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Peds Exam 2
Neuromuscular and Musculoskeletal Disorders
| Question | Answer |
|---|---|
| Pediatric Variations: Brain and spinal cord development | Embryo differentiates into brain and spinal cord at 3–4 weeks Premature infants have an immature central nervous system Spine is very mobile, so cervical spine injury risk is higher |
| Pediatric Variations: Myelinization | Structure is complete at birth Myelinization completes around 2 years of age |
| Pediatric Variations: Muscular development | Female infants have laxer ligaments Rapid growth in adolescence brings clumsiness |
| Pediatric Variations: Skeletal development | Flexible, porous bones with a thick periosteum bend not than break Ossification complete Toddler lordosis Thoracic kyphosis Androgens in adolescence fuse the growth plates and growth stops Abundant blood supply in the periosteum so bones heal faster |
| Toddler lordosis | potbellied and swaybacked |
| thoracic kyphosis | adolescence |
| Congenital and Developmental Disorders | Neural tube defects: Spina bifida Metatarsus Adductus Congenital club foot Developmental Dysplasia Hip Osteogenesis Imperfecta |
| Neural Tube Defects (NTD) - Pathophysiology | Failure of embryonal neural tube closure, location varies |
| when does the neural tube form | occurs 3-4 wks gestation, around day 28 |
| Anencephaly | absence of cerebral hemispheres |
| Encephalocele | affects brain and meninges outpocketing of brainstem |
| Spina Bifida | affects spine, spinal cord |
| Risk factors for NTD | Folic acid deficiency Diabetes, maternal drug use Fever (known cause for NTD), hyperthermia (so thats why no hot tub/sauna) |
| Folic acid deficiency can be due to | decreased intake or decreased absorption, meds could be causing it |
| who should take folic acid supplement | all women at child bearing age |
| Spina Bifida- Types | Occulta- Closed- Spina Bifida (covered by skin) Open- (covered by membrane): Meningocele, Myelomeningocele or Meningomyelocele |
| spina bifida occulta (mild form) | Cutaneous clues, hairy patch, dimple, lipoma (spinal cord didn't form perfectly) Generally benign Complications: Tethered cord |
| spina bifida open (more serious): Meningocele | Sac-like protrusion in lumbar/sacral area- meninges and CSF Spinal cord normal – minor or no deficits |
| spina bifida open (more serious): Myelomeningocele or Meningomyelocele | Spina bifida cystica Sac-like extrusion- meninges, CSF, nerve roots or portion of spinal cord Would have more deficits |
| if infant has spina bifida, | they have a sore on their back so you want them on their bellies and not their backs |
| spina bifida prenatal diagnosis | Elevated alpha-fetoprotein (NB screening) Ultrasound Cesarean delivery so cord isn't damaged through birth canal |
| spina bifida diagnosis | Newborn physical exam MRI CT Ultrasound Myelography |
| Spina Bifida- Myelomeningocele characteristics | Unprotected neural sac Lumbar & lumbosacral |
| Spina Bifida- Myelomeningocele associated manifestations | Sensory and motor dysfunction Bowel and bladder dysfunction Hydrocephalus (common and associated with SB) Chiari II malformation Seizures |
| Chiari II malformation | hindbrain is going down into spinal column through foramen magnum |
| the worse the defect, | the worse the deficits |
| Myelomeningocele Repair | Surgical closure- ASAP Monitoring for/aggressive treatment of infection Evaluation of associated clinical manifestations |
| Myelomeningocele Repair: Surgical closure- ASAP | Fetal repair (in utero) Newborn repair- closure after birth |
| three choices for Myelomeningocele Repair | 1 abort 2 fetal surgery 3 surgery after birth |
| Fetal Surgery can occur when | 18-25 weeks no later than 25 6/7 very strict requirements!! |
| advantages of fetal surgery | Arrest leakage of spinal fluid Improved psychomotor development |
| Arrest leakage of spinal fluid | Prevents herniation of hindbrain (Chiari II malformation) Prevents hydrocephalus – need for VP shunt |
| earlier the fetal surgery repair, | better the mobility |
| risks of fetal surgery | Preterm delivery Placental abruption this pregnancy and every future pregnancy |
| every child with spinal bifida will need | tether cord repair at some point |
| Management: Newborn Repair - Positioning and warmth | Isolette or radiant warmer pre-op Prone with hips flexed pre-op; prone or side-lying post-op Head turned to the side to feed Sac needs protection!! |
| Management: Newborn Repair - Infection control: pre-op | Meticulous care of the neural sac Cover with moist, sterile, non-adherent dressing Assess for leaking (CSF leak) Sterile gloves and linen Prophylactic antibiotics |
| Management: Newborn Repair - Infection control: post-op | Change dressing as ordered Monitor incision(s) Still on their belly, turn head to side to feed |
