Pediatric Orthopedic Problems



Pediatric Orthopedic Problems





ORTHOPEDIC PROCEDURES


Immobilization: Casts, Braces, and Splints


Casting, bracing, and splinting are all means of immobilizing an injured or diseased body part. The length of time can vary from a few days to several months, depending on the nature of the problem. The management of children who are immobilized differs little from that of the adult; however, age-appropriate changes must be considered. See Procedure Guidelines 54-1, pages 1744 to 1745.


Complications of Immobilization



  • Peripheral neurovascular compromise.


  • Alteration in skin integrity due to pressure or friction.


  • Loss of efficient use of affected extremity due to noncompliance.


Traction

Traction is the application of a pulling force to an injured or diseased part of the body or an extremity while a counter traction pulls in the opposite direction. Traction may be used to reduce fractures or dislocations, maintain alignment and correct deformities, decrease muscle spasms and relieve pain, promote rest of a diseased or injured body part, and promote exercise. Advances in nailing and rodding, especially external fixators for fractures and spinal curvatures, have reduced the use of traction in many centers. See Procedure Guidelines 54-2, pages 1745 to 1751.


Types of Traction



  • Manual—direct pulling on the extremity or body part. Usually used to reduce fractures before treatment or immobilization.


  • Skin—force is applied directly to the skin by means of traction strips or tapes secured by elastic bandages or by means of traction boots. Usually of short-term duration and commonly used in children in whom small amounts of force are required.


  • Skeletal—force is applied to the body part through fixation directly into or through bone by means of a traction pin or screw. Allows for greater force over longer periods or used when skin traction is not feasible, as in soft tissue injury or damage.


  • Continuous or intermittent—traction forces should be disrupted only in accordance with the health care provider’s orders.







Complications of Traction



  • Neurovascular compromise to extremity.


  • Skin and soft tissue injury.


  • Pin or screw tract infection, osteomyelitis (with skeletal traction).


COMMON ORTHOPEDIC DISORDERS IN CHILDREN


Fractures

A fracture is a break or disruption in the continuity of bone. Fractures in children differ from those in adults due to the differences in anatomy, biomechanics, and physiology of the child’s skeleton compared to that of an adult. Involvement of the epiphysis or metaphysis can disrupt the epiphyseal plate, interfering with growth (see Figure 54-1). Fractures are extremely common in children, with an estimated 42% of boys and 27% of girls sustaining fractures during childhood.



Pathophysiology and Etiology



  • Most fractures in children are a result of low-velocity trauma such as a fall.



    • Up to age 2, most fractures are sustained as a result of the child being injured by another person.


    • Fractures in neonates and infants are commonly the result of child maltreatment. Child maltreatment should be suspected when treating fractures in this age group.


  • A bone fractures when the force applied to it exceeds the amount the bone can absorb.



    • Children’s long bones are more resilient than those of adults. They are able to withstand greater deflection without fracturing.


    • Children’s bones also have thick periosteum.






    Figure 54-1. Structure of a bone.



  • The involvement of growth plates (epiphyseal plate) is unique to fractures in children. Cartilaginous growth plates are present at each end of the long bones and at one end of metacarpals and metatarsals. The plate is weaker than surrounding ligaments, tendons, and joint capsules and is disrupted before these tissues are injured.



    • Damage to the growth plate may result in cessation of or a disturbance in bone growth (depending on the extent of damage sustained at the growth plate).


    • On the other hand, acceleration in bone growth commonly occurs after a fracture in the long bones of children.


  • Children’s fractures heal more rapidly than adult fractures. The younger the child, the more rapidly bone heals.


  • Children’s fractures remodel more completely and actively than adult fractures and usually result in less disability and deformity.


Sites of Fractures in Children


As children grow, the fracture rate increases, with the peak incidence occurring in early adolescence. Forearm fractures are the most common injury.


Forearm and Wrist Fractures



  • Most common site of fracture in children, with most occurring in children older than age 5.


  • Major categories of classification include fracture dislocations, midshaft fractures, and distal fractures.


