Nsg 213
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| What musculoskeletal injury? Soft tissue damage, broken small vessels and inflammation- manifestations: pain, edema, ecchymosis, disability | contusion
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| Management of a contusion? | immediate and appropriate evaluation, cold application, relief of pooled blood, especially if under nail
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| What musculoskeletal injury? force on the ligament causes opposing ends of bones to be dislocated-manifestations: pain, deformity, limited or restricted movement of limb, possible compromise in circulation in ball and socket joints, mostly hip joint | dislocation
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| Management of a dislocation | reduction of dislocation- pulling or manipulation of extremity to bring joint end back into its socket or position
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| What does a sprain involve? | joint and ligaments
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| What is a strain? | tear at muscle-tendon junction
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| How are strains and sprains managed? | Assess 5 Ps, RICE: Rest- allow for healing, movement before tissue is healed could cause more tearing and damage. Ice: immediately 20 minutes at a time. Compression: dry wrap. Elevation: venous return
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| What time frame is critical for tx of soft tissue injuries? | w/in 12 hours
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| Weakest part of bone structure in children- very prone to injury | epiphyseal plate(cartilage growth plate) During adolescence, plates replaced with bone
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| What is the risk of recovery for a child with a fracture at the epiphyseal plate? | altered bone growth
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| What is the risk of recovery for a young child with a bend fracture? | bend fx straighten slowly and risk of incomplete straightening
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| Type of fracture where there is a break on one side and a bend on the other | greenstick- usually in young children- trauma causes incomplete fx
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| Manifestations of an elbow fx | tenderness, inability to rotate, deformity, acute pain- occurs when fall hard on outstretched hands, ulna and radius can be broken
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| Management of fractures | 5 Ps, move injured area as little as possible, splint with soft items, then firm items, elevate, cold compresses
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| What are the 5 Ps? | pain, pulses, pallor, parasthesia, paralysis
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| Why is pedaling done on a cast? | to make edges smooth- taping down edges of cast
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| Components of traction? | forward force- force on distal end of bone
counter traction- body weight- backward force
friction- body contact with bed surface
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| Purpose of traction? | fatigue involved muscle and reduce muscle spasms so bone ends can align.
immobilize the fx site until realignment has been acheived
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| What is different about the periostium of children? | It is thicker and has more blood supply than the adult, osteoblasts form rapidly and produce callus around the broken ends of the bone
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| What component of the bone healing phase serves as the "joint fixator" holding the ends together? | Callus
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| What is bone remolding? | As the callus ages and real bone is laid down at fx site, and as activity and weight bearing is increased, the shape of the bone will regain its prior angulations and dimensions- callus resolves and bone ends heal over time- 6 mos to 1 year
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| What musculoskeletal injury? Trauma causes ligament to be torn or stretched when the joint is twisted or wrenched- damage to blood vessels, muscles, tendon and nerves. Usually sudden onset | Sprain
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| Manifestions of a sprain | laxity, loss of strength, joint feels loose or a snap, pop, or tearing- swelling, inability to move
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| What musculoskeletal injury? microscopic tear at muscle tendon junction- usually occurs over time | strain
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| Manifestions of a strain | painful to touch, swollen, immediate swelling,
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| Which is more severe, strain or sprain? | strain
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| Which overuse syndrome? rotator cuff injury | swimmers shoulder- rest until symptoms clear
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| Which overuse syndrome? occurs when arm is extended under high speed frequently | little league shoulder- pain and loss of ROM, rest until healed
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| Which overuse syndrome? occurs with repetitive throwing, puttling twist on ball | little league elbow- also called tennis elbow
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| Which overuse syndrome? overuse of quadriceps with trauma to the tibial tuberosity- stress on the patellar tendon that attaches the quadriceps at the front of the thigh to the tibial tuberosity | Osgood Schlatter disease- vulnerabilty at growth spurt, age 9-16 y/o- limit stress until epiphyseal plate is fused
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| Which overuse syndrome can cause the shoulder to drop, sometimes confused with scoliosis? | back pack- backpacks worn incorrectly or too heavy
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| Interventions for a child with musculoskeletal trauma | Neurovascular checks, pain assessments, skin care, system assessment r/t immobilization
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| What can cause a pulled elbow in a child? | longitudinal pull to arm, swinging around by arms
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| At what age is a child at risk for a dislocated hip from a fall? | Under 5 years old
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| What type of child will have more pain from muscle spasms? | a child with well developed musulature along long bones
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| Do infants have a lot of muscle spasms? | No, they have little tone, fewer spasms
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| What kind of problems should be addressed in a child with extensive casting? How can we manage these things? | limited mobility, loss of time for developmental milestones, problems with hygiene- use diversional activities, promote cognitive skills and other skills that are not affected
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| Which congenital defect? extra digits | polydactyly
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| Which congenital defect? fusion of digits | syndactyly
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| How are poly/syndactyly treated? | surgical correction
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| What types of things could be the cause of underdeveloped limbs? | heredity, prenatal environmental factors, hx of thalidomide drug used for morning sickness
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| How is underdevelopment of limb structures treated? | prosthetic devices as early as possible- replaced as child grows
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| Which congenital defect? anulation of bone or within a bone distal to a joint(knee) is towards the midline. Bowlegged | Genu Varum
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| How is genu varum(bowlegged)treated? | Will correct on its own with activity after 2-3 years. Could be pathological- rickets. If doesn't resolve, orthopedic consult.
