Developmental hip dysplasia Clubfoot Fractures Scoliosis Osteogenesis Imperfecta Osgood-Schlatter Disease Osteomyelitis Muscular Dystrophy JRA

• Hereditary disorder, more common in girls

• Flat acetabulum of pelvis• Prevents femur from remaining in

the acetabulum and rotating adequately

• Head of femur is dislocated

• May be due to position in utero

Limited abduction of the affected hip Asymmetry of the gluteal and thigh fat folds Affected leg may appear shorter Positive “Ortolani click” Uneven gait in older children

Early detection is key for success

Treatment depends on age at diagnosis Pavlik Harness Hip Spica Cast ORIF

Pavlik harness Keeps hips and knees

flexed, the hips abducted, and the femoral head in the acetabulum

Worn continuously for 3 to 6 months

Effective 90% of time

Hip spica cast:For child 3-18 months ageMaintains abduction (frog-like position) Worn for 1 yearMust be changed as child grows

ORIF (surgical insertion of pin)For child >18mos Successful reduction is difficult after age 4

Skin care Hygiene Feeding Handling Immobility

Elimination Growth and

Development Clothing Transportation

Congenital deformity of the foot Can affect one or both feet Portions of foot and ankle are twisted out of

normal position Varying degrees of severity & combinations of

abnormal positions Can range from mild to severe

Three areas of deformity: ◦ The hindfoot turns

inward (varus)◦ The hindfoot turns

outward (valgus)◦ The midfoot is directed

downward (equinus)

• Early detection is critical• Part of newborn assessment•Move foot to midline

Begins soon after birth, before discharge

Manipulation with serial casting for 8-12 weeks (due to rapid growth)

Cast extends above infant’s knee to ensure correction

Surgical correction btw 4-12 mos, realignment of bones, pin insertion, cast for 6-12 weeks

Denis Browne Splints shoes attached to metal bar to maintain correction

Break in bone from stress Frequent in children- bones are not as

dense and more porous Usually occur from

◦ Falls◦ Sports◦ MVA◦ Bone disease

Symptoms:◦ Pain◦ Abnormal limb positioning◦ Decreased ROM◦ Edema◦ Ecchymosis◦ Crepitus◦ Refusal to play with extremity, guarding

Cast Surgery Pins and external devices Traction- used to align bone

◦ Skin Pull is applied to the skin and muscle

◦ Skeletal Pull is applied to the bone pins

Inspect skin◦observe for swelling, pain, discoloration,

odor◦keep cast free of foreign objects

Monitor Neurovascular Status◦keep extremity elevated for 1st day◦observe for loss of distal pulse,

discoloration, loss of movement

Clinical manifestations begin about 30 minutes after tissue ischemia starts.

Paresthesia (tingling, burning, loss of two-point discrimination)

Pain (unrelieved by medication, characterized by crying in the young child)

Pressure (skin is tense or discolored, cast appears tight) Pallor distal to cast (pale, gray, or white skin tone) Paralysis (weakness or inability to move extremity) Pulselessness distal to cast (weak or absent pulse)

◦ Promote Mobility Crutches Wheelchair Wheeled Carts (hip spica casts)

◦ Promote Growth and Development promote body image provide diversional activity cast becomes part of body, fear removal

Most common type of spinal deformity Girls>Boys Non-painful lateral curvature of spine

begins around pre-pubescent growth spurt

In NYS all children screened in 5th grade

Symptoms◦ Ill fitting clothes◦ Uneven shoulders, scapulae, hips

Treatment will not correct the curve, but prevent it from worsening

Mild Scoliosis◦ Life Long monitoring

Moderate Scoliosis◦ Bracing◦ Exercises to improve posture and flexibility◦ Electrical Stimulation to back muscles

Surgical correction: spinal realignment & straightening (Harrington Rod), followed by Milwaukee Brace worn 23 hr day

Screen and identify children Refer to orthopedisist for eval and

treatment Assess respiratory, neurological,

cardiovascular as rib cage deformity can affect

Promote understanding and compliance of treatment

Promote good body image and self esteem

Congenital abnormality Connective tissue disorder, leads to fragile

bone formation “Brittle Bone Disease” Causes recurrent pathological fractures Will not have normal growth in height

Multiple and frequent fractures Thin, soft skin Increased joint flexibility Weak muscles Soft, pliable, brittle bones Short stature

Goal protect from trauma and reduce the number of fractures

Early intervention◦ Splints, Braces, Surgical Rods◦ Childproof home

Handle child gently◦ Support trunk and extremities as child is moved.◦ Bathing and diapering may cause fractures◦ Use blanket for additional support when lifting ◦ Never pull legs upward when changing a diaper◦ Gently slip a hand under the hips to raise

Encourage well-balanced diet ◦ Additional vitamin C, vitamin D, and calcium to

encourage healing and bone growth.

