NCMA 109 Pre-Finals - Gastrointestinal System and Muskuloskeletal

Anaphy - Esophagus

25 cm long and transport the food from the mouth to stomach

Anaphy - Small Intestine

Area where the digestion and absorption of nutrients occurs

Anaphy - Large Intestine

Absorbs water (To

solidify the chime) and electrolytes so

that the chime will digest → becomes a

feces

Cleft Lip and Cleft Palate

Congenital anomalies that occur as a result of failure of fusion or facial structure. Due to folic acid deficiency. Abnormal openings in the lip and palate or both.

Cleft Lip

• Failure of maxillary and medial

nasal processes

• Opening or notch in the upper lip

• 5-8 weeks age of gestation

Cleft Palate: Midline fissure

• Opening in the roof of the mouth

• Failure of palletar to close

• 9-12 weeks age of gestation

Surgical management - Cleft Palate

• Tension-Randall Triangular Flap (Z-plasty)

• Millard Rotational Advancement Technique

• Rule of 10S before surgery:

  ■ Infant is at least 10 weeks

  ■ Infant should weight 10 kg

  ■ Infant’s Hemoglobin: 10

  g/dL

Surgical management - Cleft Palate

○ Surgery → 6-18 months

○ Veau-wardill kilner V-Y pushback

procedure

○ Furlow double opposing Z-plasty

○ Goal is to allow normal speech

development

Esophageal Atresia

● Rare malformation that represent a

failure of the esophagus to develop a

continuous passage

● Discontinuity of the esophagus

● Esophagus does not develop normally

during fetal development

Tracheoesophageal Fistula

● Failure of the trachea and esophagus to

separate into distinct structures

● Trachea and esophagus should

separated but there is an abnormal

connection between them

Risk Factors: Esophageal Atresia

● Unknown cause

● Genetic Factors

○ Predispositions

● Polyhydramnios → Risk of esophageal

atresia

● Premature newborns

● Environmental factors

Surgical management: Esophageal Atresia

● Thoracotomy with division ligation and

ligation of Tracheoesophageal fistula

● End to End / End to Side Anastomosis

○ Repair esophagus to have

normal swallowing

● Gastronomy is performed temporarily

● Cervical Esophagostomy → Opening of

esophagus to drain secretions

○ Assess the cervical

esophagostomy site, if present

for redness, breakdown or

exudate.

○ Remove accumulated drainage

frequently and apply protective

ointment, barrier dressing or a

collection device as prescribed

Gastroesophageal Reflux Disease (GERD)

● Dysfunctional lower esophageal

sphincter, which allows stomach

contents to flow back into the

esophagus due to premature

esophageal sphincter

● Lower esophageal sphincter fails to close

properly → Allows gastric contents to

flow back into the esophagus, leading to

irritation and symptoms such as

heartburn and discomfort in affected px

Risk Factors: GERD

● Premature newborn → Immature

gastrointestinal system

● Neurological impairments → Inability to

swallow and esophageal motility

● Obesity → Increase abdominal pressure

and it forces the stomach contents

upward

● Dietary → Acidic and spicy foods

● Family history

Diagnostic Test: GERD

● Esophageal pH monitoring

○ Probe is inserted to the

esophagus for 24 hours to

measure the frequency and

severity of acid reflux

● Upper GI Series (Barium Swallow)

○ To evaluate the structure of

esophagus

● Endoscopy

○ To directly visualize the

esophagus and if there is an

inflammation or ulceration

Surgical Management: GERD

If medications are not effective

● Nissen Fundoplication

○ Upper portion of the stomach is

wrapped around the esophagus

○ This strengthens the lower

esophageal sphincter and

prevents reflux

○ Monitor for Coffee colored

drainage after 24 hours:

Suspected bleeding

Hypertrophic Pyloric Stenosis

● Hypertrophy / Hyperplasia of the

muscle surrounding pyloric

sphincter resulting into thickened,

elongated and narrowed pyloric

channel

● Thickening of the pyloric muscle,

which leads to narrowing of the

pyloric canal and obstruction of

gastric emptying

Pylorus

the muscular valve that

connects the stomach to the

duodenum

Assessment: Hypertrophic Pyloric Stenosis

● Projectile vomiting

○ 3-4 ft in side lying

○ 1 ft or more in supine

○ Non-bilious vomiting that may be

blood tinged

● Infant is hungry, avid feeder (Constant

hunger)

