Orthopedics Inflammatory ProcessJan Bazner-Chandler RN, MSN, CNS, CPNP
OsteomyelitisInfection of bone and tissue around bone.
Requires immediate treatment
Can cause massive bone destruction and life-threatening sepsis
Pathogenesis of Acute OsteoUnder 1 yearthe epiphysis is nourished byarteries.In children 1 yearto 15 years theinfection is restrictedto below the epiphysis.
Clinical ManifestationLocalized painDecreased movement of areaWith spread of infectionRednessSwellingWarm to touch
Diagnostic Tests:X-rayCBCESR / erythrocyte sedimentation rateC-reactive proteinBone scan most definitive test for osteomyelitis
X-Ray18-year-old boy with painful right arm
ManagementCulture of the bloodAspiration at site of infectionIntravenous antibiotics x 4 weeksPO antibiotics if ESR rate going downMonitor ESRDecrease in levels indicates improvement
Goals of CareTo maintain integrity of infected joint / joints
Septic ArthritisInfection within a joint or synovial membraneInfection transmitted by:BloodstreamPenetrating woundForeign body in joint
Septic Arthritis of HipDifficulty walking and feverDiagnosis: x-ray, ESR, aspiration of fluid from joint
Septic HipFlexed hip on affectedside is common presentation.
Needle aspirationunder fluoroscopy
Erythrocyte Sedimentation RateESRUsed as a gauge for determining the progress of an inflammatory disease.Rises within 24 hours after onset of symptoms.
Men:0 - 15 mm./hrWomen:0 20 mm./hrChildren:0 10 mm./hr
C-Reactive ProteinDuring the course of an inflammatory process an abnormal specific protein, CRP, appears in the blood.
The presence of the protein can be detected within 6 hours of triggering stimulus.
More sensitive than ESR / more expensive
Joint Space Fluid
WBC80,000Segs88%Monos1%Lymphs11%RBC16,000Gram StainGram-positive cocci in chains
ManagementAdministration of antibiotics for 4 to 6 weeks.Oral antibiotics have been found to be effective if serum bactericidal levels are adequate.Fever controlIbuprofen for anti-inflammatory effect
Juvenile Rheumatoid ArthritisChronic inflammatory condition of the joints and surrounding tissues.
Often triggered by a viral illness
1 in 1000 children will develop JRA
Higher incidence in girls
Clinical ManifestationsSwelling or effusion of one or more jointsLimited ROMWarmthTendernessPain with movement
Diagnostic EvaluationElevated ESR / erythrocyte sedimentation rate+ genetic marker / HLA b27+ RF 9 antinuclear antibodiesBone scanMRIArthroscopic exam
Goals of TherapyTo prevent deformities
To keep discomfort to a minimum
To preserve ability to do ADL
ManagementFirst line drugs:ASA NSAIDs Immunosuppressive drugs (oral): azulvadine or methotrexate Disease modifying drugsEnbrel - IMRemicade - IV
ASA TherapyAlert: The use of aspirin has been highly associated with the development of Reyes syndrome in children who have had chickenpox or flu. Because aspirin may be an an ongoing p art of the regimen of the arthritic child, parents should be warned of the relationship between viral illnesses an aspirin, and be taught the symptoms of Reyes syndrome.
ManagementPhysical therapyExercise programMonitor ESR levelsRegular eye exams: IriditisCardiac involvement: early studies show some correlation due to inflammatory process
IriditisIntraocular inflammation of iris and ciliary body
2% to 21% in children with arthritis
Highest incidence in children with multi joint involvement disease.
Clinical ManifestationsDeep eye painPhotophobiaOften report decrease in color perceptionRedness no drainage Treatment: prednisone eye drops or PO prednisone
Muscular DystrophyA group of more than 30 genetic diseases characterized by progressive weakness and degeneration of the skeletal muscles that control movement.
Duchenne Most common form of MD and primarily affects boys.Caused by absence of dystophin a protein needed to maintain integrity of muscle. Onset between 3 and 5 yearsRapid progression: unable to walk by age 12.
TreatmentNo curePhysical therapyRespiratory therapySpeech therapyOrthopedic appliances / corrective proceduresMeds: corticosteroids and immununosuppressants to slow progression of the disease.