  • Most common cause is from a fall on an outstretched arm.


Epiphyseal or Growth Plate Injuries



  • Constitutes approximately 15% to 25% of all skeletal injuries in children.


  • The most frequent site of physeal injuries (excluding phalangeal fractures) is the distal radius and ulna.


  • The 11- to 15-year-old age group tends to sustain the majority of physeal injuries to the distal radius and ulna.


  • The mechanism of injury is usually a fall on an outstretched arm.


Clavicle Fractures



  • Frequent site of fracture in children.


  • The shaft of the clavicle is the most common site of injury.


  • A fall on the shoulder or excessive lateral compression of the shoulder is usually the mechanism of injury.


  • Treatment involves support in the form of immobilization with a sling.


  • Reduction of clavicle fractures in children occurs only in instances of extreme displacement.


Humerus Fractures



  • The mechanism of injury for the majority of humeral fractures is a fall onto an outstretched arm or hand.


  • Supracondylar fractures are the most common fractures of the humerus; they may be associated with acute vascular injury.


  • Approximately 10% of all humeral fractures occur at the shaft of the humerus; they are usually a result of twisting injuries in infants and toddlers. Direct trauma to the humeral shaft is the most common mechanism of injury in older children.


  • Distal humeral fractures occur more often in the lateral epicondyle than the medial epicondyle.


  • Less than 1% of fractures occur at the proximal humerus.


Spinal Fractures



  • Rare in children.


  • Mechanism of injury is due to significant trauma, such as a motor vehicle accident, fall from a significant height, athletic activities, beatings, or pedestrian-motor vehicle accident.


  • Most spinal fractures involve the cervical spine.


Pelvic Fractures



  • Pelvic fractures are uncommon in children and adolescents; they are commonly the result of high-energy trauma or a crush-type injury.


  • Associated injuries are present in approximately 75% of children with pelvic fractures and include hemorrhage and damage to the abdominal wall and pelvic organs.


Hip Fractures



  • Hip fractures in children are uncommon, but may occur from motor vehicle accidents, bicycle accidents, falls from significant heights, or child maltreatment (in children under age 3).


  • Hip fractures can result in avascular necrosis of the femoral head and damage to the physis resulting in growth arrest, malunion, and nonunion.


  • Pelvic avulsion fractures are more common, especially in boys ages 12 to 14.


Femur Fractures



  • Common in children. Peak incidence occurs in two age groups—children ages 2 to 3 and adolescents.


  • Femoral shaft (diaphysis) fractures are the most common location.


  • Usually the result of high-energy trauma, such as a motor vehicle accident or fall from a significant height; most common cause in children younger than age 1 is child maltreatment.


Tibial Fractures



  • The most common lower extremity fracture in children occurs in the tibial and fibular shaft—constitutes 10% to 15% of all pediatric fractures.


  • Most diaphyseal tibia fractures in children ages 5 to 6 are nondisplaced or minimally displaced spiral or oblique fractures. A rotational mechanism of injury to the lower leg is the most common cause of tibial fractures in children under age 3 (toddler’s fracture or CAST [childhood accidental spiral tibial]).


  • Greater force is required to injure the tibia in older children; motor vehicle accidents and sports injuries are the most common causes of tibial fractures in children and adolescents.



Ankle Fractures



  • Common in children and adolescents—approximately 5% of all pediatric fractures.


  • Involve the growth plate in approximately every one of six injuries.


  • Greatest incidence is in males ages 10 to 15.


  • Usually the result of direct trauma.


  • Mortise view as well as anteroposterior (AP) and lateral x-rays should be obtained.


Foot Fractures



  • Foot fractures account for approximately 6% of all fractures in children and 50% of foot fractures occur at the metatarsals.


  • Most metatarsal and phalangeal fractures are nondisplaced.


  • Mechanism of injury is usually a direct or indirect trauma, such as from falls, jumping from heights, object falling on foot, and twisting injuries.


Classification of Fractures

Jun 14, 2016 | Posted by in NURSING | Comments Off on Pediatric Orthopedic Problems

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