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| Which congenital defect? angulation of a bone distal to a joint (knee) or in a part of a bone is away from the midline (knock-knees) | Genu valgum- presents between 2-7 years- spontaneously self corrects- if doesn't, orthopedic consult
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| What is metatarus adductus(varus)? | In-toeing most likely caused by abnormal position in uterus- teach parents PROM- if doesn't work, casting can be done to correct
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| Most common form of clubfoot also associated with other conditions such as neuromuscular paralysis, spina bifida, hip dysplasia? | talipes equinus
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| What are the three forms of clubfoot? | Positional(extrinsic) clubfoot
Syndromic
Congenital(intrinsic) clubfoot
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| Which type of clubfoot? caused by intrauterine crowding, can be corrected with stretching exercises, ROM and casting | Positional(extrinsic) clubfoot
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| Which type of clubfoot? associated with other congenital anomalies, more difficult to treat, surgical intervention, reoccurance of condition | Syndromic
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| Which type of clubfoot? idiopathic, wide range of rigidity, deformity, bony abnormality requires surgical intervention- no neuromuscular issues | Congenital (intrinsic) clubfoot
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| Management of clubfoot | gradually corrected by stretching the structures via serial casting(Ponseti method- final tenotomy at last casting, followed by foot abduction brace for 2-3 mos) or if that doesn't work, surgery(insert pins to stabalize joints, serial casting 2-3 mos
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| What could wearing the shoe on the wrong foot for several months be a tx for? | clubfoot
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| Etiology of DDH(Developmental dysplasia of the hip) | abnormal formation of the hip joint in which the femoral head is not stable in the acetabulum, may occur during fetal development, at delivery, or after birth
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| Risk factors for DDH | familial tendancy, cramping or crowding of fetus in uterus, female, first born babies, breech delivery
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| What is the mildest form of DDH? | Acetabular dysplasia (preluxation)- femoral head remains in the acetabulum
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| Which test to assess for DDH? fingers over heads of femurs, infant on back with hips abducted, bring hips to adducted and flexed position, then extend legs | Barlow's test
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| Which test to assess for DDH? fingers over heads of femurs, infant on back with hips adducted and flexed, knees flexed, lifting the femurs and abducting- palpable click | Ortolan's Maneuver
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| Which assessment for DDH? standing on the affected leg/hip, that hip/pelvis tilts upward as the opposite hip/pelvis tilts downward- head of femur is slipping up and out of the acetabulum | Trendelenburg sign
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| Which test to assess for DDH? flex infant's knees in the supine position so that ankles touch buttocks, if knees not level, test is positive | Galeazzi sign
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| Management of DDH | Multiple diapers- abduction, Pavlik harness up to 6 mos- hip flexion and abduction- needs f/u every 1-2 weeks due to rapid growth, For older child, surgical intervention- tenotomy/osteotomy, bryant's traction, cast applied afterward
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| Cultural differences that increase and decrease the incidence of DDH | Mothers who wrap their child on swaddling boards with hips extended have highest incedence- Mothers who carry their infant in pouches or on their hips (widely abducted hips) have lowest incidence of DDH
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| A genetic disorder of bone predisposition to osteoporosis- frequent fractures and bone deformity, other anomolies such as blue sclera, hearing loss,easy bruising, and hypo plastic discolored teeth | Osteogenesis Imperfecta
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| Collaborative management for osteogenesis imperfecta | supportive- braces and splints, gentle handling, activity limitations, vocational guidance, genetic counseling
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| Degenerative disease of the hip joint, loss of bone mass leads to some degree of collapse of the hip joint, deformity of the ball of the femur and the surface of the hip socket develops- typically in young children | Legg-Calve-Perthes Disease- cause unknown, avascular necrosis of femoral head
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| Manifestations of Legg-Calve-Perthes Disease | limp on affected side, hip soreness, ache or stiffness(continuous or intermittent) Limp more pronounced with activity, limited ROM, knee pain is referred pain
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| Treatment for Legg-Calve Perthes Disease | rest, activity restrictions, medications, bedrest, traction, casting/bracing, surgery if necessary, PT, crutches
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| Two most critical factors that determine the child's outcome with Legg-Calve-Perthes disease | child's age at diagnosis and how much of the femoral head is affected
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| What is the displacement of the femoral head epiphysis? generalized metabolic disorder of puberty | Slipped femoral capital epiphysis
