Nursing Management of Orthopedic Physical Assessment

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Nursing Management of Orthopedic Physical Assessment Powered By Docstoc
					Orthopedic Physical
     Pediatric Nursing
Newborn Physical Assessment
               Family History
   Any family members with musculoskeletal
    problems; genetic component
                 Birth History
   Weight and height
   Gestational age
   Birth presentation
   Single or multiple birth
   Type of birth: NSVD, forceps, vaginal
    extraction, cesarean section, shoulder
   Asphyxia at birth: apgar score
          Brachial Plexus Injury
   Excessive traction of the spinal nerve roots C5-
   Many brachial plexus injuries happen when the
    shoulders become impacted during delivery and
    the brachial plexus nerves stretch or tear.
     Symptoms of Brachial Plexus
   Limp or paralyzed arm
   Lack of muscle control in arm, hand or wrist
   Lack of feeling or sensation in arm or hand
Brachial Plexus Injury
 Developmental Dysplasia of Hip
Developmental dysplasia of the hip is an
abnormal formation of the hip joint in which
the ball at the top of the femoral head is not
stable in the acetabulum. The severity of
instability varies in each patient. Newborns and
infants with DDH may have the ball of the hip
loosely in the socket, or the hip may be
completely dislocated at birth.
              Barlow Maneuver
   The maneuver dislocates a dislocatable hip
   The hip is flexed and the thigh is brought into
    an adducted position.
   From that position the femoral head drops out
    of the acetabulum or can be gently pushed out
    of the socket.
             Barlow Maneuver
   Best done on a non-crying infant.
Adducted hip position
             Ortolani Maneuver
   Reduces a posteriorly dislocated hip.
   The thigh is flexed and then adducted while
    pushing up with the fingers located over the
    trochanter posteriorly.
   The femoral head is lifted anteriorly into the
              Positive Ortolani
   A clunk and a palpable jerk are felt as the
    femoral head is re-located.
   A mild clicking sound is not a positive sign.
   Most often positive in the first 1 to 2 months of
Ortolani Maneuver
             Galeazzi Maneuver
   Flex the hips and knees while the infant / child
    lies supine, placing both the soles of the feet on
    the table near the buttocks.
   Looking to see if the knees are aligned.
   Positive sign if knees are uneven.
Galeazzi Maneuver
            Limited Abduction
   This would be a positive sign of developmental
    dysplasia of hip in the older infant.
Limited hip abduction
Asymmetry of skin fold
   Maintain hips in flexed position
   Traction to stretch muscles
   Pavlik harness
   Hip surgery
Pavlik Harness
           Metatarsus Adductus
   Most common foot deformity
   2 per 1000
   Result of intrauterine positioning
   Forefoot is adducted and in varus, giving the
    foot a kidney bean shape.
   Most often resolves on own or with simple
   Toes angle toward the midline, creating a C-
    shaped lateral foot border with a prominent
    styloid process of the fifth metatarsal.
Metatarsus Adductus
   Exercises
   Soft shoe
   Casting
   Talipes equinovarus is a congenital deformity.
   Has four main components:
     Inversion and adduction of the forefoot
     Inversion of the heel and hindfoot

     Equinus (limitation of extension) of ankle and
      subtalar joint
     Internal rotation of the leg
   Result of intrauterine maldevelopment of the
    talus that leads to adduction and plantar flexion
    of the foot.
Club Foot
     Tips to examining the toddler

