CARE OF CHILD WITH ORTHOPEDIC CONDITION

INTRODUCTION
The human body is made up of nearly 206 bones that protects and
preserve the shape of the soft tissues in the body. Our skeletal system
comprises of bones and cartilages that control and direct internal
pressure and provide stability and anchoring points for other soft
tissues. The bones in our body are joined to each other through
ligaments which are tough bands of connective tissue and the muscles
are connected to the bones through tendons. In addition to supporting
weight of the body, bones work together with muscles to maintain
body positions and to produce controlled, precise movements. Without
the skeleton to pull against, muscle fibers alone could not make a
person sit, stand, walk or run.
FUNCTIONS OF SKELETAL SYSTEM
• Provide structural support for the entire
body.
• Stores minerals and lipids. Calcium is the
most abundant mineral in the body. 99% of
the body’s calcium found in the skeleton.
• Produce blood cells.
• Protect body organs from injuries.
• Provide leverage and movement.
COMMON MUSCULOSKELETAL
DISORDERS
• Bursitis • Talipes equinovarus

• Sprain • Tendonitis

• Arthritis • Rickets

• Scoliosis • Kyphosis

• Osteomyelitis • Poliomyelitis
DISORDERS OF SPINAL CORD
KYPHOSIS
Kyphosis is a curving of the spine that causes a bowing or
rounding of the back, which leads to a hunch back or
slouching posture.
Management
• Congenital kyphosis requires corrective surgery in early age.
Scheuermann’s disease is treated with a brace and physical
therapy. Occasionally surgery is needed for large and painful
curves. For debilitating deformity or pain, surgery is an
option.

• Kyphosis caused by infection or tumor needs to be treated

more aggressively, often with surgery and medications.
LORDOSIS
A normal spine, when viewed from behind appears straight.
Lordosis is a medical term used to describe an inward
curvature of a portion of the lumbar and cervical vertebral
column.
Management
• Specific treatment for lordosis will be determined based on:
the child’s age, overall health, medical history, cause and
extent of the condition.

• The goal of the treatment is to stop the progression of the

curve and prevent deformity. Simple exercises may be
sufficient, if lordosis is associated with poor posture.
However, lordosis occurring as a result of a hip problem may
be treated as a part of the hip problem.
SCOLIOSIS
Scoliosis is the lateral curvature
of the spine. As the spine
curves, the vertebrae rotate,
pulling the ribs along. Generally
a sideway curve greater than 10
degrees is considered scoliosis.
Management

Congenital scoliosis:

• Early treatment essential, usually before preschool age.

• Complete evaluation for any other anomalies and intravenous

pyelogram recommended as minimal screening.
Neuromuscular scoliosis:

• Occasionally bracing stabilizes progression if

no structural changes are present.

Infantile idiopathic scoliosis:

• 50% resolve spontaneously.

• 50% rapidly progressive and require spinal

fusion.
Juvenile idiopathic scoliosis:

• Will not resolve spontaneously.

• Bracing or orthoplast jacket usually adequate.

• Spinal fusion indicated if rapidly progressive or

curve is severe 55 – 60 degrees.
Adolescent idiopathic scoliosis:

• Will not resolve spontaneously.

• Exercise program alone ineffective.

• Milwaukee brace or orthoplast jacket

or spinal fusion with or without
instrumentation (cast or traction may
be used preoperatively or post
operatively).
 DISORDERS OF HIP AND LOWER
EXTRIMITIES
DEVELOPMENTAL DYSPLASIA OF HIP (DDH)
• Developmental dysplasia of hip refers to a variety of conditions in
which the head of femur and acetabulum cavity are improperly
aligned and the femur head lies outside the hip socket or acetabulum
cavity.
• According to another definition – hip displacement refers to a variety
of hip abnormalities in which there is a shallow cavity with
subluxation or dislocation of femur head.
Management
The goal of developmental dysplasia of hip is to obtain and
maintain reduction of femur head within the acetabulum
cavity and to provide normal environment for optimum
growth of hip joint. Treatment available for DDH depends the
age of the child.
For newborns and infants younger than 6 months:

• Newborn hips that are Barlow positive (reduced but dislocatable) or

ortolani positive (dislocated but reducible) should be treated with a
pavlik harness as soon as diagnosed. Although other braces are
available (von rosen splint, frejka pillow), the pavlik harness is the
most commonly used device.
For children’s 6mth to 2yrs of age:

• Closed reduction are done under general anesthesia. The hip is

moved to determine the range of motion in which it remains reduced.
The reduction is maintained in well moulded Spica cast with hip in
moderate flexion and abduction. Twelve weeks after surgery, the
Spica cast is removed and an abduction orthosis is often used to
encourage further remodeling of the acetabulum.
Children older than 2yrs:

• Children 2-6yrs with hip dysplasia usually require an open reduction.

In this age group, a femoral shortening osteotomy is done to reduce
the pressure on proximal femur and minimize the risk of
osteonecrosis. Post operatively the patients are immobilized in Spica
cast for 6-12weeks.
Nursing management
• Promoting normal growth and development

• Maintaining correct position of hip

• Maintaining physical mobility

• Protecting skin from irritation

• Provide optimum nutrition

• Parental support and education

CLUB FOOT
The term club put is used to describe a common deformity in which the
foot is twisted out of its normal shape or position. any foot deformity
Involving the angle is known as talipes derived from talus meaning
ankle and pes meaning foot.
Management
Non operative management
• Easy or correctable club foot, which is corrected with manipulation,
casting and splintage alone.
• Resistant club foot is that which are responds poorly to splintage and
relapse quickly following seemingly successful manipulative
treatment. These club foot require early operative management.
These foots are said to be associated with a thin calf and a small high
heel.
Surgical treatment
• In children younger than 5yrs, correction can be achieved with soft
tissue procedure.
• Children older than 5yrs require bone reshaping.
• Lateral wedge tarsectomy or triple fusion is required if the child is
older than 10yrs.
• Plaster of Paris cast in corrected position is required for 4 weeks,
followed by splints until maturity.
Nursing management

• High risk for impaired skin integrity related to application of cast.

• Parental anxiety and grieving related to impaired adjustment to

anomalous condition.

• Parental anxiety and grieving related to impaired adjustment to

anomalous condition.
FRACTURE
A break in the continuity of bone caused by trauma twisting as a result
of muscle spasm or indirect loss of leverage or bone decalcification is
called as fracture.
Management
• To restore fracture fragments to their normal anatomic position
(reduction)
• To maintain bone fragments in place until healing occurs
(immobilization)
• To help the children regain normal functions and strength of the
affected part (rehabilitation).
• Reduction and immobilization are achieved by traction over close to
manipulation and casting until enough callus has formed at fracture
site.
Fracture reduction
Fractures are reduced before edema occurs and tissues are infiltrated by
hemorrhage. Method used for fracture reduction depends on:

• Child's age.

• Status of bone (displaced or overriding).

• Condition of skin and soft tissue.

• Status of neurovascular functioning.

Methods of fracture reduction
Open reduction Closed reduction
Methods of fracture reduction

Traction Manual reduction

Casts
• When a cast is applied for immobilizing a fracture bone, they joined
able and below the fracture are immobilized to eliminate the
possibility of moment that might cause displacement at the fracture
site.
• Most casts are made from gauze strips and bandage impregnated
with plaster of Paris. Other light weight and water-resistant materials
example fiberglass and Poly urethane resin are also being used with
increasing frequency for selected types of fractures.
Nursing management of children with cast
• Before cast is applied extremities are checked for presence of rings or
other items that might cause constriction from swelling so these are
removed.
• A tube of stockinette is structured over the area to be casted and
over it cast is applied.
• Care should be taken to form a smooth padded edge to protect skin
from injury by hard cast edges.
• Cast must be cut uncovered until it dries from inside out.
• A fan can be used to circulate air around the cast.
• A dryer or heated fan should not be used because the outside of cast
would dry before inside resulting in burns due to heat conduction
from cast to this skin.
Nursing responsibilities after the application of cast
• Neurovascular status is assisted
• Maintenance of body temperature
• Maintenance of skin integrity and prevention of infection
• Maintenance of cleanliness
• Promotion of appropriate muscle activity
• Provision of comfort measures
• Prevention of urinary stasis and constipation
• Education of parents and the child
Traction
Traction is exertion of pulling force along the long axis of a body part,
used to-

• Align bone fragments and immobilized them if they cannot be aligned

by simple traction and casting.

