2012高一數(shù)學(xué)暑假作業(yè)-基礎(chǔ)科學(xué)-

Orthopedic

DisordersJan

Bazner-ChandlerCPNP,

RN,

MSNAlterations

in

Musculoskeletal

StatusBowden

&

GreenbergMusculoskeletal

Differences

in

ChildrenEpiphyseal

growth

plate

presentBones

are

growing

/

heal

fasterBones

are

more

pliablePeriosteum

thicker

and

more

activeAbundant

blood

supply

to

the

boneThe

younger

the

child

the

faster

the

healing.Focused

Physical

AssessmentInspect

child

undressedObserve

child

walkingSpinal

alignmentROMMuscle

strengthReflexesAssessmentConcerns:Pain

or

tendernessMuscle

spasmMassesSoft

tissue

swellingCoREminder

If

an

injury

has

occurred,

examine

that

arealast

and

be

gentle

when

palpating

the

injurysiteNursing

alert

A

child

younger

than

1

year

who

presentswith

a

fracture

should

be

evaluated

forpossible

physical

abuse

or

an

underlyingmusculoskeletal

disorder

that

would

causespontaneous

bone

injury.Neurovascular

AssessmentPain?

Where

is

it??

Is

it

reduced

by

narcotics??

Does

the

pain

become

worse

when

fingers

ortoes

are

flexed?Neurovascular

AssessmentSensation?

Can

the

child

feel

touch

on

the

affectedextremityMotion?

Can

the

child

move

fingers

or

toes

below

areaof

injury

/

nerve

injuryTemperature?

Is

the

extremity

warm

or

cool

to

touchNeurovascular

AssessmentCapillary

refill?

Sluggish

capillary

refill

may

signals

poorcirculationColor?

Note

color

of

extremity

and

compare

withunaffected

limbPulses?

Assess

distal

to

injury

or

castNeurovascular

Impairment

Restriction

of

circulation

and

nerve

functionfrom

injury

or

immobilizing

device.Clinical

ManifestationsIncreased

painEdemaDecreased

movement

or

sensationDiminished

or

absent

pulses

distal

to

injury

Patient

often

described

as

restless

–

painmedication

do

not

work

–

pain

described

asdeepInterventions

Assess

area

distal

to

injury,

cast,

splint,traction

for

adequate

circulation

Release

pressure

by

splitting

the

cast

orloosening

restrictive

bandage.Notify

physicianCompartment

Syndrome

Pain

is

the

hallmark

sign,

pain

out

ofproportion

to

the

normal

clinical

course.

Must

be

diagnosed

immediately

orirreversible

neurovascular,

muscular,vascular

damage

occurs

that

can

lead

torenal

failure

and

death.Clinical

Manifestations

A

combination

of

signs

and

symptoms

characterizecompartmentsyndrome.

The

classic

sign

of

acute

compartment

syndrome

ispain,

especially

when

the

muscle

is

stretched.

There

may

also

be

a

tingling

or

burning

sensation

(paresthesias)in

the

muscle.A

child

may

report

that

the

foot

/

hand

is

“a

sleep”

If

the

area

becomes

numb

or

paralysis

sets

in,

cell

death

hasbegun

and

efforts

to

lower

the

pressure

in

the

compartment

maynot

be

successful

in

restoring

function.Physical

AssessmentFrequent

pain

assessmentIf

pain

med

does

not

work

something

is

wrongThe

muscle

may

feel

tight

or

full.

Measure

the

affected

muscle

group

andcompare

with

the

unaffected

sidePulses

below

area

of

injuryTreatmentPrevention

Don’t

elevate

the

affected

limb

above

orbelow

the

level

of

the

heart.

Dressings

should

be

removed

if

CS

issuspected.

Casts

should

be

bi-valved

in

high

risksituations.AssessmentDon’t

forget

the

five

P’s?

Pain?

Paresthesia?

Passive

stretch?

Pressure?

Pulse-less-nessSurgical

ManagementSFasciotomy

to

relieve

pressure.

The

fascia

is

divided

alongthe

length

of

the

compartment

to

release

pressure

within.Nerve

Assessment

Important

to

due

on

admission

from

ER

or

tothe

unit

Repeatafter

cast,

traction,

or

surgery

doneon

the

extremityRadius

andulna

nerve

assessmentUlnarNerveInjuryMedial

Nerve

InjuryRadialNerve

InjuryPeronealNerve

DistributionTreatment

ModalitiesGoals

of

fracture

care:?

