Pediatric Orthopedics Study Guide PDF

**Pediatric Orthopedics Study Guide** ***Scoliosis*** is defined as a lateral curve in the spine greater than \_**[10\_]\_\_ degrees.** **What is the most common form of scoliosis?** Adolescent idiopathic +-----------------------+-----------------------+-----------------------+ | **Scoliosis T...

**Pediatric Orthopedics Study Guide** ***Scoliosis*** is defined as a lateral curve in the spine greater than \_**[10\_]\_\_ degrees.** **What is the most common form of scoliosis?** Adolescent idiopathic +-----------------------+-----------------------+-----------------------+ | **Scoliosis Type** | **Common Age of | **Important Facts** | | | Onset** | | +=======================+=======================+=======================+ | **Adolescent** | 10-16 years | Most common form | | | | | | **Idiopathic (AIS)** | | Possible genetic | | | | link (often seen in | | | | multiple family | | | | members) | | | | | | | | More common in | | | | females | | | | | | | | Only 10% of AIS pts | | | | will have a curve | | | | progression that | | | | requires medical | | | | attention beyond just | | | | regular observation | | | | | | | | Present in 2-4% of | | | | children 10-16 years | | | | old | +-----------------------+-----------------------+-----------------------+ | **Congenital** | Occurs in utero, | Anomalous vertebral | | | the baby is born with | development (abnormal | | | scoliosis | development of the | | | | spine in utero) | +-----------------------+-----------------------+-----------------------+ | **Infantile** | Onset before 3 | Very rare (less | | | years old | than 1% of pediatric | | | | cases) Most get | | | | better on their own | | | | or with braces and | | | | exercises, very few | | | | require surgery | +-----------------------+-----------------------+-----------------------+ | **Juvenile** | Detected between | Accounts for 12-20% | | | ages 3 and 10 years | of all pediatric | | | old | | | | | scoliosis cases | +-----------------------+-----------------------+-----------------------+ | **Neuromuscular** | Can present at any | Associated with | | | age | neurological or | | | | muscular diseases | | | | | | | | Second most common | | | | type of scoliosis | +-----------------------+-----------------------+-----------------------+ Other Symptoms of Scoliosis One side of the rib cage appears larger than the other Waist appears uneven (due to hip being higher on one side) Body tilts to one side **One leg appears shorter than** **the other** o It actually [IS NOT] shorter!! **PAIN IS NOT A TYPICAL** **SYMPTOM** **Scoliosis Screening** Females are screened **twice** at ages **10** and **12** Males are screened **once** at age **13** or **14** Children are usually screened in school o This SHOULD NOT be the only screening they receive; research has shown that there are a lot of incidences of scoliosis that needed further evaluation that were missed at school screenings o A health professional/provider (MD or NP) should also screen children at their primary care appointment Scoliosis History questions to ask: o Family history of scoliosis or other musculoskeletal disorders o Menstrual onset ▪ There's less growth in girls after the onset of menses, which means there is less concern for scoliosis to worsen and may require less treatment in girls who have already started their menses o Development of secondary sexual characteristics and recent growth patterns o Presence of pain and neurologic changes including bowel and bladder dysfunction ▪ Is atypical for AIS **Diagnosing Scoliosis** In the **Adam's Bend Forward test**, it is important to assess for **asymmetry of the child's contour of the back,** using a tool called a **scoliometer**  o Scoliometer assesses the **SYMMETRY** of the spine o Have the child bend forward at the waist until their spine becomes parallel to the floor while holding their palms together with their arms extended o Examine the child from behind and the side o Flexibility should also be evaluated by stabilizing the spine and having the child twist side to side o **90% of curves are to the right, left thoracic concerning** **Scoliosis is a primary diagnosis of exclusion** Primary concerns with diagnosing scoliosis is the possible underlying cause and the curve progression o Ex: could it be caused by a tumor? o Ex: will the curve continue to progress and worsen in degree until it requires more intervention or is the child likely to have little progression in the future? **Curve Progression** **Double** curves (lumbar and thoracic) [progress more than] **single** curves **Larger** curves (30-40 degree) [progress more than] **smaller** curves (20-30 degree) Determinants of curve progression: o Gender o Future growth potential o Curve magnitude at time of diagnosis Females progress more than males Curve progression **increases during adolescent growth spurts**, and especially during their **peak height velocity** (the time when adolescents grow the fastest) o In females, their growth spurt occurs during their Tanner 2-3 stages o In males, their