• Decrease muscle spasms especially associated with fracture.

• Align dislocated bones.

• Prevent or treat contractures

Nursing management of children with
traction
• Educate the child and parents
• Maintaining traction
• Maintain correct body alignment
• Maintain skin integrity
• Promote appropriate muscle activity
• Providing comfort measures and pain relief
• Provide adequate fluid and nutrients
• Observing for complications
LEG CALVE PERTHES DISEASE
It is also known as osteochondritis deformance juvenillis or coxa plana,
Easy self-limiting disorder in which there is vascular necrosis of the
femoral head. The child suffers from a painful limp that is exacerbated
by activities such as walking or running.
Management

• Close clinical and radiographic monitoring

• Austere trimmy

• Assessment of child

• Rest
Nursing diagnosis
• Impaired physical mobility related to the disease process an activity
restrictions.

• Risk for impaired skin integrity related to skin contact with the brace.

• Disturbed body image related to wearing a corrective brace.

• Deficient knowledge about the condition and home management

related to the insufficient prior information.
SLIPPED CAPITAL FEMORAL
EPIPHYSIS
This is a condition that effects the upper femoral growth plate.
Hip disorder related to times of rapid growth, particularly
during adolescence.
Management
• Internal fixation

• Reconstruction of the femoral head

• Bed rest

• Bucks extension

• Use crutches
OSGOOD SCHLATTER DISEASE
The classic picture of Osgood schlatter disease is bilateral knee pain
that is exacerbated by running, jumping or climbing stairs in a very
active adolescent boy or girl who is involved in sports activities. The
child will point to the tibial tubercle as the site of pain.
Management
• Cold application
• Analgesics and NSAIDs
• Avoid long term immobilization
• Inform patient to avoid pain producing activity
• Use support devices
• Exercises
• Physical therapy (Acute and Chronic phase)
OSTEOGENESIS IMPERFECTA 
Osteogenesis imperfecta (OI), also known
as brittle bone disease, is a group
of genetic disorders that mainly affect
the bones. It results in bones
that break easily. The severity may be mild
to severe. Other symptoms may include a
blue tinge to the whites of the eye, short
height, loose joints, hearing loss, breathing
problems and problems with the
teeth. Complications may include cervical
artery dissection and aortic dissection.
Management
Medical
• Intake of calcium and vitamin D
• IV Pamidronate
• Risdronate

Surgical
• Intramedullary rod placement
• Surgery for basilar impression
• Correction of scoliosis
Home care
• Physical therapy
• Nutrition
• Oral hygiene
Nursing diagnosis

• Risk for injury related to fragile bones.

• Impaired dentition related to genetic predisposition.

• Impaired physical mobility related to loss of integrity of bone

structures.
OSTEOMYELITIS
Osteomyelitis is a pyogenic bone infection. for example, by the
bacteria salmonella or staphylococcus. Osteomyelitis is sometimes a
complication of surgery or injury, although infection can also reach
bone tissue through the bloodstream. Both the bone and the bone
marrow may be infected. Symptoms include deep pain and muscle
spasms in the area of inflammation, as well as fever. Treatment includes
bed rest, use of antibiotics, and sometimes surgery to remove dead
bone tissue.
Management
Medical Management
• Initial goal is to control and arrest the infective process.
• Affected area is immobilized; warm saline soaks are provided for 20
minutes several times a day
• Blood and wound cultures are performed to identify organisms and
select the antibiotic
• Intravenous antibiotic therapy is given around-the-clock.
• Antibiotic medication is administered orally (on empty stomach)
when infection appears to be controlled; the medication regimen is
continued for up to 3 months
• Surgical debridement of bone is performed with irrigation; adjunctive
antibiotic therapy is maintained.
Nursing Diagnosis
• Pain related to inflammation and

