Musculoskeletal



Musculoskeletal





Compartment Syndrome

Susan K. Emerson



Etiology/Types



  • Trauma.



    • Fractures (majority of cases).


    • Crush injuries.


    • Contusions.


    • Gunshot wounds.


  • Tight casts, dressings, or external wrappings.


  • Extravasation of intravenous (IV) fluids/medications or intraosseous infusion.


  • Burn injuries.


  • Post ischemic swelling (e.g., reestablished blood flow after blocked circulation).


  • Bleeding disorders.



Clinical Presentation



  • The five P’s (not always all together and not always reliable).



    • Pain with passive stretch.


    • Pain out of proportion to clinical situation.


    • Paresthesia.


    • Paralysis.


    • Pulses absent.


  • In children, the three A’s may precede the five P’s by several hours.



    • Anxiety (increasing).


    • Agitation.


    • Analgesic requirement.


Diagnostic Evaluation



  • Measurement of compartment pressure.



    • >30 mmHg typically requires fasciotomy.



      • Consider clinical picture in management plan.


  • Radiography of involved area to evaluate for fracture.


Management



  • Medical emergency.


  • Institute therapeutic management while awaiting surgical specialty evaluation.



    • Remove binding devices (e.g., casts, splints).


    • Keep extremity at the level of the heart.



      • Elevation or dangling of extremity may further impair blood flow.


    • Control pain.


    • Administer oxygen.


    • Correct hypotension, if present.


  • Acute fasciotomy is the definitive therapy; open all involved compartments.



    • Typically performed at the bedside; may be performed in operating room (OR) depending on level of urgency.


    • Antimicrobials may be administered to prevent surgical infection.



      • Use coverage for common skin pathogens (e.g., Staphylococcus aureus).


  • Postprocedure: close evaluation for continued compartment syndrome and signs of infection, infection prevention, and pain control.



    • In many cases, the wound is closed after several days or a graft is placed.




Legg-Calvé-Perthes Disease

Dana L. Lerma



Etiology



  • Not entirely clear.


  • Potential causes include infection, inflammation, trauma, and acetabular retroversion.


Epidemiology



  • Most commonly affects children between 4 and 8 years of age.


  • More common in males.



Clinical Presentation



  • Mild to moderate pain in the hip on the affected side.


  • Pain may radiate to the thigh or knee, most commonly.


  • Occasionally, pain is more severe.


  • Leg length discrepancy or limp may be present.


  • Internal rotation and abduction of the affected leg are limited.


Diagnostic Evaluation



  • Radiograph of the hip or pelvis is the first diagnostic approach (Figure 19.1).


  • MRI or bone scan may also be indicated during the early stages of the disease progression to detect changes that may be more difficult to discern on radiograph.


Management



  • Initial management is dependent on the extent of epiphyseal involvement.






    FIGURE 19.1 • Legg-Calvé-Perthes Disease Anteroposterior (AP) Radiograph of Bilateral Hips and Pelvis. AP radiograph of bilateral hips and pelvis of patient with Legg-Calvé-Perthes disease in the right hip.


  • Treatment is aimed at maintaining the femoral head properly placed in the acetabulum and maintaining adequate range of motion.


  • Mild Legg-Calvé-Perthes disease (LCPD).



    • Normal activity with observation.


  • Severe LCPD.



    • Activity restriction.


    • Physical therapy (PT).


    • Possible bracing to maintain proper positioning of the femur.


  • Long-term management of severe cases may include:



    • Extensive PT and rehabilitation.


    • Prolonged immobilization with use of orthotics or spica casting.


    • Close follow-up by an orthopedic specialist.


  • Rarely, surgery is indicated, but in some severe cases may be beneficial.


Osteomyelitis

Susan K. Emerson




Types



  • Acute or chronic.



Risk Factors



  • Hemoglobinopathies (e.g., sickle cell disease).


  • Chronic renal disease.


  • Type 1 diabetes.


  • Compromised immune system.


Etiology



  • Staph. aureus is the most common organism in children (except neonates), 70% to 90% of infections.