   Start the exam by getting a good history.
   Often the toddler will get bored and climb off
    the parents lap and explore the room.
   Observe the child moving around the room.
   If the child does not get up and move around,
    pick up the child, move the child a few feet away
    and have them walk back to the caretaker.
                   Gait Exam
   Observe child walking without shoes and with
    minimal clothing.
   In the toddler the stance will be wider and arms
    are held out for balance.
   The 3-year-old should have a more mature
   Look for toe-walking
Toddler Walking
                         Red flags!
   A toddler who is not walking by 15 to 18
     Check to see if there is an older child in the
     Ask parent is child is “cruising” or will pull
      themselves up to a standing position.
Infant Cruising
Gait Deformities
                 Genu varum
   Bowing of the legs
   Normal up to 3 years of age
Genu Varum
     When is bowlegged considered a
   Tibial-femoral angle greater than 15 degrees.
   Associated internal tibial torsion
   Intercondylar (knee) distance greater than 4 to 5
   Joint laxity in the older child.
Figure II intercondylar distance
Blount Disease
                Genu Valgum
   “Knock-Knees”
   Physiologic valgum tends to peak at around 24
    to 36 months and self corrects at about 7 to 8
   Tibial-femoral angle less than 15 degrees of
    valgus in a child over 7 to 8 years of age.
   Awkward gait
   Intermalleolar (ankle) distance with knees
    together greater than 4 to 5 inches.
   Often associated with short stature.
Intermalleolar Distance
          Differential Diagnosis
   Rule out other causes of limb deformity.
         What in the history would be
   Vitamin D intake
       Whole milk, butter, egg yolks, animal fat and liver,
        especially fish liver oil.
   Environment:
     Cool mountain areas of Asia and Latin America
      where babies are kept wrapped up and inside.
     Crowded cities where children are not exposed to
        Osteogenesis Imperfecta
   Genetic disorder
   Caused by a genetic defect that affects the
    body’s production of collagen.
   Collagen is the major protein of the body’s
    connective tissue.
   Less than normal or poor collagen leads to weak
    bones that fracture easily.
        Osteogenesis Imperfecta
   Often called “brittle bone disease”
   Characteristics
     Demineralization, cortical thinning
     Multiple fractures with pseudoarthrosis

     Exuberant callus formation at fracture site

     Blue sclera

     Wide sutures

     Pre-senile deafness
Brittle Bone Disease
                Clinical Pearl
   Child may present as child abuse.
   The infant / child may have a minor reported
    accident that results in significant injury.
            3-month-old with OI

Old rib fractures

                       Old fractures/demineralization
             School Age Child
   Osgood-Schlatter Disease
   Tibial Torsion
   Popliteal Cyst
        Osgood-Schlatter Disease
   Inflammation of tibial tubercle, an apophysis
   Cause: repetitive micro-trauma to the tibial
    tubercle apophysis, which results in
    inflammation, microfractures, and new bone
    formation at the tubercle apophysis.
   Most common:
     Boys ages 10 to 15 years
     Girls ages 8 to 14 years
   Recent physical activity: track, soccer, football,
    gymnastics, surfboarding
   Pain increases during and immediately after
                Physical Exam
   Point tenderness pain, prominence over the
    tibial tubercle
   Pain with knee extension against passive
    resistance or with full passive knee resistance.
   Decreased ROM
Osgood-Schlatter Disease
   R.I.C.E. - rest, ice, compression, and elevation
   medications (for discomfort): Ibuprofen
   elastic wrap or a neoprene knee sleeve around
    the knee
   activity restrictions
   physical therapy (to help stretch and strengthen
    the thigh and leg muscles)
                      Tibial Torsion
   Tibial torsion is a term used to describe the
    normal variation in tibial rotation.
     Medial tibial torsion describes abnormal medial
      rotation or twisting, resulting in in-toeing of the feet.
     Lateral tibial torsion results in out-toeing.
   Often parent states that the child seems to be
    tripping over their own feet.
   Observe the child’s gait.
   Have the child kneel down and look at the feet
    from behind.
Tibial Torsion
              Thigh-foot Angle
   A line drawn thru the heel should intersect with
    the second toe of the foot. The image shows a
    foot with MTA where the line intersects with
    the fourth toe.
   90% will resolve by age 8 years
   Avoid prone sleeping and sitting on feet.
                 Popliteal Cyst
   Often called Baker’s Cyst are synovial lesion that
    result from herniation of the synovium of the
    knee joint into the popliteal space.
              Clinical Findings
   Swelling behind the knee with or without pain.
Popliteal Cyst
                Growing Pains
   Occur in 13 to 18% of children
   Called “leg aches”
   Cause: thigh and calf muscle fatigue
              Clinical Findings
   Discomfort appears in evening or late in the day;
    may even wake the child up from sleep.
   Pain gone by the morning with no limitation of
   Occurs in front of thighs, in the calves or
    behind the knees.
   No tenderness
   No guarding
   No decreased ROM
   No limp
   About 6% of school-aged children have
    coordination problems serious enough to
    interfere with simple motor tasks such as
    running, buttoning or using scissors.
   First identified in 1975
   Now called: developmental coordination
    disorder or DCD.
Duchenne’s Muscular Dystrophy
   Difficulty rising to a standing position
             Scoliosis Screening
   Should be done with every well child physical
    from about age 8 or 9.
   May be referred to you after screening at school.

