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Peds Exam 2
Alteration in Mobility in Neuromuscular and Musculoskeletal Disorders
| Question | Answer |
|---|---|
| skeletal development: flexible bones | More flexible and porous, thick periosteum Bend, don’t break |
| skeletal development: posture by age - toddler years | toddler lordosis, potbellied and swaybacked |
| skeletal development: posture by age - adolescence | thoracic kyphosis |
| skeletal development: growth plate | Ends of bones: epiphysis and physis Androgens in adolescence fuse growth plates; growth is complete Ossification complete in adolescence |
| who is at higher risk due to longer open growth plates | boys |
| skeletal development: bone healing | strong periosteum with abundant blood supply Children heal from bone breaks much easier since their blood supply is abundant |
| rickets is the | softening and weakening of bones |
| most often cause of rickets | Vitamin D deficiency: Impaired calcium and phosphorus absorption Defective bone mineralization |
| Impaired calcium and phosphorus absorption causing rickets | releases calcium from bone into bloodstream which makes the bones soft |
| other causes of rickets | Mineral deficiencies (calcium or phosphorus) Limited sun exposure bc decrease vit D Kidney disease - unable to regulate the minerals GI disorders bc can't absorb fats and minerals are fat soluble Rickets of prematurity (premies) |
| signs and lab findings of rickets | !!Bowed legs!! Bone pain Cavities Weak muscle tone Growth delays Low serum calcium and phosphate High alkaline phosphatase |
| complications of rickets | skeletal deformities and fractures |
| rickets preventative management | AAP- all infants 400IU of vit D after birth - may be provided in formula 1-18 years- min. daily 600IU of vit D through cow milk or soy |
| management of rickets | Correct calcium imbalance Calcium ad phosphorus supplements Exposure to sunlight Vitamin D supplements Dietary sources of vit D Fish, liver, processed milk |
| Calcium ad phosphorus supplements must be | Given at alternate times because if they are given together they will have decreased absorption |
| dietary sources of Vit D | Fish, liver, processed milk |
| Slipped Capital Femoral Epiphysis (SCFE) is a | hip disorder that involves spontaneous displacement proximal femoral epiphysis and the capital femoral epiphysis remains in acetabulum |
| SCFE occurs when | the femoral head stays in the joint but the bone slips behind the growth plate |
| spontaneous displacement proximal femoral epiphysis | At the growth plate Posteriorly and inferiorly |
| capital femoral epiphysis remains in acetabulum | Deformation femoral head alignment Stretches blood vessels |
| when does SCFE occur | during or before growth spurt |
| when are kids at a higher risk for SCFE | obesity |
| SCFE clinical manifestation | Limp - affected side Pain in hip, groin, thigh or knee Affected leg externally rotated Loss of hip flexion, abduction, and internal rotation Shorter affected leg |
| if there is pain in their hip, groin, thigh or knee due to SCFE, it may | limit ability to bear weight |
| SCFE diagnosis | Physical exam X-ray |
| SCFE management | Non weight bearing immediately Surgical in situ pinning is a requirement |
| SCFE post op management | No or limited weightbearing and crutches for weeks to months Activities are restricted until bone fuses together, removie pin when growth plate is closed |
| Legg-Calve-Perthes disease is a | Self-limiting avascular necrosis of femoral head - ball of femur is not getting blood supply but femur blood supply is different since the growth plates are still open so only the head becomes necrotic |
| Legg-Calve-Perthes disease generally affects | 1 side of hip younger children |
| what group of kids are at higher risk for Legg-Calve-Perthes disease | higher risk in boys, especially boys 4-8 |
| cause of Legg-Calve-Perthes disease | unknown |
| 4 stages of Legg-Calve-Perthes disease | Avascular -necrosis Fragmentation- resorptive Reossification Remodeling |
| when a child experiences Legg-Calve-Perthes disease, they have a | temporary disturbance of blood flow to femoral capital epiphysis |
| stage 1 of Legg-Calve-Perthes disease | Avascular -necrosis Bone will weaken and die |
| stage 2 of Legg-Calve-Perthes disease | Fragmentation- resorptive Body replaces bone with cartilage which can cause microfractures |
| stage 3 of Legg-Calve-Perthes disease | Reossification Blood flow is restored and new bone forms |
| stage 4 of Legg-Calve-Perthes disease | Remodeling |
