SG# 16: Alterations in Rest and Activity

1. SG# 16: Alterations in Rest and Activity By Prof. Unn Hidle Updated Spring 2010

3. DEVELOPMENTAL DISLOCATION (DYSPLASIA) OF THE HIP (DDH)CLUB FOOTOSTEOMYELITISJUVENILE RHEUMATOID ARTHRITISDUCHENNE MUSCULAR DYSTROPHYSCOLIOSISFRACTURESOSTEOGENISIS IMPERFECTA (OI)

5. DEVELOPMENTAL DISLOCATION (DYSPLASIA) OF THE HIP (DDH)

6. DEVELOPMENTAL DISLOCATION (DYSPLASIA) OF THE HIP (DDH) • Pathophysiology: abnormality where the femoral head is not stable in the acetabulum • Ligaments may also be stretched depending on the degree of dislocation • If not repaired, worsens as child gets older • 1-2:1000 births • Females > males (first born)

7. Anatomy

8. 3-(4) types • Preluxation (mild dysplasia) is a delay in acetabular development (acetabular hypoplasia) where the femoral head remains in contact within the acetabulum • Subluxation is an incomplete dislocation where the femoral head remains in contact, but there is a stretched ligament and capsule which causes the femoral head to be partially displaced = most common (“hip click”) • Dislocation is the most severe form where the femoral head completely loses contact with the acetabulum and the ligament is pulled and taut

10. Etiology: • Suspected to be genetic • Associated with positioning of the infant (positive to keep infant straddled: hips abducted, i.e. “sling” or Baby Bjorn) • Estrogen and other prenatal hormones: Have an effect on fetal pelvis as well • Other factors contributing: Breech (esp. Frank); multiple births and LGA babies

11. HIP DYSPLASIA

12. Hip Dysplasia: Which one?

13. Assessment • Newborn: Uneven length of legs or one hip appears more prominent. Most common tests: • Ortolani sign • Barlow sign • Also, uneven gluteal folds • Only diagnosed by MD or NP (not by RN – has to be specially trained) • Either one of the test is positive if femoral head can be felt to slip into acetabulum (dislocated) when hips are externally rotated and abducted. • An audible click (“hip click”) may be heard if dislocation is present

14. Ortolani’s Sign

18. 6-10 weeks of age: • Limited leg abduction is noted • Positive Gallazzi sign = shortening of leg on the side of the dislocation • Asymmetrical thigh and gluteal folds • Less mobility or flexibility on one side • Adduction contractures • Broadening of the perineum when there is a bilateral dislocation

19. If undiagnosed……. • Child may develop a waddling gait • Obvious limp • Possibly toe walking • Trendelenburg sign • See demonstration!

20. Diagnosis • X-ray: not reliable until 3-6 months. Ossification has not taken place until then • After 3-6 months, will show an upward slant to the roof of the acetabulum (>40 degrees) • High-resolution ultrasound

21. Treatment – age dependent • 0-6 months: SPLINT (Pavlik harness or Frejka pillow – used to double diaper). Helps tighten ligaments and maintain ball and socket location. Worn until ossification takes place around 3-6 months and stability is confirmed by X-ray. IMPORTANT: teach normal development during this prolonged time in a harness + teach proper skin care (wash, dry well , assess for pressure areas and massage skin with lotion = stimulate circulation)

22. Treatment – age dependent • If this is not successful due to adduction contracture, then skin traction is used to slowly stretch the hip into full abduction • Closed reduction: Joint is positioned (external manipulation) into place under anesthesia. Then maintained with a body cast (HIP SPICA) which is changed periodically to maintain growth – Amount of time of spica cast is individualized depending on healing!

23. Pavlic Harness and Spica Cast

24. Pavlik Harness

25. Pavlic Harness

26. Positions with Pavlic Harness

27. Frejka Pillow

28. If not detected until 6-18 months: • First gradual reduction by manipulation under anesthesia (closed reduction), traction and spica casting. • Open surgery may be necessary if soft tissue is obstructing reduction. This soft tissue is removed • Also requires a SPICA CAST

29. Pelvic Osteotomies

30. Chiari Pelvic Osteotomy

31. Older child: • The deformity is usually more severe due to adaptive changes and etiological factors (JRA, CP) • Require preoperative traction, open surgical reduction for realignment followed by a spica cast, tenotomy of contracted muscles and possibly osteotomy procedures to reconstruct an acetabular roof • > 4 years of age – procedure very difficult • > 6 years of age – procedure not advised due to severe shortening and contracted muscles and deformity of bone structure

32. Complications • Delay in the development of walking (especially if he/she is in a cast) • Skin irritation and/or breakdown from positioning devices • Differences in leg lengths which may persist • Growth disturbances of upper thigh is NOT common (only hip is affected) • If treated early and successfully, children end up with normal hip joint function