Lateral curvature of spine

         Clinical Manifestations
•   Pain is not a normal finding
    for idiopathic scoliosis
•   Often present with uneven hemline
•   Unequal scapula
•   Unequal hips
   Unequal shoulder heights
   Unequal scapula
   Unequal waist angles – hip touches arm and
    contralateral arm hangs free
   Unequal rib heights when the child stands in a
    forward bend.

   Bowden & Greenberg
                 Mild Scoliosis

                       Mild forms

                       Strengthening and


Ball & Bindler
   Alert: If pain is a reported symptom of the
    child’s scoliosis, it should be investigated
    immediately. Pain is not a normal finding for
    idiopathic scoliosis, and the presence of this
    symptom could be signaling an underlying
    condition such as tumor of the spinal cord.
      Common Pediatric Orthopedic
   Legg-Calves-Perthes Disease
   Slipped Capital Femoral Epiphysis
   Infection: septic arthritis
   Inflammation of a joint: rheumatoid arthritis
         Legg-Calve-Perthes Disease
   Often called avascular necrosis of the femoral
   Cause: some ischemia episode of unknown
    etiology that interrupts vascular circulation to
    the capital femoral epiphysis.
   Takes place over about 18 to 24 months
   More common in boys age between 4 and 8
    years of age.
   Acute or chronic onset with or without history
    of trauma to the hip such as jumping from a
    high place.
       Acute: sudden onset of pain in the groin or knee
        often occurring at night and stiffness

       Chronic: Mild aching in hip (groin area) or referred
        to the knee or anterior thigh. Limping after activity
        or in the morning
   Antalgic gait with a positive Trendelenburg sign
   Muscle spasm
   Decreased abduction, internal rotation, and
    extension of the hip
   Pain on rolling the leg internally
Trendelenburg Sign
AP Pelvis and frog-leg lateral
             Slipped Capital Femoral
   Upper femoral epiphysis slips from its position
    in the hip joint
   Most common hip disorder in the adolescent
     Occurs more commonly in males
     Skeletal immaturity:
          Males 10 to 15 years
          Females 11 to 12 years

       African American and Polynesian populations more
   Acute or chronic thigh or knee pain
   History of mild trauma to the hip area
   Child is often large for age or overweight
   Pain in groin or diffusely over knee or anterior
   Pain and decreased internal rotation
   Antalgic limp (due to shorter leg)
   External rotation of leg when walking
   External rotation of the thigh when hip is flexed
   Thigh atrophy (measure and compare)
   Limited abduction and extension
Clinical Manifestations
                Septic Arthritis
   Infection within a joint or synovial membrane
   Infection transmitted by:
     Bloodstream
     Penetrating wound

     Foreign body in joint
Septic Hip
Diagnostic Tests


               Needle aspiration
               under fluoroscopy
    Erythrocyte Sedimentation Rate
   ESR
   Used as a gauge for determining the progress of an
    inflammatory disease.
   Rises within 24 hours after onset of symptoms.

   Men:      0 - 15 mm./hr
   Women: 0 – 20 mm./hr
   Children: 0 – 10 mm./hr
   Administration of antibiotics for 4 to 6 weeks.
   Oral antibiotics have been found to be effective
    if serum bactericidal levels are adequate.
   Fever control
   Ibuprofen for anti-inflammatory effect
      Juvenile Rheumatoid Arthritis
   Chronic inflammatory condition of the joints and
    surrounding tissues.

   Often triggered by a viral illness

   1 in 1000 children will develop JRA

   Higher incidence in girls
          Clinical Manifestations
   Swelling or effusion of one or more joints
   Limited ROM
   Warmth
   Tenderness
   Pain with movement
          Diagnostic Evaluation
   Elevated ESR / erythrocyte sedimentation rate
   + genetic marker / HLA b27
   + RF 9 antinuclear antibodies
   Bone scan
   MRI
   Arthroscopic exam

Description: Nursing Management of Orthopedic Physical Assessment- pediatric nursing