    • Community-acquired methicillin-resistant Staph. aureus (MRSA) is becoming more prevalent.


  • Other offending organisms include group A hemolytic streptococcus, Streptococcus pyogenes, Strep. pneumoniae.


  • Group B streptococcus is the most common organism in neonates.


  • Pseudomonas is associated with puncture wounds, especially of the foot.


  • Haemophilus influenzae: incidence has decreased since advent of H. influenzae vaccine.


Clinical Presentation



  • Depends on child’s age and bone involved.


  • May have history of recent injury or infection.


  • Discrete tenderness at site of infection in affected bone.


  • May be associated with erythema, warmth, and edema of affected extremity.


  • Limp or refusal to bear weight; lower extremity.


  • Refusal to use extremity; upper extremity.


  • Fever, chills, vomiting.


  • Neonates may present with irritability, change in sleep habits, and decreased PO intake.


  • May appear toxic if long duration of infection.


Diagnostic Evaluation



  • Laboratory values.



    • White blood cell (WBC) count is highly variable with poor correlation to treatment.


    • C-reactive protein (CRP) is the most sensitive marker to monitor therapeutic response. Rises more quickly (e.g., within 6 hours of infection) and declines more quickly with effective therapy.


    • Erythrocyte sedimentation rate (ESR) rises and declines more slowly than CRP (e.g., elevated within 24-48 hours).


    • Blood cultures are positive in approximately 50% of cases and become negative soon after appropriate therapy is initiated.


  • Radiography.



    • Plain radiograph.



      • Early radiographs are often normal or demonstrate soft tissue edema.


      • Late radiographs (e.g., 1-2 weeks) demonstrate metaphyseal reaction and possibly an abscess (Figure 19.2).


    • MRI.



      • Highly sensitive and specific.


      • Demonstrates bone and soft tissue reaction.


      • Can assist in identifying associated abscess.


      • Differentiates between soft tissue and bone infection.


      • Imaging study of choice in patients with focal symptoms and strong suspicion of diagnosis.


    • Computed tomography (CT).



      • Identifies abscess and areas of destruction.


    • Ultrasound.



      • Maybe helpful in evaluating for abscess; though unable to image details of the bone.


Management



  • Nonoperative.



    • Indicated in early disease or disease without abscess.


    • Antibiotics should be started intravenously once a biopsy/culture has been obtained.



      • IV antibiotics provide optimal bactericidal levels in the affected bone and reduce dissemination of disease.






        FIGURE 19.2 • Classic Osteomyelitis Anteroposterior (AP) Radiograph of Ankle. AP view of the ankle in a child with classic osteomyelitis. There are lytic areas in the fibular metaphysis with periosteal new bone formation. The epiphysis is normal.



      • Empiric antibiotics should include coverage for Staph. aureus (e.g., oxacillin or first-generation cephalosporins). If MRSA is suspected, select vancomycin, linezolid, or clindamycin.


    • May require peripherally inserted central catheter (PICC) line placement.


    • Transition to oral antibiotics once patient is afebrile and ESR and CRP have normalized; may require long-term IV antibiotics (e.g., 6-8 weeks).


    • Consider diagnostic imaging to evaluate for deep vein thrombosis (DVT) in patients with MRSA infection and in patients requiring a long hospital stay, admission to the intensive care unit, or surgical intervention.


    • Consultation with orthopedic surgeon, infectious disease specialist, and occupational/physical therapist.


  • Operative treatment.



    • Indications.



      • Abscess on radiographic study.


      • Failure to respond to antibiotics.


      • Purulent drainage on aspiration.


      • Chronic infection.


    • Removal of abscess/purulent drainage.


    • IV antibiotics: may require PICC line placement for long-term IV antibiotics.


    • Transition to oral antibiotic when patient is afebrile and ESR and CRP have normalized.


    • Consider diagnostic imaging to evaluate for DVT.


    • Consultation with orthopedic surgeon, infectious disease specialist, and occupational/physical therapist.

Jan 30, 2021 | Posted by in NURSING | Comments Off on Musculoskeletal
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