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| Manifestations of a slipped femoral capital epiphysis | limp, groin, thigh, knee pain- referred pain, can also have avascular necrosis of the femoral head, limited ROM, unable to bear weight, external rotation of foot
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| What is the cause of slipped femoral capital epiphysis? | possible imbalance of growth hormone with testosterone- tends to occur in overlarge children, particularly boys
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| How is Slipped femoral capital epiphysis diagnosed? | LATERAL x-ray- anteroposterior x-ray will not show
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| Management of slipped femoral capital epiphysis | bedrest, non weight bearing, surgery- pins to stabalize the femoral head until growth plate is closed, pin removed after closure
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| What is kyphosis? | abnormal covex curvature of thoracic spine, shoulders slouch
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| What is lordosis? | pronounced concave curvature of lumbar spine, if severe, painful
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| How is kyphosis and lordosis treated? | promote correct posture, regular exercise, braces, spinal fusion in severe cases
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| What is scoliosis? | three dimensional curvature of spine, lateral curvature, spinal rotation with rib asymmetry, thoracic hypokyphosis more commonly during growth spurt
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| What is the cause of scoliosis? | One side of the vertebral joint grows faster than the other side, one side of spine has more bone than other side
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| What are the 4 manifestations of scoliosis? | truncal asymmetry, uneven shoulders and hips, one sided hump, prominent scapula
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| Tx for child with 10- 30 degrees of scoliosis | observed for progression, seen every 6 mos for follow up
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| If scoliosis progresses to 30-50 degrees, what is done? | A TLSO(thoraco-lumbar spinal orthotic) is worn more than 20 hours a day - if successful, the curve will be reduced by half or better- successfully stops progression in 80% of children
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| What is done if scoliosis is more than 50 degrees? | spinal fusion surgery followed by bone graft
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| How long after spinal surgery does it take for the child to possible return to unrestricted activity? | 12 mos if all is well
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| What is muscular dystrophy? Duchenne- most common form | x linked inherited muscle disease of childhood, progressive weakenss, muscle fiber degeneration and muscle wasting, absence of dystrophin, glue that holds muscles together
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| Manifestations of muscular dystrophy | child follows growth and development until about 3 years old, then begins to lose gross motor control, weakness, fatigue, overdeveloped calves, lordosis, contracted achilles tendon, frequent falls, waddling gait, lax shoulder muscles, purple feet, cx,
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| As muscular dystrophy progresses, what symptoms will be seen? | dysphagia, difficulty with speech, profound weakness and wasting, mental deficiency, contractures, loss of ability to ambulate 9-11 y/o
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| At what stage of muscular dystrophy will these symptoms be seen? profound muscular atrophy, bad contractures, respiratory failure (around age 10), cardiac failure, death and dying issues | latent stage
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| How is muscualr dystrophy diagnosed? | muscle biopsies, CK, EMG, NCV (Nerve conduction velocity), Single condition amplification/internal primer sequencing- allows total evaluation of dystrophin gene to find mutations
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| How is muscular dystrophy treated? | prednisone, deflazacort, albuterol, creatine(builds up muscle's energy supply), calcium blockers, gentamycin
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| Infection of bone, occurs from direct trauma or seeded by pathogens in the blood | osteomyelitis
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| Manifestiations of osteomyelitis | pain, warmth, tenderness, decreased ROM
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| Treatement for osteomyelitis | abx per culture assay, IV meds followed by oral, dead bone debridement, positioning limb in alignment, gentle handling, support and rest, non weight bearing if long bones affected, gradual return to activities after infection gone
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| Infection of the joints(synovial tissues-joint cavity) that occurs from local tissue infection (cellulitis) or seeded from pathogens in the blood | Septic arthritis
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| Manifestations of septic arthritis | inflammation, pain, swelling, tenderness of joint
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| How is septic arthritis treated? | joint aspiration followed by IV abx, surgical intervention for trauma repair, removal of foreign objects, rest of joint
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| What is the term used to describe arthritis/inflammation of the synovium with onset before 16 years of age? It is an autoimmune inflammatory disease causing inflammation of joints and other tissues. | Jevenile Idiopathic Arthritis
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| Manifestations of juvenile rheumatoid arthritis | may begin with swollen knuckle, spiking fever, or unexplainable rash, can be subtle or obvious. May have limping, sore wrist, finger, or knee. swollen and enlarged joints. stiffness in neck or hips. rashes come and go, in 1 area and then another.