● Irritability and crying

● Olive shaped mass (Palpable mass felt

in the abdomen) is in the epigastrium

just right of the umbilicus

• visible peristalsis

Diagnostic test: Hypertrophic Pyloric Stenosis

● Abdominal ultrasound: Shows thickened

pyloric muscle and elongated pyloric

canal

● Barium Swallow: Shows the classic string

sign. This indicated very narrow passage

of contrast through the pylorus

Surgical Management: Hypertrophic Pyloric Stenosis

● Pyloromyotomy

○ Ramstedt procedure: Incision

through the muscle fibers of the

pylorus that may be performed

by laparoscopy

● Laparoscopy

Intussusception

Telescoping of one intestinal segment into another → obstruction + ↓ blood supply (surgical emergency)

Intussusceptum

Segment that slides inward

Intussuscipiens

Segment that receives the inward part

Common Site of Intussusception

Ileum → colon junction (ileocecal)

Causes of Intussusception

• <1 yr: Idiopathic

• >1 yr: Lead point (e.g., Meckel’s diverticulum, polyps, tumors, Peyer’s patches)

Risk Factors: Intussusception

● Viral infections: Enlarged lymph node in

the intestines

● Peyer’s Patches: Enlarged lymphoid

tissues

● Tumors

● Intestinal polyps

● Meckel’s Diverticulum: Lead point in

invagination

Assessment: Intussusception

● Colicky pain - Suddenly drawing-up

their legs and cry

● Intermittent severe abdominal pain

● Bile-stained and gastric content vomitus

● Olive-shaped mass

○ Palpable sausage-shaped mass

in Right upper quadrant

● Target Sign or Donut Sign on ultrasound

○ Telescoped bowel segments

● Pseudokidney Sign

○ Layers of the intussusceptum and

mesentery resemble the

structure of a kidney

Hirschsprung's Disease

● Aganglionic megacolon

● Absence of ganglion cells in a segment

of the intestine

○ Lower portion of the sigmoid

colon just above the anus

■ Rectosigmoid colon

● Higher in siblings of the child with

disorder

● Cause: Abnormal gene on chromosome

10

Assessment: Newborn

● Delayed meconium passage

● Meconium after 24 hrs and increased

abdominal size (distention)

● Chronic constipation

● Refusal to suck

● Bilious vomiting and feeding intolerance

● Symptoms become apparent until 6-12

months

Assessment: Infant and Children

● Poor weight gain and malnutrition

● Chronic Constipation

● Abdominal distention

● Ribbon like and foul smelling stools

● Explosive stool

● Episodes of diarrhea and vomiting

● Signs of Enterocolitis

● Explosive, watery diarrhea

● Fever

● Appears significantly ill

Medical Management: Hirschsprung's Disease

● Bowel decompression → Removes the

contents of the bowel irritation

● IV fluids for hydration

● Nutritional support to ensure nutrients

are still given to the child

● Monitor enterocolitis

Pharmacological management: Hirschsprung's Disease

● Metronidazole → Prevents infection

● Acetaminophen and Ibuprofen

● Removes discomfort

● Stool softeners → Releases the stools

Surgical Management: Hirschsprung's Disease

● Transanal space endorectal pull through

procedure → Removes aganglionic

segment and reconnecting the healthy

bowel

● Removal of affected portion with

anastomosis of the intestine

● 2 stage operation

○ Temporary colostomy: Allows

bowel rest and healing

○ Bowel repair: 12-18 months

○ Permanent colostomy: no nerve

endings on anus

fracture

A break in the continuity of the bones

Fractures in children tend to be different

in adults because:

• Children: Bones are porous → bend easily

• Thick periosteum: May not fully break

• Epiphyseal plate: Can absorb impact

• Healing: Faster

• Risk: Growth disturbance → under/overgrowth, angulation

Types of Fractures: Close or simple fracture

Bone is broken, by the skin is lacerated

Types of Fractures: Open or compound fracture

Skin may be pierced by the bone

or by a blow that breaks the skin

at the time of the fracture. The

bone may or may not be visible

Transverse Fracture

Fracture is at right angles to the

long axis of the bone

Greenstick Fracture

Fracture on one side of the bone,

cause a bend on the other side of

the bone

Comminuted Fracture

A fracture that results in three or

more bone fragments

Oblique Fracture

The fracture is diagonal to a

bone’s long axis

Spiral Fracture

At least one part of the bone has

been twisted

Assessment: Fractures

● Pallor

● Paresthesia - ask about numbness in

extremities

● Pain - ask for pain scale

● Pulse - assess for pedal pulse (if absent,

may indicate impeded blood flow)