Limit calories to maintain weight ◦ Immobility can lead to overweight

Support normal growth and development◦ Socialization◦ Swimming improves muscle tone◦ Wheelchairs and adaptive equipment

Thickening & enlargement of tibial tuberosity

Results from microtrauma (sports-related)

Bilateral knee pain exacerbated by running, jumping, climbing stairs

Self-limiting condition◦ rest, ice, heat, NSAIDs

Immobilization of limb may be necessary

Support other methods of exercise, sports

Bacterial infection of bone Common in children age 1-12 years Can follow open fractures, burns, skin

abscess, foreign body Infecting organism spreads through the

bloodstream from the penetrating injury to the bone

Pain, warmth, tenderness, limited ROM localized to the area of infection

Usually in the extremitiesIn younger child- more subtle symptoms, irritability

Increased WBC’s◦ Increased sed rate◦ Increased C-reactive protein◦ Positive blood culture◦ MRI shows bone purulence and edema

4-6 weeks of Antibiotics (PICC line)

Limit weight bearing on extremity

Aggressive therapy is needed to prevent◦ Disruption of the growth plate, interrupt growth ◦ Septic arthritis and joint damage◦ Recurrent infection

Administer IV antibiotics Teach care of PICC line Strict aseptic technique and transmission-

based precautions during all dressing changes.

Good hygiene Teach signs of spread of infection

◦ increasing pain, difficulty breathing, increased pulse rate, fever

Promote Development

◦ Provide suggestions for the family if the child will be immobilized at home.

◦ Assist the family in planning for completion of school tasks

Inherited disease with progressive deterioration of muscle cells

Causes progressive muscle weakness and atrophy

Several different types All differ by age of onset and severity The most common form of childhood

muscular dystrophy is Duchenne muscular dystrophy

X-linked recessive disorder Affects boys, symptoms by age 3 Will meet early motor milestones birth to age

3 At age 3 see:

◦waddling gait, difficulty climbing stairs, frequent falls; easily tired, when walking and running

As disease progresses:◦toe walking, hypertrophied calves, lordosis

Speech & swallowing become impaired

More pronounced muscle weakness (scoliosis)

Wheelchair by junior high

Tachycardia Pneumonia Heart failure age 20

Maintain ambulation as long as possible Physical therapy, adaptive equipment Braces to prevent contractures Promote independence Prevention of injury Prevention of infection

Chronic inflammation of synovium with eventual erosion of articular cartilage

Cause is autoimmune+ ANA (antinuclear antibodies) + RF (rheumatoid factor)

Girls affected more

Stiffness in AM Swelling Tenderness Painful to touch Warm to touch,

seldom red Loss of motion Increased WBC’s &

sed rate

Goals of care1. Maintain joint fx (splints, ROM)2. Prevent physical deformities3. Relieve symptoms (pain &

inflammation) NSAID’s (aspirin, ibuprofen,

naproxen) SAARD’s Slower Acting

Antirheumatic Drugs(gold, D-penicllamine)

Facilitate medication compliance Encourage child to be as independent as

possible Moist heat (bath or whirlpool) especially

in morning Prevention of injury Promote functioning Most common complication

severe hip involvement with loss of function

A 3-year-old child is suspected of having Duchenne’s muscular dystrophy. Which of the following assessment findings by the nurse would support this diagnosis?

1. A history of delayed crawling2. Outward rotation of the hips3. Difficulty climbing stairs4. Wasted muscle appearance

A child is admitted to the hospital suspecting osteomyelitis. Which of the following serum laboratory values noted by the nurse supports this diagnosis? (Select all that apply)

1. Positive Blood Cultures2. + ANA3. WBC 15,0004. Sed Rate 55. Decreased C-Reactive Protein

An adolescent diagnosed with moderate scoliosis describes all of the following symptoms. Which one would the nurse conclude is not associated with the initial diagnosis?

1. Back pain2. Skirts that hang unevenly3. Unequal shoulder heights4. Uneven waist angles

A 4-year-old child with osteogenesis imperfecta is admitted to the hospital unit. Which of the child’s nursing diagnosis has the highest priority?

1. Impaired skin integrity related to cast2. Pain related to fractures3. Risk for injury related to disease state4. Disturbed body image related to short

stature

Which item should the nurse remove from the bedside table of a 4-year-old child who has just been placed in bilateral long leg casts?

1.Legos2.Etch-a-sketch3.Fireman’s hat4.Coloring book

The nurse is assessing a child in a newly applied cast to the lower leg for a tibia fracture. The nurse medicates the child for pain, which is ineffective. The nurse should further assess:

1.Color of toes.2.Apical pulse.3.Skin temperature.4.Blood pressure

A 14-year-old states her fingers and wrists are stiff in the morning, hurt, and are swollen. The nurse suspects this adolescent will be tested for:

1.Osteomyelitis2.Osgood-Schlatter Disease3.Rheumatoid Arthritis4.Fractures