| Management: Newborn Repair - Monitoring | Hydrocephalus risk: increased ICP, head circumference daily Intake and output: Foley or straight cath every 3 hours Skin integrity |
| Management: Newborn Repair - Precautions | Latex sensitivity precautions |
| Spina Bifida Nursing Management Long Term | Monitoring for complications r/t hydrocephalus Neurogenic bladder - require intermittent catheterization for rest of their life Bowel evacuation- bowel routine daily, bowel regime, enema every AM Latex sensitivity Hydrocephalus- Shunt |
| children can place cath as young as | 6yo by themself |
| with spina bifida cath placement, family uses | clean technique not sterile technique |
| Hydrocephalus- Shunt | Risk of infection or malfunction Check OTC |
| Spina Bifida Nursing Management Long Term: development | PT/OT, wheelchair, walkers, dietary |
| Spina Bifida Nursing Management Long Term: children are at risk for | skin breakdown, burns- decreased sensation |
| Spina Bifida Nursing Management Long Term: intellectual | generally intellectually normal myelomeningoceal - treat like paralysis, find their baseline |
| Metatarsus Adductus | Medial adduction of toes and forefoot, heel and ankle in normal position!!! Most common congenital foot deformity Most outgrow by first birthday If severe, may need casts, splints |
| Medial adduction of toes and forefoot aka | Pigeon toes or intoeing |
| Most outgrow by first birthday because they respond well to | stretching |
| Metatarsus Adductus can be caused by | position they were in inutero |
| Congenital Clubfoot Talipes Equinovarus is a | severe bony deformity of foot/ankle, elevated heel and ankle is not neutral |
| Congenital Clubfoot Talipes Equinovarus | Classification/Bilateral in 50% of cases Etiology is unknown with a familial tendency |
| when is club foot diagnosed | Is usually diagnosed at birth with physical exam |
| timeline of clubfoot | happens around 9th week gestation and resolves by the 14th week |
| ratio of boys and girls in clubfoot | 2 males: 1 girls |
| what can cause clubfoot | low amniotic fluid, smoking |
| Clubfoot Talipes Equinovarus Types | Positional/postural Syndromic Congenital club foot- true clubfoot |
| Positional/postural clubfoot | No bony abnormality, tightness and shortening soft tissue May resolve spontaneously |
| Syndromic clubfoot | Severe, other anomalies (deficits) High incidence recurrence |
| Congenital club foot- true clubfoot | KNOW!! Idiopathic Bony abnormality shortening of achilles tendon!!! |
| Club Foot- Diagnosis | Prenatal ultrasound Physical exam X-ray not required Should be evaluated for hip dysplasia |
| Physical exam for diagnosing clubfoot | Affected foot- smaller/shorter, empty (boggy) heel pad, midfoot medial crease Affected limb -shorter with calf atrophy |
| KNOW Congenital Clubfoot Management: correction | Ponseti method serial casting – gradual stretching Percutaneous heal cord tenotomy- long leg cast 3 weeks |
| KNOW Ponseti method serial casting | gradual stretching as well as they can cast for 7-10days, stretch more, cast for 7-10 more days and repeat for about 10 wks |
| Percutaneous heal cord tenotomy- long leg cast 3 weeks | do this after ponseti method, lengthen achilles tendon |
| KNOW Congenital Clubfoot Management: maintenance | Foot orthotic- Ponseti sandals or Denis Brown bar Set to abduction |
| Foot orthotic- Ponseti sandals or Denis Brown bar | keeps feet in place! keep them on for 24hr/day for 3-6 months then just for naps and bedtime |
| Congenital Clubfoot doesn't cause problems until | child starts walking but it is much easier to correct at birth |
| Congenital Clubfoot Management: follow up | Follow-up observation- prevent recurrence |
| Congenital Clubfoot Management: may need | Surgery- lengthen and release Achilles tendon, tendon transfer |
| Congenital Clubfoot- Nursing Management assessment | Neurovascular checks and skin integrity |
| Congenital Clubfoot- Nursing Management education | Cast care Follow-up for cast changes Change diaper frequently so they don't soil Check for decrease circulation (pallor, coldness) - call provider |
| Osteogenesis Imperfecta (OI) genetic pattern | autosomal dominance in most types |
| Osteogenesis Imperfecta (OI) is a | genetic collagen defect that leaves bones easily fractured |
| genetic defect: OI | COL1A1 or COL1A2 genes code for pre-collagen Faulty bone mineralization Abnormal bone development |
| fragile bones: OI | Bones fracture easily, often with little force Increased susceptibility to fracture throughout life |
| over 20 types of OI | Classified by clinical features and inheritance pattern Type I: mildest and most common, once ambulating Type II: most severe, lethal in infancy, fractures in utero |