● Paralysis

Diagnostics: Fractures

● Radius Radiographic Examination ○

Reveals initial injury and subsequent

healing progress

● Blood Studies

● Bleeding

● elevated aspartate transaminase

● Muscle Damage

● Decreased hemoglobin and hematocrit

● Lactic dehydrogenase

Principles of Splinting

• Stabilize fracture & assess site

• Check distal pulse & cap refill (before/after splint)

• Prepare splint (measure on uninjured limb)

• Apply & secure splint (pad, position of function)

• Immobilize joints above & below

• Assess 5 Ps: pain, pallor, pulse, paresthesia, paralysis

• Monitor circulation & neuro status

• Elevate + cold compress

• Call EMS, give analgesics

• Educate patient/family & maintain skin integrity

Pirani Scoring System

● Devised by Shafiq Priani, MD of

Vancouver

● Consist of 6 categories (3 in the hindfoot,

3 in the midfoot)

Varus

inward rotation - bottom of the

feet face each other

Valgus

outward rotation

Calcaneus

upward rotation - would

walk on heels

Quinus

downward rotation - would

walk on toes (tiptoe walk)

Scoliosis

● Spinal deformity that manifests as

lateral curvature of spine

● Most commonly in adolescent girls (due

to release of hormones)

● Familial pattern; associated with other

neuromuscular condition

● Idiopathic majority (di known ung cause)

Signs of scoliosis

● Uneven shoulders

● Curve in spine

● Uneven hips

Scoliometer

● Is an inclinometer designed to measure

trunk asymmetry, or axial trunk rotation.

It's used at three areas

○ Upper thoracic (T3-T4)

○ Middle thoracic (T5-T12)

○ Thoraco-lumbar area (T12-L1 or

L2-L3)

Lordosis

Inward curve of lumbar spine (just above

the buttocks)

Kyphosis

An excessive, forward-rounding

curvature of the upper back (thoracic

spine) exceeding 50 degrees, often

called a hunchback

Management: Scoliosis

● If the curve is greater than 20 degrees,

treatment can consist of conservative,

non surgical approach

● If the curve is greater than 40 degrees, it

may require surgery with spinal fusion

and wearing of braces for 23 hours — Not

24 hours to not impede circulation and

to allow rest

● Milwaukee brace - worn 23 hours/day for

3 years

● Plastic jacket vest

● Spinal fusion

● Teach/ encourage exercise

Development of Dysplasia of Hip

● Congenital hip dysplasia

● Improper formation or displacement of

the hip socket

Congenital Hip Dislocation

● Displacement of the head of the femur

from the acetabulum

● Present at birth although not always

diagnosed

● Familial disorder

● Unknown cause: may be fetal position in

utero

● Acetabulum is shallow and the head of

femur is cartilaginous at birth

Barlow’s Test

● With infant on back, bend knees

● Affected knee will be lower because the

head of the femur dislocates towards

the bed of gravity

● Additional skin folds with knees bent

● When lying on abdomen, buttocks of

affected side will be flatter

● Flex and ADDuct the hips (by bringing

thighs towards the midline)

Positive Test

● Femoral head dislocated posteriorly

from the acetabulum

● Dislocation is palpable as head slips out

of acetabulum

● Diagnosis is confirmed with Ortolani test

Ortolani’s Test

● Ortolani’s click

• With an infant supine, bend knee

and place thumb on bent knees

fingers at hip joint

• Bring femur 90 degrees to hip,

then abduct

• Palpable click- dislocation

● Hips are examined one at a time

● Flex hips and knees at 90 degrees

● Thigh is gently Abducted

○ POSITIVE TEST

■ Femoral head reduces

into the acetabulum

■ A palpable and audible

clunk as hip reduces

Trendelenburg Test

● If child can walk

● Have child stand on affected leg daily

● Pelvis will dip on normal side as child

attempts to stay erect

E.Osteogenesis Imperfecta

● Connective tissue (collagen) disorder in

which fragile bone formation leads to

recurring (pathologic fractures)

