Orthopedic Assessment Jan Bazner-Chandler CPNP, CNS, MSN, RN
Musculoskeletal Differences in Children • Epiphyseal growth plate present • Bones are growing / heal faster • Bones are more pliable • Periosteum thicker and more active • Abundant blood supply to the bone • The younger the child the faster the healing.
Focused Physical Assessment • Inspect child undressed • Observe child walking • Spinal alignment • ROM • Muscle strength • Reflexes
Assessment Concerns: • Pain or tenderness • Muscle spasm • Masses • Soft tissue swelling
CoREminder • If an injury has occurred, examine that area last and be gentle when palpating the injury site.
Nursing Alert • A child younger than 1 year who presents with a fracture should be evaluated for possible physical abuse or an underlying musculoskeletal disorder that would cause spontaneous bone injury.
Neurovascular Assessment • Circulation • Nerve function
Neurovascular Assessment • Sensation • Can the child feel touch on the affected extremity • Motion • Can the child move fingers or toes below area of injury / nerve injury • Temperature • Is the extremity warm or cool to touch
Neurovascular Assessment • Capillary refill • Sluggish capillary refill may signal poor circulation • Color • Note color of extremity and compare with unaffected limb • Pulses • Assess distal to injury or cast
Neurovascular Impairment • Restriction of circulation and nerve function from injury or immobilizing device.
Clinical Manifestations • Increased pain • Edema • Decreased movement or sensation • Diminished or absent pulses distal to injury • Patient often described as restless – pain medication does not work – pain described as deep
Interventions • Assess area distal to injury, surgical site, cast, splint, or traction • Notify physician • Release pressure by splitting the cast or loosening restrictive bandage per physician order.
Compartment Syndrome • A painful condition that results when pressure within the muscles builds to dangerous levels. This prevents nourishment from reaching nerve and muscle cells. • Muscle groups in legs, arms, hands, feet and buttocks can be affected.
Clinical Manifestations • The classic sign of acute compartment syndrome is pain, 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 has begun and efforts to lower the pressure in the compartment may not be successful in restoring function.
Physical Assessment • Assess pain and if pain medication is working. • The muscle may feel tight or full. • Measure the affected muscle group and compare with the unaffected side. • Check pulses below area of injury
Treatment • Prevention!!!! • Don’t elevate the affected limb above or below the level of the heart. • Dressings should be removed or loosened if CS is suspected. • Current standards: a split is applied for the first 48 hours until swelling from injury / surgery has gone down.
Surgical Management Siumed.edu Fasciotomy to relieve pressure. The fascia is divided along the length of the compartment to release pressure within.
Nerve Assessment • Important to do on admission from ER or to the unit and pre and post surgical procedure