| if there are defects in COL1A1 or COL1A2 genes code for pre-collagen, then there is | Faulty bone mineralization Abnormal bone development Increased susceptibility to fracture throughout life |
| time of presentation of OI depends on | type of OI |
| Osteogenesis Imperfecta (OI) CMs | bone fragility joint hypermobility short stature blue sclera hearing loss dentinogenesis imperfecta |
| bone fragility in OI | Varying degrees of fragility and deformity >100 fractures with little trauma |
| joint hypermobility in OI | Unstable, overly mobile joints |
| short stature in OI except for | Type 1: near-normal height |
| blue sclera in OI | Thin sclera reveals underlying vessels type II, collagen in sclera is so thin so you can see thr vasculature under |
| hearing loss in OI | Progressive, from middle ear bone changes in 20s fracture of ossicles |
| Dentinogenesis imperfecta in OI | Fragile, small, discolored teeth |
| complications from OI | Fractures hearing loss acute and chronic pain scoliosis respiratory problems |
| OI management: medication | Bisphosphonates: IV pamidronate; oral alendronate or risedronate Increases bone density and prevents fractures More beneficial for vertebral bones than long bones |
| when are Bisphosphonates given for OI | given at 4 mo intervals, have decreased Ca |
| OI management: supportive care | Braces and splints Physical therapy, want to avoid disuse osteoporosis Surgery Positioning and activity support, encourage holding but carefully |
| goals for OI management: prevent! | Positional contractures and deformities weakness and osteoporosis malalignment of lower extremity joints that prohibits weight bearing |
| OI mangement: DOs | Touch and hold the infant — don’t be afraid to Support fully when lifting: one hand under legs and buttocks, the other under shoulders, head and neck Provide supported positioning Handle a limb minimally if fracture is suspected |
| OI mangement: DONTs | Hold by the ankles when changing a diaper Push, pull, or force an arm or leg into an awkward position Lift from under the armpits |
| OI management: education and screening | Teach prevention and suitable activities refer for genetic counseling screen for OI in children with fractures Positioning!!! |
| in children with OI, | they have a high pain tolerance!! if untreated, compartment syndrome can happen, pain is what they say it is so listen to them!!! |
| Developmental Dysplasia of the Hip (DDH) occurs when | there is abnormal development of the hip Head of femur slips in and out of acetabulum if the femur loses contact with the acetabulum, then it doesn't grow properly and is shallow and doesn't maintain alignment |
| when does acetabulum develop | after 5 years |
| three degrees of DDH | dysplasia subluxation dislocation |
| dysplasia DDH | mild, just not perfect |
| subluxation DDH | pulling, head isn't perfect but there is some contact |
| dislocation DDH | most severe! ball of femur has no contact with the acetabulum |
| DDH etiology and patho | gender: females have more laxity birth order: first born higher risk family Hx Intrauterine position: breech or multiple fetus, increases strain on hips oligohydramnios large infant joint laxity postnatal positioning - if constantly swaddled |
| any female who is breech | is checked for DDH |
| Dev DDH diagnosis/exam | screening confirmation |
| Dev DDH diagnosis/exam: screening | Barlow (will feel clunk and hear sound) and Ortolani (put back into place and then hear sound) maneuver Positive- DDH |
| Dev DDH diagnosis/exam: confirmation | Ultrasound: not before 6 wks, if too early then US is overread and gives a false positive X-ray: not reliable because femoral head is ossified, so have to wait 4-6 months |
| DDH findings on physical exam | Positive Barlow or Ortolani maneuver Asymmetrical skin folds: compare legs! Limited hip abduction; hip clunk on abduction Leg length discrepancy Limping, toe walking, or a waddling, duck-like gait |
| Leg length discrepancy in DDH | shortening of the femur, knee height difference with knees flexed and feet flat on the table |
| DDH treatment: Newborn to 6 months of age | GOLDEN STANDARD Pavlik harness- 12 weeks for 23hrs/day, aligns head of femur with acetabulum Surgical closed reduction and hip spica cast-12 weeks Only if the Pavlik harness fails to maintain reduction |
| DDH treatment: 6- 24 months old | Hip abduction orthosis if mild Bryant skin traction- if adduction contracture Buttocks lifted Surgical closed reduction Hip spica cast -12 weeks, then possible orthotic device |
| if child has Hip spica cast, | they can't sit or go in carseat so should get bean bags to prop them up on |
| DDH treatment: older children | More difficult Traction Surgical pelvic and femoral osteotomy Hip spica cast -12 weeks |
| best method of treatment for DDH | pavlik harness |
| DDH: hip spica cast concerns | concern for toileting so double diaper them moleskin so it's not rough on the edges |