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| What type of fever is characteristic of systemic juvenile rheumatoid arthritis? | High fevers that tend to spike in the evenings and suddenly disappear
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| Name some tests that will be used to diagnose juvenile rheumatoid arthritis. | CBC, cultures(r/o infection), bone marrow aspiration (r/o leukemia), ESR, leucocytosis, ANA(common, not specific- also may predict likelyhood of getting eye disease with IJA), RF, x-rays, bone scan, samples of synovium, test for viral disease
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| If a child has inflammation of the joints, what other part of their body should be examined? | Eyes, inflammation of joints may be associated with inflammation of the eyes
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| Meds used to treat Juvenile Arthritis | NSAIDS, methotrexate, methotrexate plus folate to ward off side effects, corticosteroids, Autologous stem cell transplantation, etanercept or the monoclonal antibodies infliximab and adalimumab- blocks the TNF
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| What treatment besides meds is used for Juvenile Arthritis? | OT and PT, ROM, sports restrictions, balanced diet with calcium
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| A fast-growing, highly malignant tumor which accounts for over half of the soft tissue sarcomas in children | rhabdomyosarcoma- most common in children 1-5 y/o
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| What are the four major sites where rhabdomyosarcoma is found? | 1. head and neck, around eyes 2. genitourinary tract 3. extremities 4. trunk, chest and lungs
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| manifestations of rhabdomyosarcoma | noticeable lump on child's body, depends on where the tumor is located as to what symptoms will be seen
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| How is rhabdomyosarcoma diagnosed? | tests for blood, muscle, and marrow- diagnosis depends on recognition of differentiation toward skeletal muscle cells
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| treatment options for rhabdomyosarcoma | chemo, radiation, sometimes surgery. Removal of tumor is very difficult, if in extremities, amputation.
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| most common type of bone cancer in children | osteosarcoma- arises in ends of bones, most frequently large bones of humerus and femur and tibia.
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| manifestations of osteosarcoma | pain and swelling, pain severe enough to make child limp
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| How is osteosarcoma confirmed? | biopsy, CT, MRI- commonly metastasizes to other parts of body, such as lungs, so CT scans of chest, x-rays ,bone scans are done
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| How is osteosarcoma managed? | surgery is primary tx, followed by chemo- prostesis important part of therapy
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| common name for primitive neuroectodermal tumor- rare disease where cancer cells are found in the bone or soft tissue | Ewing sarcoma- most commonly in pelvis, femur, humerus, and ribs- most frequently in male teenagers
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| Where does the cancer arise from in ewings sarcoma? | bone marrow spaces of bone
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| two goals for management of ewings sarcoma and tx | 1. cure cancer 2. save as much function of affected area as possible- tx with chemo and radiation- surgery scheduled 2-4 mos after chemo begins
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| What is an autograft? | bone graft from a patient's own tissue after removing cancerous tissue
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| What is an allograft? | bone graft from donor's tissue after removing cancerous tissue
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| What is a rotationplasty? | used for young or athletic pts with ewings sarcoma- tumor is removed by cutting above and below the knee. lower portion of leg is rotated and reattached so that ankle becomes knee. get prosthetic ankle and foot
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| how are prosthetic implants used? | used when portion of bone is removed and replaced with implant
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