● Brittle bone disease

● Rare genetic disorder in which bones are

fragile and fracture easily resulting in

bone deformity

● An autosomal dominant disease

• Involves error in synthesis of collagen, a

  connective tissue

Radiographic Features: E.Osteogenesis Imperfecta

● Bones are thin and under-tubulated

(gracile), normal in length or shortened,

thickened and deformed by multiple

fractures

● Intra-sutural (Wormian) bones can be

identified on skull radiographs

● In severe form of osteogenesis

imperfecta the diagnosis may be made

before birth by detailed UTZ in the

second trimester

● Cranial enlargement

● Shortening of limb bones as a results of

intrauterine fractures

Osteogenesis Imperfecta and Eyes

The reduced functioning of Type 1

collagen leads to the thinning of the

sclera and consequent showing of the

underlying veins through the whites of

eyes

Blue sclera

is one of the major

symptoms of OI and helps in the

diagnosis of the disorder

TYPE I OSTEOGENESIS IMPERFECTA

● Most common

● People who have type 1 disease

generally reach normal height and have

few obvious skeletal deformities

● Typically causes more fractures during

childhood than in adulthood

● Hearing loss is pronounced and begins

early in childhood

TYPE II OSTEOGENESIS IMPERFECTA

• Most severe & rare, often fatal (stillborn)

• Causes multiple fractures (long bones + ribs)

• Beaded ribs, short & broad bones

• Poor skull ossification

• Abnormal collagen → severe respiratory problems

TYPE III OSTEOGENESIS IMPERFECTA

● Produces obvious skeletal deformities.

Fractures before birth are common;

● UTZ can detect them in the fetus

● Also affects the lungs and muscles

● Hearing loss begins in early childhood

and often becomes complete by

adolescence

TYPE IV OSTEOGENESIS IMPERFECTA

● More severe than type 1 but less severe

than type 3

● Fractures are most common before

puberty

● Hearing loss begins in early childhood

and is often profound

Signs and Symptoms: Osteogenesis Imperfecta

● All people with OI have weak bones,

which makes them susceptible to

fractures

● Usually below average height (short

stature)

● History of multiple fractures

● Bone deformity

● Increased serum alkaline phosphatase

● Poor skeletal development

● Soft brownish teeth

● Hearing loss

● Blue tint to the whites of their eyes (blue

sclera)

Management: Osteogenesis Imperfecta

● Orthopedic surgery - intramedullary rod

insertion

● Bisphosphonates to increase bone

mineral density

● Lightweight leg braces to aid in mobility

and ambulation

Care of Child with Cast

● If cast is of plaster - will remain wet for at

least 24 hours

● Cast must remain open to the air until

dry

● Casted extremities are elevated to help

blood return and reduce swelling

● Initial chemical hardening reaction may

cause a change in an infant’s body

● Choose toys too big to fit down cast

● Do not use baby powder near cast -

medium for bacteria

Common Injury

● Dislocation - joint displaced

● Bruise - soft tissue injury

● Sprain - overstretched ligament

● Fracture - cracked or broken bone

● Concussion - injury to the brain

Acute Injury

● Occur when there is sudden stress on

the body

● Three main causes

● Collision with opponents or obstacles

● Being struck by an object

Chronic Injury

● Caused by continuous stress on a body

part over a long time

● Caused by training too hard, not

allowing time for recovery, poor footwear

and bad technique

● Overuse injuries occur due to repeated

powerful muscle movements

RICE Management

● R- Rice

● I- Ice

● C- Compression

● E- Elevation

No H.A.R.M management

● Heat - precipitating factor for bleeding

● Alcohol

● Running

● Massage

Hard Tissue Injury

● Bone injuries

● Bone fractures either cracks or breaks

Soft Tissue Injury

● Involves damage to skin, muscles,

tendons, ligaments or cartilage

● An open injury means that skin has been

broken- blood usually escapes.

● A dosed injury occurs beneath the skin-

there is no external bleeding.

● Closed injuries include bruising, pulls,

strains, and sprains

Least to Most Severe

1. Blister

2. Sprain with torn ligaments

3. Sprain with stretched ligaments

4. Strained muscle

5. Bruising

6. Bad cut

7. Dislocation

D.R.A.B.C Management

● Danger

● Response

● Airway

● Breathing

● Circulation

Causes and Treatment: R.I.C.E.

Sprain wrenching force tears ligament

Causes and Treatment: Concussion

brain injured by the blow

to the head — D.R.A.B.C and go to the

hospital