Peds Orthopedics

Scoliosis

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

if greater then 10 degrees on screen => referal

Congenital Scoliosis

condition of birth with a lateral curvature of the spine

anomolous vertebral development

Infantile Scoliosis

onset of scoliosis before 3yrs old

Juvenile scoliosis

Detected between ages 3-10

neuromuscular scoliosis

associated with neurological or muscular diseases

Adolescent Idiopathic Scoliosis

• Present in 2 to 4 percent of children between 10 to 16 yrs. old

• Possible genetic link because it is often seen in multiple family members.

• most common form, More common in girls

• Of adolescents diagnosed with AIS, only 10% have curve progression requiring medical attention.

Curve Progression

•Double curves progress more than single curves

•Larger curves (30-40°) progress more than smaller curves (20-30°)

•Females progress more than males

•Increase risk of curve progression during Peak Height Velocity during adolescent growth spurt (girls Tanner 2-3, boys Tanner 3-5)

Scoliosis S/Sx

•One shoulder higher than other

•One shoulder blade sticks out more than other

•One side of rib cage appears larger than the other

•One hip higher and more prominent

•Waist appears uneven

•Body tilts to one side

•One leg appears shorter than other

•Head not centered over body

•PAIN ON SPINE IS NOT A TYPICAL SYMPTOM

Scoliosis Screening

Females screened twice (age 10 and 12)

Males screened once (age 13 or 14)

should not just be just in school

Scoliosis Hx Questions

•Primarily diagnosis of exclusion

•Family history of scoliosis or other musculoskeletal disorders

•Menstrual onset

•Development of secondary sexual characteristics and recent growth patterns

•Presence of pain and neurologic changes including bowel and bladder dysfunction because this is atypical for AIS

Adams bend forward test

Bend forward at waist until spine becomes parallel to the floor while holding palms together with arms extended.

Examine child from behind and side looking for asymmetry in the contour of the back (rib hump)

Flexibility should also be evaluated by stabilizing the spine and asking the child to twist to both sides

Ninety percent of curves are to the right, left thoracic concerning

Scoliometer

Measuring device that may be used to obtain a measurement of the number of degrees that the spine is deviated in scoliosis.

7-10: just monitor

>10: needs referal

Screening tool

Scoliosis Diagnosis Primary concerns

Primary concerns: possible underlying cause and curve progression

Determinants of progression: gender, future growth potential and curve magnitude at time of diagnosis.

What is evaluated for potential growth of scoliosis curve

•Tanner Stage assessment

•Risser scale-evaluates skeletal maturity

•Bone Age

•Cobb Angle

Risser scale-evaluates skeletal maturity

the further along the growth plate has closed on the hip the less growth there is left

higher the number the less curve progression risk

Bone age

A measure of physical maturation based on x-ray examination of bones, typically the wrist and hand growth plates

determines closer of the growth plate

Cobb Angle

Measured to define scoliosis. > 10° is needed for dx.

Bracing Treatment

•Skeletally immature child

•Curve > 30° Or

•Curve which increased from 10°- >25°

•Goal: prevent curve progression or until curve progression can't be controlled

•Worn 18 - 23 hours/day

•Part time or night time bracing may be effective for curves <35°

•Should be continued until growth stopped

•Compliance a cause for poor results

Spinecor Brace

research has shown to NOT be effective!

RSC Brace

in conjunction with exercises can correct lateral and rotational curves

Schroth Method

PT approach to scoliosis treatment based on exercises tailored to each pt's spine curvature

lots of lengthening and stretching

*includes use of RSC brace when not stretching

*exercises MUST be done every day to be effective

surgery for scoliosis objectives

Indication: Cobb angle >45°

Objectives of surgery

1. Arrest progression

2. Achieve maximum permanent correction

3. Improve appearance

4. Keep short & long term complications to a minimum

short & long term complications of scoliosis

- nerve damage

- organ damage from compression

Surgery for scoliosis method

•Fusing the vertebrae along the curve

•Supporting fused bones with instrumentation attached to spine

•Bone grafts fuse the vertebrae together

•Many surgical variation exist using different instruments, procedures and surgical approaches.

•Cause of scoliosis usually determines type of procedure

Complications of scoliosis Surgery

•Bleeding

•Postoperative pain

•Infection

•Nerve damage

•Pseudoarthrosis

•Disk degeneration and low back pain

•Complications that involve lungs and circulation

•Flat back syndrome with Harrington rod.

•function takes a long (no sports for a year)

•no NSAIDS

Clubfoot

•Involves bone deformities & malposition with soft tissue contractures

•Talipes Equinovarus (TEV) most frequently occurring clubfoot (95%)

•Early evaluation & treatment for optimum correction

Talipes Equinovarus (TEV)

Complex deformity of the ankle & foot

- forefoot adduction: toes point in

- midfoot supination: turns upward

- hindfoot varus-heel: turns inward

- ankle equinus-toes: point downward

Clubfoot Incidence

•1-2/1,000 live births

•Affects boys nearly twice as often as girls

•Bilateral in 50% of the cases

•A positive family history is associated with an increased incidence

Etiology of Clubfoot

Exact cause is unknown:

* intrauterine positioning

* neuromuscular or muscle abnormality

* genetic predisposition

* arrested fetal development of skeletal and soft tissue

* amniotic banding

* oligohydramnios, a decreased amount of amniotic fluid

* breech delivery

categories of clubfoot

positional, syndromic, congenital

positional clubfoot

Occurs primarily from intrauterine crowding (twins, LFGA)

Responds to simple stretching and casting

Syndromic (tetralogic) clubfoot

associated with other congenital abnormalities (spina bifida)

More severe form, often requires surgery

congenital (idiopathic) clubfoot

occur in otherwise healthy infants

It is the most common form.

other symptoms of clubfoot

•Small foot

•Shortened Achilles tendon

•Underdeveloped calf muscle

•Empty heel bed

•Transverse plantar crease (image)

•Normal leg lengths

Diagnosis of clubfoot

•May be detected antenatally

•Diagnosis at birth - visual inspection

•Radiographs to confirm degree and severity of deformity

•MRI may also be used

Clubfoot Treatment

•Early treatment is essential to achieve successful correction and reduce chance of complications

•Serial casting is begun immediately or shortly after birth.

