Lecture 9b: Peds Orthopedics and Nursing Care

Define scoliosis.

lateral, 3-dimensional curvature of the psine that usually involves spinal rotation

What Cobb angle indicates scoliosis?

> 10 degrees

What Cobb angle indicates spinal asymmetry?

< 10 degrees

In what two categories is scoliosis grouped into?

onset and etiology

What are the 2 onset classfications of scoliosis?

1. Early onset

2. Late onset

What are the 3 etiology classifications of scoliosis?

1. Congenital scoliosis

2. Neuromuscular scoliosis

3. Idiopathic scoliosis

Define congenital scoliosis.

caused by a deformity in the development of the vertebral column in utero

When does the abnormal development of congenital scoliosis occur?

6 weeks of gestational age

Congenital scoliosis includes the failure of ________, or failure of ________.

formation; segmentation

How can a spinal deformity be discovered in congenital scoliosis?

on prenatal ultrasound

Name 3 symptoms of neuromuscular scoliosis.

• spasticity

• weakness

• low muscle tone

Name 9 syndromes that can cause scoliosis.

• Cerebral Palsy

• Muscular Dystrophy

• Spinal Muscular Atrophy

• Neurofibromatosis

• Myelomeningocele

• Ehlers'-Danlos Syndrome

• Marfan syndrome

• Osteogenesis imperfecta

• Achondroplasia

Define neuromuscular scoliosis.

result of muscle imbalance and lack of trunk control

What can early detection do for neuromuscular scoliosis?

early intervention may help improve function and delay progression

Name 4 examples of function that can be improved in neuromuscular scoliosis.

• ambulation

• positioning in wheelchairs

• prevention of p[ressure ulcers

• cardio-pulmonary function

What are the 3 sub-categories of idiopathic scoliosis?

• infantile

• juvenile

• adolescent

Which type of idiopathic scoliosis is the most common? How many of the cases does it make up?

adolescent idiopathic scoliosis; 80-85%

What are the 2 primary concerns regarding scoliosis?

• activities of daily living

• aesthetic appearance

What is different between girls and boys in adolescent idiopathic scoliosis?

• girls are at risk for larger cruves requiring tretamnet

• boys are less at risk but tend to progress quickly

WHat are the 4 main curve patterns in idiopathic adolescent scoliosis?

• thoracic

• throac-lumbar

• lumbar

• double major

3 aspects of inspection in assessment for scoliosis?

1. shoulder height asymmetry

2. pelvic/hip asymmetry

3. head in line with center of sacrum

What is Adam’s forward-bending test?

• assess degree of rotation and deformity

• patient bends forward at waist with knees straight and palms together

• thoracic or lumbar prominence noted

What does a scoliometer?

measures angle of trunk rotation; run along spine from top to bottom during forward bend test

What scan is used to diagnose scoliosis?

x-ray

When is an x-ray required to confirm diagnosis?

• clinically evident scoliosis based on physical exam

• thoracic or lumbar asymmetry on physical exam

• family history of scoliosis

What 4 things does a 3 foot spine x-ray identify?

• site of deformity and curve pattern

• magnitude of curve

• skeletal maturity

• spondylolysis/spondylolisthesis

Define the Cobb angle.

degree of curvature measured according to Cobb method

Define the Risser Sign.

degree of ossification and fusion of iliac crest/apophysis

What is the Risser Sign used to assess?

Skeletal maturity using x-ray

How does skeletal maturity progress?

stepwise fashion from lateral to medial

What can skeletal maturity correspond with in females?

menarche status

Patients should be monitored when….

• Cobb angle <25 degrees and still growing at time of presentation

• curve more than 45 degrees and finished spinal growth

Patients should be treated when…

• Cobb angle >25 degrees considered for bracing if skeletally immature

• Cobb angles >45-50 degrees at time of diagnosis will likely require surgery

What does bracing do for scoliosis?

• arrests curve progression

• does not correct curvature

• reduces chance of progressing to surgery

In what level skeletal maturity can bracing be used?

skeletally immature: Risser 0-2

What is the goal of operative intervention of scoliosis?

prevent curve progression through spine stabilization

Name the 2 broad categories of operative interventions in scoliosis.

1. Growth Modulation Techniques

2. Definitive Fusion

Name 2 types of Growth Modulation Techniques.

1. MAGEC Rods - magnetic growing rod

2. Vertebral Body Tethering

Name an example of definitive fusion.

posterior spinal fusion

Describe a spinal fusion.

• steel rods are put in place to help support the fusion of the vertebrae

• bone grafts are placed to grow into the bone and fuse the vertebrae

What is monitored in the PACU of a post-spinal fusion surgery patient?

• vital signs

• CMS

• fluid balance

• urinary output

• pain control

On post-op surgical unit recovery goals?