| Legg-Calve-Perthes disease manifestations | Limping Soreness, ache or stiffness in hip, groin, thigh or knee Limited range of motion- hip |
| how long can Legg-Calve-Perthes disease CMs last | could last 18 months or years |
| Legg-Calve-Perthes disease manifestations are | insidious, gradual onset |
| soreness and ache in Legg-Calve-Perthes disease gets | Worse with activity, improves with rest |
| difference in pain btwn Legg-Calve-Perthes disease and SCFE | Legg-Calve-Perthes disease pain gets relief with rest SCFE is horribly painful and does not relieve with rest |
| Legg-Calve-Perthes disease diagnosis | X-ray, perfusion MRI |
| Legg-Calve-Perthes disease management | Containment of femoral head in acetabulum Rest or activity restriction, limit weight bearing NSAIDS PT Abduction brace or casting Surgery if all else fails |
| primary treatment for Legg-Calve-Perthes disease | rest!! |
| why do you want to contain the femoral head in the acetabulum | so everything grows appropriately |
| why do you consult PT for Legg-Calve-Perthes disease | for range of motion to maintain the function of their hip |
| if all other techniques aren't successful for Legg-Calve-Perthes disease, | surgery is needed: Femoral and/or pelvic osteotomy, tenotomy |
| difference in treatment btwn Legg-Calve-Perthes disease and SCFE | Legg-Calve-Perthes disease: only needs surgery is bracing is not successful SCFE: need surgery!! |
| who has better outcomes in Legg-Calve-Perthes disease | younger children because they have a longer time for the bone to form while the plate closes |
| Scoliosis is a | Complex spinal deformity that includes lateral curvature and vertebral rotation |
| Scoliosis is classified according to | age |
| age classifications of scoliosis | Congenital- fetal development Infantile- birth, up to 3 years Juvenile- 3-10 years Adolescent > 10 years |
| Congenital- fetal development of scoliosis | bones were not formed properly |
| scoliosis etiology | Idiopathic Neuromuscular Congenital |
| most common type of scoliosis | Idiopathic |
| idiopathic scoliosis | Assoc with pre-adolescent growth spurt Adolescent idiopathic scoliosis |
| Neuromuscular scoliosis | Spina bifida, cerebral palsy pulls spine out of place |
| congenital scoliosis | vertebral defect |
| ratio of men and women in scoliosis | females 7: males 1 |
| Scoliosis Clinical Manifestations | Asymmetry!!! Shoulder height Scapular or flank shape: more pronounced on one side Hip height Pelvic obliquity One side rib cage sticks out |
| complications of scoliosis | Impaired lung function Back pain Change in appearance: may affect self image |
| Impaired lung function in scoliosis | if severe enough, one side is shorted and lung won't be developed on that side |
| is scoliosis painful | no |
| scoliosis diagnosis | Screening Physical assessment X-ray |
| scoliosis screening ages | girls between 10-12 boys between 13-14 |
| scoliosis screening tools | Adam’s forward bend test- screening Scoliometer -initial screening |
| x ray in scoliosis | Cobb angle (standard measurement of angle curvature) done in all children and determines degree of curve which treatment is then based off of |
| Management of Scoliosis: goal | prevent progression |
| scoliosis treatment: mild curvature (<20) | observation |
| scoliosis treatment: moderate curvature (20-40) | bracing |
| scoliosis treatment: mild curvature (>40) | surgery |
| what is scoliosis influenced by | age and skeletal maturation |
| when does curve stop | when child stops growing so ideally surgery is done after they're done growing |
| scoliosis bracing purpose | slow progression, not undoing progression |
| scoliosis bracing is used for | Moderate curves in growing adolescent Prevent further progression of curve Long duration/body image may contribute to poor adherence |
| huge issue with scoliosis bracing | compliance!! must be worn 23 hr a day |
| scoliosis surgery is done in | Extreme cases >40 curve |
| when is surgery done in scoliosis | ideally fusion is done after child is done growing UNLESS balance, respiratory status, comfort |
| surgery types fo scoliosis | spinal fusion expandable/growing rods - if still growing vertical expandable prosthetic titanium ribs (VEPTR) Halo-gravity traction before surgery |
| spinal fusion in scoliosis | Surgical and stabilization Area of fusion becomes immobile Risser staging !!! |
| Risser staging in scoliosis | look at hip growth plates so you don't need separate x rays |
| what surgeries are done for scoliosis if child still growing | expandable/growing rods vertical expandable prosthetic titanium ribs (VEPTR) |
