PEDS Acquired Disorders

Fractures

• 42% of boys and 27% of girls will suffer a fracture during childhood

• The most common fractures are in the wrist and forearm

• Most heal well with minimal treatment

• Midclavicular, humerus or femur fractures can occur during the birth process.

Spiral fracture

in kids, can indicate sign of abuse.

5 Ps; Compartment Syndrome

pain (increased out of proportion), pulselessness, pallor, paresthesia, and paralysis.

Casts

• Traditionally plaster, now commonly fiberglass 

• Immobilize a bone that has been injured or a diseased joint

• Holds the fracture in reduction

Cast Application

• Allow child to touch casting material, choose colors.

• Age appropriate explanations of cast application.

• Explain that it may feel warm in the cast, as the cast drying.

• Pre-medicate as needed, distraction is good too. 

• Instruct family to keep cast still until fully dried.

Cast Care

• Circulation, Movement & Neuro checks frequently

•  Compartment syndrome 5 “Ps” – report immediately!

  • Pain

  • Pulselessness

  • Pallor

  • Paresthesia

  • Paralysis

•  Never insert anything into the cast for the purposes of itching!

•  Protect from wetness

•  Change position frequently

•  Crutch use

Rickets

Softening or weakening of the bones

• Nutritional Deficiencies – Calcium, vitamin D

• Limited exposure to sunlight

• Chronic renal disease

• GI disorders involving altered fat absorption: Crohn, celiac, cystic fibrosis

• Premature infants

• Treatment: Correct calcium imbalance with calcium and phosphorous supplements. Some children may require Vitamin D supplements.

• Exposure to moderate amounts of sunlight.

Slipped Capital Femoral Epiphysis

• Femoral head dislocates form neck and shaft of femur. Left side affected more than right.

  • Teenage growth spurt

  • Hormonal alterations

  • Obesity

• Treatment: 

  • Surgery to:

    • Prevent further slippage 

    • Minimize deformity

    • Avoid necrosis of cartilage and/or femoral head

Scoliosis

•  Lateral curvature of the spine that exceeds 10 degrees.

•  May be congenital, associated with other disorders, or idiopathic (most common, occurs during adolescence).

•  Idiopathic mostly seen in girls, most obvious during growth spurt.

Idiopathic Scoliosis - Treatment

• Aimed at preventing progression of curvature and decreasing impact on pulmonary and cardiac function.

• Treatment based on age of the child, expected future growth and severity of the curve.

• Monitor curve progression.

• Surgical correction is often required fir curves greater than 45 degrees.

Monitoring curvature

• < 10 degrees – normal variation

• < 20 degrees – monitor for changes

• 20-40 degrees – bracing (type depends on location and severity) have to get a brace and surgery

• > 40 degrees – surgery to realign and fuse spine with rods.

Nursing Management - Scoliosis

•  Encouraging brace compliance

• Noncompliance because: uncomfortable, pain, heat, poor fit, body image, family environment

•  Skin integrity with brace

• Promote positive body image

•  Provide preop care

•  Provide postop care – neurovascular checks, log-rolling, pain management, IV antibiotics, monitor for excessive blood loss, skin care, prevent complications, arrangements for schoolwork/tutor

Osteomyelitis

• Bacterial infection of the bone and soft tissue around the bone (Staph aureus most common, also group A and B streptococcus, E. Coli, S. pneumoniae, H.flu).

• Acquired hematogenously. Bacteria from blood invade rapidly growing bone. Trigger inflammatory response, pus, edema, vascular congestion.

• Bone tissue can die.

• Risk factors: Impetigo, varicella lesions that get infected, infected burns, trauma, orthopedic surgery

Manifestations and Diagnosis of Osteomyelitis

• Manifestations: 

  • Irritability, lethargy, possible fever, pain, change in activity level (patient usually refuses to walk)

• Labs: Increased WBC, ESR, CRP and positive blood cultures

• DX: CT, MRI, X-ray, aspiration to confirm organism

Treatment and Nursing Care of Osteomyelitis

• IV antibiotics (up to 4 weeks of antibiotic therapy depending on organism and extent of infection)

• Pain management

• Bed rest, initially

• Antipyretics

• Crutches or walker

• Developmentally appropriate diversions

• Watch for septic thromboembolisms!

Septic Arthritis = Joint infection

• Bacteria invade joint space.

• Most often hip or knee.

• Usually occurs in children less than 3 yrs.

• Bacteria gain access through bloodstream but can also happen due to direct puncture through injections, IV starts, wound infections, surgery or injury.

• Staph Aureus most common causative agent. Also: MRSA, streptococcus, N. meningitidis, H. influenzae

• Sepsis of hip joint may cause avascular necrosis

• This is a medical emergency!

Manifestations of a septic joint

•  Toxic (sick) appearance

•  Fever

•  Pain

•  Refusal to bear weight or straighten joint

•  Limited range of motion – any attempt to test  ROM will result in pain

•  Child will hold joint in a position of comfort

• High risk for septic PEs and other thromboembolisms!

Diagnosis and Treatment - Septic Arthritis

•  WBCs may be normal or with elevated, elevated ESR and CRP

•  Fluid from joint aspiration (orthopedic surgeon does) may have elevated WBCs; culture determines organism

•  Joint radiograph will show subtle soft tissue changes in joint space

•  Positive culture from joint aspiration

•  Goals of treatment are to prevent destruction of the joint:

  • IV antibiotics for minimum of 10 days 

  • May be discharged after 72 hours if child can tolerate po antibiotics and there is improvement

  • Care of aspiration site

  • Watch respiratory status (PEs) 

  • Pain relief

  • Physical Therapy