To

regain

alignment

and

length

of

the

bonyfragments?

To

retain

alignment

and

length?

To

restore

function

of

the

injured

partTractionRealign

bone

fragmentsProvide

restPrevent

or

improve

deformityPre

or

post

operative

positioningReduce

musclespasmimmobilizationFracturesTreatment

determinedby

type

of

fractureFracturesRW

Chandler

MDSalter

Fracture

Iand

IISalter

Fracture

III,

IV

and

VSalter-Harris

ClassificationIf

injury

involves

growth

plate

in

animmaturebone,

growthdisturbance

may

follow.

Classification

system

describes

the

injury

andthe

potential

for

growth

disturbance.Bucks

TractionBall

&

BindlerPrinciples

of

TractionCounter

traction

with

weights

Make

sure

all

ropes

and

pulleys

are

aligned

andweights

are

hanging

freelyDo

not

remove

weights

unless

instructed

to

do

soTraction

must

be

applied

at

all

timesBryants

TractionBryants

TractionUsed

for

child

under

3

yrsHip

dysplasia

/

fractured

femurButtocks

do

not

rest

on

mattress

Assess

neurovascular

and

restriction

by

acebandages

–

compartment

syndromeSkeletal

Traction·Pull

directlyappliedto

boneby

pin·Pin

care·Increased

risk

ofinfectionBall

&

BindlerExternal

FixatorExternal

FixationRWChandler

MDExternal

FixatorBall

&

BindlerPin

Care

Provide

pin

care

as

ordered.

Cleanse

areaaround

pin

with

normal

saline

or

half-strengthhydrogen

peroxide.

Have

parent

/

caretaker

demonstrate

pin

carebefore

dischargeExternal

FixatorRW

Chandler

MDExternal

FixatorRWChandler

MDPlates

and

PinsR.Chandler

MDPlates,

screws,

andwires

are

used

to

alignbone

fragments.Post-operative

CareAssess

color,

sensation,

cap

refill,

movement, pain,

and

pulsesCircle

any

drainage

noted

on

cast

or

dressing.Pain

controlEdema

=

ice

to

areaPulmonary

function

=

C&DBPulmonary

Embolism

A

complication

of

a

fractured

leg

is

apulmonary

embolism.

Fat

escapes

themarrow

when

the

bone

is

fractured

and

cantravel

through

the

blood

stream

and

becomelodged

in

small

vessels

like

the

arteriolesandcapillaries

of

the

lung.

Primary

symptom

is

shortness

of

breath

andchest

pain.InterventionsPlace

patient

in

high

fowlersAdminister

oxygenCall

MDChest

x-ray

Outcomes

are

better

for

a

health

person;poorer

for

person

with

pre-existing

lungproblems.Orthopedic

DisordersCongenitalAcquired

/

traumaInfectiousTales

EquinovarusTales

equinovarus

orClub

footObvious

deformity

notedat

birth.Surgical

correctionBowden

&

GreenbergTales

EquinovarusClubFoot1

to

2

per

1000Males

more

affected

Involves

both

the

bony

structures

andsoft

tissue.The

entire

foot

is

pointing

downward.Interventions

Manipulation

and

serial

castingimmediately

Surgery

isperformed

between

4

to

12months

if

full

correction

is

not

achievedwith

castingNursing

Diagnosis

Impaired

physical

mobility

related

to

castwear

Altered

parenting

related

to

emotionalreaction

following

birth

of

child

with

physicaldefect

Risk

for

impaired

skin

integrity

related

tocast

wear.Knowledge

deficit:

cast

care

and

home

careMetatarsus

AdductusMost

common

foot

deformity2

per

1000Result

of

intrauterine

positioning

Forefoot

is

abducted

and

in

varus,giving

the

foot

a

kidney

bean

shape.Metatarsus

AdductusTurning

in

of

footTreatment:·Passive

manipulation·Soft

shoes

at

night·Serial

castsBowden

&

GreenbergDysplasia

of

the

Hip

Abnormality

in

the

development

of

theproximal

femur,

acetabulum,

or

both.Girls

affected

6:1Familial

historyBreech

presentationMaternal

hormonesOther

ortho

anomaliesClinical

ManifestationsHead

of

femur

lies

outside

the

acetabulum■

+

Ortolani

maneuverAsymmetrical

lower

extremity

skin

foldsDiscrepancy

in

limb

lengthAsymmetry

of

skin

foldHip

ExamInterventionsMaintain

hips

in

flexed

positionTraction

to

stretch

musclesPavlik

harnessHip

surgeryBowden

&

GreenbergPavlik

HarnessBowden

&

GreenbergNursing

Diagnosis

Knowledge

deficit

regarding

care

of

harnessor

castImpaired

physical

mobility

Risk

for

impaired

skin

integrity

related

topressure

from

casts

or

bracesAltered

skin

perfusion

due

to

casts

or

braces

Risk

for

altered

growth

and

developmentdue

to

limited

mobilityHarnessJB

ChandlerOsteogenesis

ImperfectaOsteogenesis

ImperfectaGenetic

disorder

Caused

by

a

genetic

defect

that

affectsthe

body’s

production

of

collagen

Collagen

is

the

major

protein

of

thebody’s

connective

tissue

Less

than

normal

or

poor

collagenleads

to

weak

bones

that

fracture

easyOsteogenesis

ImperfectaOften

called

“brittle

bone

disease”CharacteristicsDemineralization,

cortical

thinningMultiple

fractures

with

pseudoarthrosisExuberant

callus

formationBlue

scleraWide

suturesPre-senile

deafnessGenetic

Defect

Type

I:

autosomal

dominant:

age

atpresentation

2

–

6

years.Common

age

for

child

abuse.

Often

present

as

suspected

childabuse3-month-old

with

OIOld

fractures/demineralizationOld

rib

fracturesType

IIAutosomal

RecessivePre-

or

perinatal

deathPulmonary

hypoplasiaFetus

with

severe

OIRibfractures

/

poorly

developed

spine

/

limbs

&

craniumNew

Born

with

OINursing

Diagnosis

Risk

of

injury

related

to

diseaseprocess

Risk

for

altered

growth

anddevelopment

Knowledge

deficit:

disease

processand

care

of

childCaReminder

Signs

of

a

fracture,

especially

inaninfant,

are

important

items

to

teachcaregivers.

In

a

baby,

these

signs

aregeneral

symptoms,

such

as

fever,irritability,

and

refusal

to

eat.Bowden,

1998Cerebral

Palsy

Groupof

disorders

of

movement

andposturePrenatal

causes

=

44%Labor

and

delivery

=

19%Perinatal

=

8%Childhood

=

5%Cerebral

PalsyrAssessmentDevelopmental

surveillance

is

key

Diagnoses

often

made

when

child

is

6to

12

months

of

agePhysical

exam:Range

of

motionEvaluation

of

muscle

strength

and

tonePresence

of

abnormal

movement

orcontracturescaReminder

Reflexes

that

persist

beyond

theexpected

age

of

disappearance

(e.g.,tonic

neck

reflex)

or

absence

ofexpected

reflexes

are

highlysuggestive

of

CP.Bowden,

1998Clinical

ManifestationsHypotonia

or

HypertoniaContracturesScoliosisSeizuresMental

RetardationVisual,

learning

and

hearing

disordersOsteoporosis

–

long

term

due

to

lackof

movementTeam

ManagementLegg-Calve-PerthesSelf-limiting

diseaseFemoral

head

losesbloodsupplyFour

times

more

common

in

malesPeak

age

4

to

7

yearsClinical

ManifestationsPainLimping

Limited

hip

motion

especially

internalrotation

and

abduction

is

classic

signManagement

Goal

of

care

is

to:

Keep

femoral

headin

the

hip

jointTractionAnti-inflammatoryPhysical

therapyOsgood-SchlattersPainful

prominence

of

thetibial

tubercleGAssessment

Tip:

