U2L5: Alterations in Mobility

skeletal differences in children (4)

- flexible bones

- posture

- growth plates

- bone healing

why are childrens bones more flexible?

more porous & thick periosteum -> bends doesn't break

toddler posture (3)

- lordosis

- potbellied

- swayback

adolescence posture

thoracic kyphosis

what are the names of ends of bones?

epiphysis & physis

how do children growth plates differ than adults?

incomplete growth of growth plates - androgens fuse growth plates in adolescence

how does bone healing in children differ than adults?

heal faster -> strong periosteum w abundant blood supply

physis (epiphyseal plate)

cartilage growth plate that receives a separate blood supply

- weakest point of long bones

rickets

softening & weakening of bones

rickets causes (5)

- vit D def (most common)

- mineral def -> calcium & phosphorus

- limited sun exposure

- kidney disease

- GI disorders

what causes vit D def?

impaired calcium & phosphorus absorption -> defective bone mineralization

signs of rickets (5)

- bowed legs

- bone pain

- cavities

- weak muscle tone

- growth delays

ricket complication

deformities

rickets preventative measures (2)

- infants get 400IU of vit D after birth -> possibly provided in formula

- 1-18 yrs >600IU of vit D daily

rickets management (3)

- calcium & phosphorus supplements qd -> correct imbalance

- exposure to sunlight

- vit D supplements

how should you take calcium & phosphorus supplements?

alternate times -> giving tgt can decrease absorption

slipped capital femoral epiphysis (SCFE)

spontaneous displacement of femoral epiphysis from the growth plate -> ball stays attached to acetabulum

epiphysis

ball of femur

who is SCFE most common in?

boy in their preteens & teens during or before their growth spurt

risk factor of SCFE

obesity

SCFE clinical manifestations (5)

- limp

- pain in hip, groin, thigh, or knee

- affected leg externally rotated

- loss of hip movements

- shorter affected leg

what manifestation of SCFE indicates hip evaluation?

gradual progression of knee pain

SCFE dx (2)

- physical exam

- x ray

SCFE management

surgical in situ pinning -> pin removed when growth place closes

*required

SCFE post op management (2)

- no or limited weight bearing

- crutches

legg calve perthes disease

avascular necrosis of femoral head -> femur lives since it receives a different blood supply

who is legg calve perthes disease most common in?

boys 4-6 y/o

- runs in families

4 stages of legg calve perthes disease

1. avascular necrosis

2. fragmentation - resorptive

3. re-ossification

4. remodeling -> shape may be diff

fragmentation phase of legg calve perthes disease

body removes dead bone & replaces it w cartilage

re-ossification phase of legg calve perthes disease

BF restored & new bone forms

legg calve perthes disease manifestations (3)

- intermittent limping

- soreness or stiffness -> worse w activity & improve w rest

- limited ROM in hip

legg calve perthes disease dx

x-ray

legg calve perthes disease management (4)

- contain femoral head in acetabulum

- rest or activity restriction (primary tx)

- NSAIDs

- PT

legg calve perthes disease tx (2)

- abduction brace

- if brace unsuccessful then surgery

abduction brace for legg calve perthes disease

pt stays in brace for a minimum of 6 wks & is used to maintain alignment -> most successful the younger the pt is

legg calve perthes disease surgery (2)

- femoral or pelvic osteotomy

- tenotomy

scoliosis

complex spinal deformity causing lateral curvature & vertebral rotation

most common type of scoliosis

adolescent idiopathic

congenital scoliosis

develops during fetal development -> vertebral defect

infantile scoliosis

develops from birth up to 3 yrs

juvenile scoliosis

develops from 3-10 y/o

adolescent scoliosis

develops during >10 y/o

idiopathic scoliosis

associated w pre adolescent growth spurts

neuromuscular scoliosis

associated w spina bifida & cerebral palsy

who does scoliosis affect more commonly?

females

asymmetrical scoliosis clinical manifestions (5)

- shoulder height

- scapular shape

- hip height

- pelvic obliquity

- rib cage sticks out

scoliosis complications (3)

- impaired lung fxn

- back pain

- change in appearance

scoliosis dx (4)

- adams forward bend test

- scoliometer

- physical assessment

- x-ray -> cobb angle determines degree of curve

when is scoliosis most commonly dx in girls & boys?