| vertical expandable prosthetic titanium ribs (VEPTR) needs | permanent fusion once done growing |
| Halo-gravity traction before surgery is reserved for | severe curves |
| Halo-Gravity Traction is done | PRIOR to surgery for severely curved spine |
| how does Halo-Gravity Traction work | Applies pully traction in bed, wheelchair, walker Gently stretches and straightens spine Reduces risk of damaging nerves or soft tissue or injuries |
| Halo-Gravity Traction clinical pearls | Requires hospitalization Mobility encouraged Neuromuscular and neurovascular assessment Pain medications Pin care |
| Management of Scoliosis Post Op: pain and comfort | high importance!! Pain control: continuous and demand PCA (IV acetaminophen and toradac) Psychosocial impact |
| Management of Scoliosis Post Op: monitoring | Neurovascular assessment Monitor vitals: hypotension from blood loss Skin integrity |
| Neurovascular assessment in scoliosis | pulses, perfusions, movement, sensation |
| Management of Scoliosis Post Op: positioning and mobility | Lie flat immediately post op (for day 0) Log roll q2 while awake, but q4 when asleep Out of bed post op day 1, ambulate post op day 2 |
| Management of Scoliosis Post Op: drains and complications | Hemovac to drain, Foley until able to get OOB Transient ileus/urinary retention Pulmonary toileting |
| Fractures are causes by | resistance against bone is yielding to the force acted on it |
| children at risk for fractures | Activity level Limited coordination Incomplete ossification |
| what children do fractures usually occur in | older infants |
| common causes of fractures in childhood | Birth trauma: big babies and small moms Trauma: Falls, Motor vehicle collisions, Sports, Non-accidental trauma (abuse) |
| most common fracture in toddlers | radial/ulnar fractures because when they fall, they try to catch themselves with their hands |
| 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 (multiple) |
| types of fractures in children | greenstick, transverse, spiral, buckle |
| greenstick | Incomplete fracture, bend on opposite side beyond it's limits children have soft bones so they don't break, they bend |
| transverse | Straight line across the bone |
| spiral | Spirals around the bone from rotation match mechanism to injury!! |
| spiral should raise a concern of | abuse!! |
| buckle | Compression of porous bone – bulging area of bone could just be a bump, seen in younger children |
| Physis (epiphyseal plate) | Cartilage growth plate Between epiphysis and metaphysis Weakest point of long bones |
| to check if growth plates are closed, | use left hand for xray for consistency in world wide comparison |
| Growth Plate (Physeal) Injuries may affect | subsequent bone growth in that area where the fracture was |
| Growth Plate (Physeal) Injuries are | Difficult to detect on X-ray |
| Growth Plate (Physeal) Injuries may require | surgical intervention |
| since there is cartilage where the growth plates are, | they are the easiest to fracture |
| Growth Plate (Physeal) Injuries are classified by | Salter-Harris classification |
| Salter-Harris classification: type I | KNOW Separation or slip growth plate without fracture of bone |
| Salter-Harris classification: type II | KNOW Separation of growth plate, breaking off metaphysis |
| Salter-Harris classification: type III | Fracture extending through joint surface |
| Salter-Harris classification: type IV | Fracture of growth plate, epiphysis, metaphysis, end of the bone |
| Salter-Harris classification: type V | Crushing injury of epiphysis |
| fractures close to growth plate heals | faster because there is an increased blood supply |
| Clinical Manifestations of Fractures | Muscle tightness - can pull bone out of alignment Generalized swelling Pain/tenderness Deformity Diminished function/use of affected area Bruising Crepitus |
| goals of fracture management | Regain alignment and length (reduction) Retain alignment and length (immobilization) Restore function to the injured parts Prevent further injury and deformity |
| if there is a displaced fracture, | need alignment first |
| if there is a non displaced fracture, | go right to casting |
| (1) reduction of fractures is to acheive | Re-alignment of bony fragments |
| reduction of fractures by | Closed reduction Percutaneous pin fixation Open reduction |
| (3) Restoring function when fractures occur | Weight bearing Active movement !!!Begins once fracture is deemed stable - after abt 6 weeks in cast PT and OT rarely needed |
| (2) Immobilization with fractures is to | maintain alignment |
| Immobilization with fractures types | casting internal or external fixation traction |