Asking

the

child

to

squat

or

extendhis

or

her

knee

against

resistanceusually

elicits

pain

and

is

a

goodindicator

of

Osgood-Schlatter

Disease.Osgood-SchlattersDue

to

repetitivemotionAffects

children

10

to

14

years

oldMales

3:1

Diagnosis

is

based

on

clinical

signsand

symptoms·

Pain,

heat,

tenderness,

and

local

swellingManagement·Reduce

activity·Stretching

before

activity·Anti-inflammatory·Avoid

activity

that

cause

painSlipped

Capital

Femoral

Epiphysis

Top

of

femur

slips

through

growth

plate

in

aposterior

direction.Ages

10

to

14

in

girlsAges

10

to

16

in

boysHigh

proportion

are

obeseClinical

ManifestationsPain

in

groinLimpLimited

abductionLeg

may

be

shorterClinical

ManifestationsManagementSurgeryCrutch

walkingScoliosisLateral

curvature

of

spineMClinical

Manifestations

Pain

is

not

a

normal

findingfor

idiopathic

scoliosisOften

present

with

uneven

hemlineUnequal

scapulaUnequal

hipsScreeningScreeningBowden

&

GreenbergMild

ScoliosisMild

formsStrengthening

andstretchingBall

&

BindlerSevere

ScoliosisAssessment

alert:

If

pain

is

a

reported

symptom

ofthe

child’s

scoliosis,

it

shouldbeinvestigated

immediately.

Pain

is

not

anormal

finding

for

idiopathic

scoliosis,and

the

presence

of

this

symptomcould

be

signaling

an

underlyingcondition

such

as

tumor

of

the

spinalcord.BracingCustom

designed

braceChild

wears

at

nightBowden

&

GreenbergModerate

ScoliosisMilwaukee

braceWhaley

&

WongScoliosisSpinal

FusionPost-operative

CarePain

managementChest

tube

in

many

casesTurn,

cough,

and

deep

breathLog-rollNursing

Diagnoses

Body

image

disturbance

related

tobracingRisk

of

injury

related

to

brace

Impaired

physical

mobility

related

tobrace

wear

Risk

for

non-compliance

with

treatmentregimenInflammatory

ProcessOsteomyelitisSeptic

arthritisJuvenile

arthritisOsteomyelitisWOsteomyelitis

Infection

of

bone

and

tissue

aroundbone.Requires

immediate

treatment

Can

cause

massive

bone

destructionand

life-threatening

sepsisPathogenesis

of

Acute

OsteoUnder

1

yearthe

epiphysis

isnourished

byarteries.In

children

1

yearto

15

years

theinfection

is

restricto

below

theepiphysis.OsteomyelitisMost

common

organismStaphylococcus

areusOClinical

ManifestationLocalized

painDecreased

movement

of

areaWithspread

of

infectionRednessSwellingWarm

to

touchDiagnostic

Tests:X-rayCBCESR

/

erythrocyte

sedimentation

rateC-reactive

protein

Bone

scan

–

most

definitive

test

forosteomyelitisX-Ray18-year-old

boy

with

painful

right

armOsteomyelitisManagementCulture

of

the

bloodAspiration

at

site

of

infectionIntravenous

antibiotics

x

4

weeksPO

antibiotics

if

ESR

rate

going

downMonitor

ESR·

Decrease

in

levels

indicates

improvementGoals

of

Care

To

maintain

integrity

of

infected

joint

/jointsSeptic

Arthritis

Infection

within

a

joint

or

synovialmembraneInfection

transmitted

by:BloodstreamPenetrating

woundForeign

body

in

jointSeptic

Arthritis

of

HipDifficulty

walking

and

fever

Diagnosis:

x-ray,

aspirate

fluid

fromjoint,

ESRSeptic

HipDiagnostic

TestsX-rayNeedle

aspirationunder

fluoroscopyErythrocyte

Sedimentation

RateESR

Used

as

a

gauge

for

determining

theprogress

of

an

inflammatory

disease.

Rises

within

24

hours

after

onset

ofsymptoms.Men: 0

-

15

mm./hrWomen:

0

–

20

mm./hrChildren: 0

–

10

mm./hrWBC31,700bands4%segs85%monos6%lymphs5%HgB12.4MCT35.4Platelets394,000C-

reactive

protein8.2

mgESR

/sed

rate39C-Reactive

Protein

During

the

course

of

an

inflammatoryprocess

an

abnormal

specific

protein,

CRP,appears

in

the

blood.

The

presence

of

the

protein

can

be

detectedwithin

6

hours

of

triggering

stimulus.More

sensitive

than

ESR

/

more

expensiveJoint

Space

FluidWBC80,000Segs88%Monos1%Lymphs11%RBC16,000Gram

StainGram-positive

cocci

inchainsManagement

Administration

of

antibiotics

for

4

to

6weeks.

Oral

antibiotics

have

be