•Successive casting allows for gradual stretching of skin and tight structures on medial side of foot.

casting for clubfoot

•Every few day for first 1 to 2 weeks

•Then every 1 to 2 weeks until maximum correction is achieved.

•Avoid overcorrection can cause rocker bottom foot.

•If corrected, child wears splint (Denis Browne Splint) or corrective shoes.

•If deformity has not been corrected, surgical intervention is required between 3 - 12 months.

Clubfoot prognosis

•Parents should realize that outcomes are not always predictable and depend on severity of deformity, age of child at initial intervention, compliance with treatment, and development of bones, muscles & nerves

•Surgical intervention does not restore the ankle to an entirely normal state with the affected foot & leg remaining smaller & thinner than unaffected side.

•Most children after surgical repair are able to walk with out a limp and run or play.

•25% chance of reoccurrence

•With severe deformities, repeated surgeries.

Contusions Injuries

damage to soft tissue, subcutaneous structure & muscle

Sprains

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

Strains

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

Dislocation & Subluxation

dislocation and subluxation refer to the displacement of bones that form a joint.

These conditions affecting the joint most often result from trauma that causes adjoining bones to no longer align with each other. A partial or incomplete dislocation is called a subluxation

Therapeutic Management of injuries (contusion, sprain, etc)

RICE - NO HEAT

- 20 min of ice max with barrier

Immobilization

Fractures

•In children, they are result of increased mobility &/or immature motor & cognitive skills

•Infancy - RARE

•Traumatic musculoskeletal injuries most frequent

•Clavicle most frequent bone broken

•Epiphyseal injuries - Salter-Harris classifications

Stress Fractures

•Overuse injury

•Becoming more common in adolescents who limit intake of calories and calcium to remain lean for sports

Stress Fractures Symptoms

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

RDA - calcium

1500 mg/day for adolescents

Fracture Diagnosis

Symptoms

- pain or tenderness @ site

- immobility or decreased ROM

- deformity of extremity

- edema @ site, crepitis, ecchymosis or muscle spasms

X-rays - sometimes of both extremities

Cast Care Edu

nothing down cast

compartment syndrome sign

keep dry

keep elevated

Nursing of Fractures

Initial Assessment

- cause of fracture

- examine fracture site

- neurovascular evaluation

Asses & manage fat embolism

- after crush injury of long bones

- dyspnea, restless, fever over 103, petechie rash tachycardia, tachypnea, hypoxia

Compartment Syndrome

•Results from swelling caused by trauma & immobilizing device

•Severe pain unrelieved by analgesics

•Pain more intense than what would be expected from fracture

•Pallor, paresthesia, lack of pulse distal to the trauma

•Pain with extending fingers or toes

Complications of Fractures

•Infection

•Neurovascular injury

•Vascular injury

•Mal-union or delayed

•Leg length discrepancy

Osteomyelitis

•Infection of bone

•Occurs in metaphyseal region of long bones

•Most frequent between 5 to 14 years

•Exogenous

•Hematogenous

exogenous Osteomyelitis

a bone infection caused by germs entering the bone directly from an external source, such as a deep wound, open fracture, or surgery

Hematogenous Osteomyelitis

a bone infection that occurs when pathogens from a distant infection in the body travel through the bloodstream to the bone

acute: within 2 weeks of infection

subacute: longer exposure

Why is Osteomyelitis more common in kids

their growing bones, particularly the metaphysis of long bones, have a rich blood supply that can carry bacteria from an infection in another part of the body

Organisms that cause Osteomyelitis kids

•Staphloccus aureus: most common over 5 years

•Haemophilus influenzae, Strep pneumonia,

•Salmonella & Staph aureus - Sickle Cell Disease

•E coli & B strep - most common in neonates

•Pseudomonas - puncture wounds over 6 years.

•Nisseria gonorrhea - sexually active adolescents

Symptoms of Osteomyelitis

Symptoms – vague & son-specific

- infant: fever, irritability, poor feeding

- older child: pain, warmth & tenderness over site of infection, fever, lethargy, decreased ROM

Diagnosis of Osteomyelitis (lab values and other tools)

Lab Data

- leukocytosis & elevated ESR

- blood cultures

- bone cultures

CT scan & MRI (actual diagnosis)

Therapeutic Management of Osteomyelitis

• Long term IV antibiotics

• monitor for side effects

• Complete bed rest

• Immobilization of affected limb

• May require surgical drainage

Nursing management of Osteomyelitis

• Positioning

• Careful & gentle moving of limb

• Pain control

• Monitor vital signs

• Antibiotic therapy

• May require isolation

• May require casting

• Nutrition

• Non-weight bearing

• Physical therapy