| DDH: bryant skin traction | butt has to be off bed at a 90 deg angle if child has severe DDH, they can develop contractions and need to do bryant traction prior to surgery |
| DDH Splinting: Pavlik harness | Off only for bathing; do not adjust the straps Gentle massage daily under the straps to increase circulation Place diaper and undershirt under the straps so no breakdown No lotions or powder bc increase risk of breakdown Can use normal car seat |
| DDH Casting and traction | Hip spica cast: cast care, double diaper, special car seat Traction: skin care, maintain proper position, pain control |
| DDH assess | Skin integrity since at risk for breakdown Neurovascular status Development |
| DDH Parental support and education | Counsel on feeding, hygiene, safety during splinting or casting, and car seat safety |
| What is Torticollis | Muscular condition: tightness of the sternocleidomastoid muscle Infant’s head tilted to one side — wryneck Painless |
| wryneck happens when | neck is only positioned in one spot |
| Torticollis management | !!!stretch and PT Physical therapy: passive, gentle stretching several times a day Immobilize the affected shoulder, gently turn the head toward the unaffected side, hold 10–30 seconds Tubular orthosis for torticollis (TOT) collar |
| causes of Torticollis | In-utero positioning or difficult birth May have hip dysplasia Preferring one side |
| complication of Torticollis | KNOW Plagiocephaly: flattening of one side of the head |
| Blount’s Disease (Tibia Vara) is | Developmental disorder of tibia that causes progressive bowing of leg(s) and doesn't resolve Affects growth plate of tibia, puts pressure on |
| Blount’s Disease (Tibia Vara) risks | Early walkers (before 12 months) Obesity Family history More common in black children (females) Bilateral or unilateral - typically on 1 side |
| Blount’s Disease (Tibia Vara) types | Infantile- 1-3 years of age (most common) Juvenile -4-10 years Adolescent- 11yrs and older |
| Blount’s Disease (Tibia Vara) management | Bracing- early mild cases: 23 hours/day for months to years (COMPLIANCE) Surgery –severe or older children (osteotomy, reshape bone) |
| Cerebral Palsy (CP) is | Chronic, non progressive motor dysfunction Insult to the motor portion of the brain Non-progressive & persistent Abnormal muscle tone, body movement and posture Potential perceptual, language, or intellectual deficits |
| CP is an insult to the motor portion of the brain | Abnormal brain development Anoxia plays a significant role |
| Cerebral Palsy (CP) is the | Most common permanent disability of childhood |
| Clinical Manifestations of CP | Delayed gross motor development Abnormal motor function Altered muscle tone Abnormal posturing Reflex abnormalities Mild to severe |
| Abnormal motor function in CP | early preferential unilateral hand preference uncoordinated or involuntary movements poor sucking, feeding difficulties |
| Altered muscle tone in CP | increased/decreased resistance to passive movement |
| Associated Deficits with CP | Seizures Vision, hearing, or speech problems Learning disabilities Behavior problems Respiratory problems Bowel and bladder problems - incontinent Bone abnormalities, including scoliosis - can pull bones out of alignment |
| Cerebral Palsy Classification | spastic dyskinetic ataxic mixed |
| spastic CP | Hypertonicity- spasticity Poor control –motion, balance and posture Hemiparesis, Quadriparesis, Diplegia |
| dyskinetic CP | Abnormal involuntary movement Athetoid Dystonic damage to basal ganglia, problem with trunk |
| ataxic CP | Lack of coordination with purposeful movement Wide based gait damage to cerebellum, least common |
| mixed CP | Combination of spastic and dyskinetic |
| Diagnosis of CP | Prenatal, birth and postnatal history Metabolic and genetic testing MRI- evaluate structures or abnormalities Neurological exam Assessment of muscle tone, behavior and abilities Failure to meet developmental milestones |
| Management of CP | no cure!! comprehensive approach medications nutrition support surgery charting an optimal developmental course |
| comprehensive approach for CP | Physical, occupational, speech therapy, orthopedic surgeries Meet their max potential |
| medications for CP | relieve spasticity – baclofen, botulinum A (Botox), valium seizure control – antiepileptics, ketogenic diet |
| nutrition support for CP | Aspiration risk |
| surgery for CP | Selective dorsal rhizotomy: cut out nerves in back to relieve spasticity Orthopedic – for joint deformaties |
| Charting an optimal developmental course for CP | Includes modifying environment |
| CP is a problem with | brain, not the muscles!!! |
| CP patients fail to | KNOW meet developmental milestones and never have met them!!! universal delay in all motor |
Created by:
leh195