• good pain management

• frequent and early mobilization

• fluid balance regulation

• diet tolerance

Expected activity for POD 1?

standing at bedside BID

Expected activity for POD 2?

walking BID or more

What is the diet protocol for post-op spinal patients?

progressive over 3 days

What specific neurovasc checks are included in post-op care?

ankle dorsiflexion

What medication implications are there for post-op spinal patients?

APS follows patient for PCA + PO adjuncts while in hospital

Bowel protocol for post-op spinal patients?

restoralax daily

Assessment nursing responsibilities for post-op spinal patients?

• monitor effects of PCA and PO analgesia

• peripheral neurologic signs in extremities

• bladder function/flatus

• surgical site and dressing check q4h

Mobility nursing responsibilities for post-op spinal patients?

• support patient with standing and walking in the hallway

• encourage sitting up, bending legs and moving feet

Emotional nursing responsibilities for post-op spinal patients?

reassuring fears of turning due to pain and damage to surgical area

Activity restrictions for discharge?

return to school 1 month post-op; no contact sports for 6 month

Diet instructions for discharge?

as tolerated, increased fluids and fibre-rich foods

Medication instructions for discharge?

• narcotic PRN

• tylenol x3D then PRN

• Celebrex x7D

• Baclofen x7D

• PEG 3350

Hygiene instructions for discharge?

• may shower 5-7 days post-op

• no baths or soaking for 6 weeks

What type of joint is the hip?

ball and socket joint

What part of the hip joint is the “ball”?

femoral head

What part of the hip joint is the “socket”?

acetabulum

Define Developmental Dysplasia of the Hip.

complete spectrum of abnormality in the developing hip that can range in severity from acetabular dysplasia to subluxation to complete dislocation of the hip joint

Describe the natural history of DDH in the first few weeks of life.

mild dysplasia with mild instability; usually benign course

What symptoms in DDH patients may indicate progressive dysplasia?

instability and frank dislocation

What can DDH that persists into adulthood can lead to?

• abnormal gait

• decreased strength

• LLD with hip deformity

• rapid degeneration of joint and arthritis in hips and knees

Name the 5 F’s risk factors for DDH.

1. Family history

2. Fetal position

3. First born infant

   1. Females

4. Fluids

What fetal position indicate a higher risk of DDH?

feet first/breech

What fluid level indicate a higher risk of DDH?

history of oligohydramnios

Neck assessment findings indicative of DDH?

• preference to one side

• plagiocephaly

• torticollis and strength

Spine assessment findings indicative of DDH?

dysraphism

Upper and lower extremities assessment findings indicative of DDH?

• generalized motor assessment and reflexes

• foot abnormalities

Hip assessment findings indicative of DDH?

• asymmetrical creases

• range of motion

• barlow or ortolani maneuver

• Galeazzi sign

How does swaddling affect the hips?

• keeping the hips in a legs together extended knee position have higher rate of hip dysplasia

Goal of treatment for DDH under 6 months?

obtain and maintain concentric reduction of the hip and allow for healthy development of the acetabulum and hip joint

Treatment for DDH under 6 months?

Pavlik Harness

How does a Pavlik Harness help DDH?

• holds hips in a flexion and abduction position

• prevent adduction of the hip

When are secondary treatment options used for DDH?

• if the Pavlik Harness has failed to reduce the hip

• child is over 6-12 months at diagnosis

Name 3 types of secondary treatment options for DDH.

1. Fixed abduction brace

2. Closed reduction under anesthesia and hip spica cast

3. Open reduction +/- pelvic osteotomy and hip spica cast

What is the age limit for closed reduction under anesthesia and hip spica cast?

2 years of age

Name 4 types of hip procedures that require hip spica cast.

• femur fractures

• developmental dysplasia of the hip

• pelvic osteotomies

• CP procedures

Describe a spica cast.

plaster case from upper torso down to the ankles

Name 3 variations of the spica cast.

• bilateral full leg

• unilateral

• bilateral short leg

What is the objective of the spica cast?

immobilization of the hip, pelvis, and/or femur

Pain management for DDH/spica cast?

• single shot spinal

• IV narcotics via NCA/PCA

• PO narcotics

• antispasmodics

• adjuncts

• stool softener

Key positioning for skin care and incontinence management in spica cast?

reverse trendelenburg

Other elements of skin care and incontinence management in spica casts?

• children who have had osteotomies may have ++ genital swelling

• check skin for breakdown from cast

• keep cast as clean and dry as possible

• sponge bath only while in cast

• combat smells with eucalyptus oil

Parent and family teaching for skin care and incontinence management in spica cast?

• diapering technique; double and sometimes triple diaper!

• patients can sit on the toilet with support from parents

• clothing to upper body only; has to be loose and larger rather than typical size

• check skin daily for sores

• casts are not waterproof so no bathing or swimming

• watch food that may spill into front of cast or get trapped inside

• if skin becomes itchy, no objects underneath