| casting types | Plaster or fiberglass/air cast |
| plaster casts | 24–48 hrs to dry; position with pillows, prevent depressions in cast, not seen as often, can indent with fingers so use palm to handle |
| fiberglass cats | dries quickly within an hour, feels warm inside cast some can be waterproof |
| casts include | joints above and below fracture to keep immobile |
| Traction Types | Skin traction: Bryant’s, Buck’s Skeletal traction: Halo |
| bryants traction | ace wrap, butt is elevated |
| bucks traction | leg fully extended in air |
| skeletal traction | goes into bone |
| halo traction | goes into skull |
| nursing management for traction | Maintain traction Maintain body alignment Maintain skin integrity Make sure weights are suspended!!! |
| Nursing Care for fractures | Pain Immobilization Incisional and pin care |
| pain | meds and ice for first 24 hrs elevate |
| Incisional and pin care | push down on skin around the pin so the pin doesn't adhere to the skin, if you don't do this the skin will adhere which will be SO painful |
| what to use to do Incisional and pin care | use q tip and 1/2 strength hydrogen peroxide |
| cast care | Frequent repositioning Petaling cast edges, unless waterproof Limit moisture Elevate extremity Education: keep foreign objects out of cast Not too tight |
| petaling a cast | moleskin on end of cast unless waterproof!! |
| cast removal | Frightening, generates heat (use cool wet cloth), tickling sensation Skin care after removal Offer cast to family |
| Skin care after removal of cast | dry and dead skin - do NOT peel! use oil or lotion! |
| Neurovascular integrity when casted: assess and maintain | Pain Skin color Sensation Mobility Skin temperature Pulses Capillary refill in every digit of extremity |
| compartment syndrome due to fractures/cast | Increased pressure within fascia compromises circulation to enclosed muscles and nerves |
| 6 Ps of compartment syndrome | pain out of proportion (earliest sign) pulselessness (LATE FINDING, want to recognized before this) pallor (decreased blood flow) parasthesia (tingling) paralysis pressure |
| pain out of proportion, for example | all of the sudden the pain meds aren't working |
| what does compartment syndrome require | immediate intervention: fasciotomy!! |
| what should you not do during compartment syndrome | avoid cold, do not elevate (want level with the heart so not hanging either) don't want to further decreases blood flow |
| complications of fractures | Circulatory impairment Nerve compression Compartment syndrome Mal-union Infection Pulmonary, fat emboli |
| Overuse Syndromes are | Soft tissue injuries affecting bone muscle, ligament, and/or tendon due to cumulative microtrauma from repeated use |
| during overuse syndromes, the bones are | growing faster than the muscles |
| you can identify overuse syndromes from | No identifiable injury but significant pain |
| risks for overuse syndromes | Year-round competitive sports (esp if same sport), multiple sports same time Early specialization, repetitive movements Immaturity, growth patterns |
| CMs of overuse syndromes start vague! | Decreased strength or speed (first Sx) Pain pattern Swelling |
| overuse syndromes are diagnosed through pain pattern | first there is pain after the activity, then during if they aren't limiting, then even when they are limiting and then even at rest |
| Overuse Syndromes Management | RICE: Rest, Ice, Compression, Elevation Limit, don’t eliminate activity Ibuprofen Participate in other activities |
| Overuse Syndromes prevention | One sport at a time One day/week rest, 2-3 months off year Multiple sports- one full day off Early identification |
| Dislocation of Elbow: Nursemaid’s elbow are common in | less than 5 years |
| Dislocation of Elbow: Nursemaid’s elbow | Displacement of bone end from articulation with joint Child usually pulled by their arm or wrist |
| manifestations of Dislocation of Elbow: Nursemaid’s elbow | Pain in elbow or wrist Refusal to use limb |
| treatment of Dislocation of Elbow: Nursemaid’s elbow | Closed manual reduction Immobilization |
| hip dislocation common in | less than 5 years |
| hip dislocation commonly due to | a fall |
| hip dislocation risk | avascular necrosis- decreased blood flow to femoral head so need relocation within hours |
| shoulder dislocation most often in | adolescents related to sports |
| shoulder dislocation requires a | temporary restriction of joint |
| temporary restriction of joint for shoulder dislocation by | Bandage, sling |
| what should happen asap in shoulder dislocation | reduction |
Created by:
leh195