33. NURSING • Early detection: Nursery • Prevent complications of IMMOBILITY once treatment has begun • Neurovascular status • 5 Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis • Assess splinting, traction and casting • Promote drying, good airflow, cast exposed and off bed, elevated casted extremities, hygiene in diaper are, skin hygiene • Perform passive range of motion on non-injured extremities unless client can perform active ROM. Change position frequently: sheepskin or alternate pressure device or mattress • Assess for infection (Osteomyelitis = odor, heat, edema, decrease in N/V status, fever, increased WBC)

34. Assess for pain: Administer pain medications as needed • Promote G&D by providing age appropriate activities. • Encourage parents/caregivers to become involved in child’s care • Support • Teaching

35. What do you think? • Nursing interventions aimed at preventing problems associated with immobilization include which one of the following? • Encouragement in self-care and allowing patients to do as much for themselves as they are able. • Fluid restrictions with strict I&O • Limitation of active range-of-motion exercises to once per day • Decrease sensory stimulation to allow adequate rest

36. What do you think? • Which one of the following is a complication of immobility that is easily prevented by an appropriate nursing intervention? • Disuse atrophy and loss of muscle mass. • Constipation • Hypocalcemia • Pain

37. CLUB FOOT

39. CLUB FOOT • Talipes equinovarus (TEV) = congenital clubfoot which is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus and ankle equinus. • Shortened tendons restrict movement outward, causing the foot to turn inwards and tightened achilles tendon makes the foot point downward (inversion with plantar flexion) • In other words, the foot is plantar flexed with an inverted heel and adducted forefoot

40. CONGENITAL CLUBFOOT

41. TEV involves the bone deformity with malposition and soft tissue contracture. • The foot is twisted out of its normal position • It requires early evaluation and treatment for optimum condition • TEV is the most frequently occurring of all club foot conditions = 98%

42. Etiology • Usually unilateral but can also be bilateral • Boys > girls • 1:700 – 1:1000 births • Cause unknown • Thought to be a genetic component • Theories: • Some feel that it stems from abnormal positioning and restricted movement in utero. • Others feel it is arrested development in the embryo leading to a rigid deformity • Associated with positive family history

43. Diagnosis • Visible – by physical exam • Congenital clubfoot = Talipes equinovarus (TEV) is referred to as idiopathic or true club foot (it is fixed and cannot be passively corrected) • The types of deformities are identified based on their variations: • TALPIS VARUS = inversion or bending inward • TALPIS VALGUS = eversion or bending outward • TALPIS EQUINUS = plantar flexion with toes lower than heel (“tip-toe”) • TALPIS CALCANEUS = dorsiflexion with toes higher than heel (walking on heels)

44. Treatment • The goal of treatment is to achieve a painless, plantigrade and stable foot • Ideally initiate in the newborn period with 3 stages: • Correction of the deformity • Maintenance of the correction until normal muscle balance is regained • F/U observation to avert possible recurrence of the deformity

45. Rapid growth at time of infancy aids in remodeling • Usually manipulation and serial castingis the primary treatment • First cast is applied in the first few days of life • Manipulation and casting are then repeated frequently. First every few days X 1-2 weeks, then Q1-2 weeks • Parents are of the taught how to remove cast at home • Casting is repeated until maximum correction is achieved within 8-12 weeks • Avoid overcorrection with “rocker bottom” foot • With each change, the infant will experience some brief, temorary discomfort which is relieved • With each change, the progress of the foot is assessed

46. If they are unable to correct using casting, then surgery is done to • Correct the bony deformity • Release tight ligaments or lengthening or replacing tendons • Surgery involves pin fixation and the releasing of tight joints and tendons. • Surgery is followed by casting and then a varus preventing brace

47. Nursing Consideration • Skin care, cast care, checking N/V status, reposition, S/S of infection • Teach parents importance of maintaining appts. for cast checks and cast care at home • Reinforce teaching from orthopedist etc. • Encourage “normalizing” child’s life as much as possible • Consult with recreation, education and SW (assistant devices, etc)

48. What do you think? • To reduce anxiety in the child undergoing cast removal, which of the following nursing interventions would the nurse expect to be LEAST effective? • Demonstrate how the cast cutter works to the child before beginning the procedure • Use the analogy of having fingernails or hair cut • Explain that it will take only a few minutes. • Continue to reassure that all is going well and that their behavior is accepted during the removal process

49. OSTEOMYLITIS

50. OSTEOMYLITIS • An infectious process in the bone; usually chronic with intermittent acute or subacute exacerbations • Most frequently in children <10 years of age • Boys 2X > girls