Buckle
 Compression Of Porous Bone
o Occurs Near Growth Plate
o Tends To Be Seen In Young Children
 Spinal Fracture
 Twisting Motion
o Planted Foot, Twist To Throw Football
o Skiing
o Maltreat In Nonambulating Child
 Epiphyseal Growth Plate injury
 Weakest Point Of Bones
 Can Result In Growth Disturbance
Assessment
 History
 Child’s Story May Not Be Reliable
o Child May Be Afraid Of Getting In Trouble
 Muscle Contraction
 Muscles Contract To Splint Fracture
 Swelling Peaks In 1 – 2 Days
Swelling and cast placement
 Swelling Peaks In 1 – 2 Days
 Current Trend Is To Cast 1 – 2 Days After Fracture
o Don’t want to cast before swelling is done because you risk tissue damage and squishing
of the arm or whatever in the cast
 Elevate
o Above the level of the heart to help reduce swelling
 Bivalve Cast, If Needed
 Cut the cast in half then wrap it all with an ace bandage, holds the limb immobile, but loosened it
to allow for circulation
Synthetic Casts
 Dry Quickly (10 – 30 Minutes)
 Lightweight
 Can Be Durable In Water
Cast Application
 Assess Limb For Alteration In Skin And Jewelry
 Tube Of Cloth Stockinet Over Area
 Bony Prominences Covered With Cotton Sheeting
 Wet Casting Material Molded To Limb
 Stockinet May Be Pulled Over Rough Edges Of Cast And Secured With Casting Material
Casts: Nursing
 Cast To Dry Inside Out
 Don’t use heaters or blow dryers or whatever
 Reposition Wet Cast With Palms To Avoid Pressure Points (Hot Spots)
 These hot spots are sites of skin breakdown and possible infection
 After The Cast Has Dried Petal The Cast, If Needed
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Petaling is like softening. Use tape that is strong, moisture resistant. Cut a circle on the tape that
will be on the inside of the cast so there are no sharp edges or whatever against the skin. Kids
don’t really like when you do this…
 With a Spica cast, don’t use the bar between the legs to move the child. If the bar breaks they have to go
back and get a new cast. Also, for babies, put the diaper up underneath the cast, not over, or else it will
get shitty, literally…
Arm Sling
 Distributes Weight Evenly Over Large Area Of The Shoulders And Trunk, Not Just Neck
 Discouraged After First Few Days, Especially With Short Arm Cast
 Encourage Normal Movement, increases circulation which speeds up recovery
A few other items
 Windows
 Allows Abdominal Expansion
 You basically cut a hole over the abd so they can eat
 Odor
 Can Indicate Infection
 Objects in Cast (very common for kids)
 Moisture in Cast
 5 P’s of Circulation
Cast removal
 Cast Cutter
 Cuts By Vibration
 Generates Heat
 Noisy
 Flakey Skin
Traction
o Purpose of traction
 Fatigue Muscle To Reduce Muscle Spasms
 Realign Bone
 Immobilize During Healing
o Check these
 Position Of Frames, Splints, Etc.
 Ropes & Pulleys
 Alignment
 Good Working Order
 Weights
 Correct Amount
 Hanging Freely
 Bed Position
o Manual Traction
 Limb is help in position by person
 Nurses are frequently the manual traction, we hold leg in position when someone is putting a cast on for
example
 Once traction is released, the muscle spasms come back (this is with any kind of traction)
o Skin Traction
 Primary Purpose Is To Decrease Painful Muscles Spasms
 Limited Weight To Prevent Skin Injury
 If “Oked” By Physician Remove Bandage Every 8 Hours to Assess Skin
 Manual Traction
o Buck Traction
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Short Term Immobilization
Preoperative Management Of
 Muscle Spasm Associated With Fractures
 Dislocated Hip
 Pediatric pt tends to migrate toward the foot of the bed. May draw a line and tell the kid “Hey don’t let
your butt get past this line”
Bryant’s Traction (rarely seen)
 Hip Dislocation Or Fractured Femur
 Weigh Less Than 40 Pounds
 Buttocks Off The Bed
 This Is The Countertraction
 7 – 10 Days
 Spica Cast, Maybe
Skeletal Traction
 Primary Purpose Is Bone Realignment
 Pins, Wire, Tongs, Screws Are Implanted In Bone
 Longer Traction Time And Heavier Weights Than Skin Traction
 Nursing Alert  “Skeletal traction is never released by the nurse (unless under direct supervision of a
practitioner.)”
90° - 90° Traction
 Two 90° Angles
 Steinmann Pin Or Kirschner Wire In The Distal Fragment Of Femur
 Lower Portion Of Leg Is Supported In Cast Boot Or Sling
 Most common form of traction seen in pedi
Traction Assessment
 Inspect Skin At Least Every 8 Hours
 External Hardware
 Inspect Insertion Sites For Inflammation
o Drainage
o Color
o Odor
 Pin Care Controversy
 Pin Care Prevents Infection
 Pin Care Disrupts Skin’s Natural Barrier To Infection
Triad of Injuries
 When A Child Is Hit By A Car Assess For
 Broken Femur
 Chest Injury
 Head Injury