- girls: 10-12

- boys: 13-14

scoliosis management

goal is to prevent progression & tx is based on degree of curvature -> curve stops when child stops growing

mild scoliosis tx

<200 -> observation

moderate scoliosis tx

20-40o -> bracing

severe scoliosis tx

>40o -> surgery

bracing types in scoliosis pts (3)

- boston & wilmington

- charleston

- thoracolumbosacral orthotic (TLSO)

how does bracing tx scoliosis?

prevents further progression of curve -> doesn't fix it

*worn until stop growing

scoliosis brace tx problems

long duration/body image may contribute to poor adherence

types of surgeries used to tx scoliosis (3)

- spinal fusion

- expandable/growing rods

- halo-gravity traction

spinal fusion

uses risser staging to ensure growing is done -> area of fusion becomes immobile

expandable/growing rods

done for children still growing & cant wait -> uses VEPTR & used for thoracic insufficiency

*gets spinal fusion once done growing

halo gravity traction

used before spinal fusion & applies pully traction to stretch spine -> reduces risk of damaging nerves

* requires back brace after

halo gravity traction management (4)

- mobility encouraged

- neuromuscular & vascular assessments

- pain meds

- pin care -> push skin in so doesn't get stuck

scoliosis post op pain control

continuous & demand PCA

scoliosis post op positioning & mobility (3)

- lie flat immediately post op

- log roll q2 hrs

- OOB day 1 & ambulate day 2

scoliosis post op drains & complications (3)

- hemovac & foley

- transient ileus/urinary retention

- pulmonary toileting

scoliosis post op monitoring (3)

- neurovascular assessment

- monitor for hypotension

- skin integrity

children at risk for fractures (3)

- increased activity

- limited coordination

- incomplete ossification

most common fracture in children

radial/ulna

most common causes of fractures in childhood (5)

- birth trauma -> small pelvis can fracture collarbone

- falls

- motor vehicle collisions

- sports

- abuse

closed/simple fracture

without break in skin

open/compound fracture

bone visible through skin

complicated fracture

damage to organs from bone fragments

comminuted fracture

break or splinter in more than 2 fragments

greenstick fracture

incomplete fracture -> bone bends

transverse fracture

straight line across the bone

spiral fracture

spirals around the bone

buckle fracture

compression causing a bulging area of bone

physeal (growth plate) injury dx

difficult to detect on x-ray

type 1 physeal injury

separation of growth plate without fracture of bone

type 2 physeal injury

separation of growth plate breaking off metaphysis

type 3 physeal injury

fracture extending through joint surface -> horizontal

type 4 physeal injury

fracture of growth place, epiphysis, metaphysis, & end of bone -> vertical

type 5 physeal injury

crushing injury of epiphysis

fracture clinical manifestations (5)

- muscle tightness

- generalized swelling

- deformity

- diminished fxn

- crepitus

goals of fracture management (4)

- reduction -> regain alignment

- immobilization -> retain alignment

- restore fxn

- prevent further injury

ways to achieve reduction for fractures (3)

- closed reduction

- percutaneous pin fixation

- open reduction

ways to achieve maintenance of alignment (immobilization) for fractures (3)

- casting

- internal/external fixation

- traction

plaster casting

takes 24-48 hrs to dry, position w pillow, & prevent depressions in cast

fiber glass casting

dries quickly & feels warm inside cast

ways to restore fxn for fractures (3)

- weight bearing

- active movement

- begins once fracture is deemed stable

types of tractions (2)

- skin traction -> bryants & bucks

- skeletal traction -> halo

how does bucks traction work?

keeps legs fully extended to keep bone aligned

traction nursing management (3)

- maintain traction

- maintain body alignment

- maintain skin integrity

cast care (4)

- frequent repositioning

- petaling cast edges unless waterproof

- limit moisture

- elevate extremity

cast removal

warn child of heat & tickling sensation

compartment syndrome

increased pressure within fascia compromises circulation to enclosed muscles & nerves

6 Ps to watch for regarding compartment syndrome (6)

- pain out of proportion

- pulselessness

- pallor

- paresthesia

- paralysis

- pressure

compartment syndrome tx

fasciotomy -> requires immediate intervention

- avoid cold & do not elevate (further restrict BF)

fracture complications (6)

- circulatory impairment

- nerve compression

- compartment syndrome

- mal-union

- inf

- pulmonary emboli

overuse syndrome

soft tissue injury affecting bone muscle, ligament, & or tendon

who is overuse syndrome most common in?

young children