swelling

• Impaired physical mobility associated with pain, immobilization

devices, and weight-bearing limitations

• Risk for extension of infection: bone abscess formation

• Deficient knowledge about treatment regimen

Nursing Management
• Protect the affected extremity from further injury and pain by
supporting the limb above and below the affected area.
• Prepare the client for surgical treatment, such as debridement, bone
grafting or amputation, as appropriate.
• Administer prescribed medications, which may include opioid and
non-opioid analgesics and antibiotics.
• Promote healing and tissue growth.
• Provide local treatments as prescribed (e.g. warm saline soaks, wet to dry
dressings)
• Provide a diet high in protein and vitamins C and D.
JUVENILE ARTHRITIS
• Juvenile arthritis is a disease in which there is inflammation (swelling)
of the synovium in children aged 16 or younger. The synovium is the
tissue that lines the inside of joints. Juvenile arthritis is an
autoimmune disease.
• Juvenile rheumatoid arthritis (JRA), also known as Juvenile
Idiopathic Arthritis (JIA), is the most common chronic rheumatologic
disease in children and is one of the most common chronic diseases
of childhood.
Management
• Exercise
• Synovectomy
• Osteotomy and arthrodesis
• Total hip and knee replacement
• NSAIDs
• Disease modifying anti rheumatic drugs
• Corticosteroids
• Immunomodulators
Nursing diagnosis
• Acute pain related to tissue distension by fluid accumulation /
inflammation, joint destruction.
• Impaired physical mobility related to skeletal deformities, pain,
discomfort,activity intolerance, decreased muscle strength.
• Disturbed body image related to changes in ability to perform usual
tasks.
• Self-care deficit related to musculoskeletal impairment.
• Deficient knowledge related to lack of exposure/recall.
MUSCULAR DYSTROPHIES
Muscular dystrophy is a group of diseases that cause progressive
weakness and loss of muscle mass. In muscular dystrophy, abnormal
genes (mutations) interfere with the production of proteins needed to
form healthy muscle.
Management
• Encourage to remain ambulatory for as long as possible.
• Active and passive daily ROM exercise program.
• Splinting and bracing ( to maintain lower extremity stability and avoid
contractures)
• Low-calorie, high-protein diet to avoid excessive weight gain
(ambulation becomes more difficult if the child is overweight)
• Increase fiber and fluids in diet (to prevent constipation.)
• Stool softeners if needed.
• Support groups for parents to assist them with coping (Muscular
Dystrophy Association) 
CONCLUSION
Musculoskeletal problems affect muscles bones joints and tendons all
of which are necessary for movement and therefore are critical to the
child's development many musculoskeletal problems occur because of
vigorous motor activities that are part of a child's daily life but the rapid
growth of the skeletal system plays a significant role as well most
musculoskeletal problems are short term but a number of chronic
musculoskeletal conditions require long-term treatment and nursing
assistance
REFERENCE
• Meherban Singh, Medical emergency in children, 5th edn, CBS publishers.
• Beherman, Nelsons text book of pediatrics, 17th edn, Elsevier publishers.
• Arun Babu, Pediatrics for medical graduates, 1st edn, Elsevier publishers.
• Terrikyle, Essentials of pediatric nursing, 1st edn, Wolterkluer publishers.
• Krishna Handa, Pediatric nursing, 1st edn, Lotus publishers.
• Wong’s; Marilyn, Essentials of Pediatric Nursing, 8th edition, Elsevier Publication.
• Rimple Sharma, Essentials of Pediatric Nursing, 2th edition, Jaypee Brothers Medical
Publishers.
• Manoj Yadav, A Text Book of ChildhealthNursing, 2011 edition, Choice books & printers (P) ltd.
• www.nurseslab.com
• www.mayoclinic.com
Thank you…