growth spurt occurs during their Tanner 3-5 stages **Evaluating Growth Potential (helps us determine how much curve progression to expect)** Tanner Stage Assessment o Where are they in their tanner stage? o If they have already passed the tanner stage at which their peak growth and growth spurt occurs, then further curve progression is expected to be minimal to none o If they haven't started or are in the middle of their tanner stage at which their growth spurt and peak height velocity occur, they still have a lot of growing to do, and as such further curve progression is expected Risser Scale o Evaluate skeletal maturity o Is an x-ray that grades the progress of the bony protrusion at the iliac crest o The higher the number, the less growth potential they have left ▪ Ex: a child with a scale of 1 = a child your pretty concerned about because they still have quite a bit of growth left Sanders Bone Age Test o Uses x-ray imaging to determine how much growth potential a child has left o Looks at the epiphyseal plates of the child's hand ▪ Ex: in a child whose  fusion of the epiphyseal plates of their hand has not happened yet, this indicates they have quite a bit more growth left (around 7 years old) ▪ Ex: in a child whose plates are pretty much fused, this indicates that they have little growth left (around 15 years old) Cobbs Angle o Comes after the Risser Scale and Sanders Bone Age Tests have been done o Determines that **MAGNITUDE** of the curve in the child's spine o Measures the superior and inferior vertebrae of the scoliotic curve ▪ Aka the top and bottom of where the curve starts and ends **Scoliosis Treatment:** +-------------+-------------+-------------+-------------+-------------+ | Type of | Indicated | Goal/Object | Length of | Additional | | | Angle of | ives | Tx | Facts | | treatment | Curvature | | | | +=============+=============+=============+=============+=============+ | Bracing | Curve of | **Prevent | Should be | [Types of | | | | curve** | continued | braces | | | **greater | | **until | include:]{. | | | than 30 | **progressi | growth has | underline} | | | degrees** | on** | stopped** | Milwaukee | | | or a | or until | | | | | | curve | Is worn | **TLSO | | | curve that | progression | 18-23 hours | (most | | | has | can't be | a day | frequent)** | | | **progresse | controlled | Part time | Boston | | | d** | | or night | | | | | | wearing may | Charleston | | | **from 10** | | be | | | | | | effective | Providence | | | **degrees | | for curves | | | | to** | | | Spine Core | | | | | of less | (does | | | **greater | | than 35 | **not** | | | than 25 | | degrees | work) **RSC | | | degrees** | | | (corrects | | | | | | lateral** | | | | | | | | | | | | **curve AND | | | | | | rotation of | | | | | | the | | | | | | spine)** | | | | | | | | | | | | \*wear | | | | | | clothes | | | | | | under brace | | | | | | to prevent | | | | | | skin | | | | | | breakdown! | +-------------+-------------+-------------+-------------+-------------+ +-------------+-------------+-------------+-------------+-------------+ | Schroth | Coupled | To decrease | Must be | A lot of | | | with | the curve | done EVERY | these | | Method | | when | SINGLE DAY | exercises | | | Bracing | coupled | for as long | address | | (exercises) | (ONLY WITH | with | as the | elongation | | | RSC) | | brace is | of the | | | | bracing | worn in | spine to | | | | | order for | help | | | | | it to work | decrease | | | | | | the curve | +=============+=============+=============+=============+=============+ | Surgery | A **Cobb | Objectives | **Post-Op** | Complicatio | | | Angle of | | | ns | | | greater | | Recovery | include: | | | than 45** | **Arrest** | takes place | | | | degrees or | | in the ICU | Bleeding | | | | **progressi | | | | | people who | on** | There is | | | | | | usually a | Postoperati | | | were not | | large | ve | | | | **Achieve** | | pain | | | successful | | amount of | | | | with | **maximum** | blood loss | Infection | | | bracing | | | | | | | **permanent | during | Nerve | | | | ** | surgery so | damage | | | | | pts often | (risk is | | | | **correctio | | low) | | | | n** | receive | | | | | | blood | | | | | Improve | during or | Pseudoarthr | | | | | | osis | | | | appearance | after the | (if | | | | | surgery | | | | | Keep | (family | the fusion | | | | short and | | fails to | | | | | donates | | | | | long term | before | heal) | | | | | surgery) | | | | | complicatio | | Disk | | | | ns | Pts will | degeneratio | | | | | have a | n | | | | to a | drain post | | | | | minimum | op to | and lower | | | | | prevent | back pain | | | | Surgical | blood | | | | | Procedure: | | | | | | | accumulatio | Complicatio | | | | Fuse the | n | ns | | | | | under the | that | | | | vertebrae | | | | | | along | surgical | involve | | | | | site | lungs and | | | | the curve | | | | | | using | Pts will | circulation | | | | | have a lot | (is still a | | | | bone grafts | of pain | | | | | (bone graft | post-op, | big | | | | usually | they are | complicatio | | | | from the | often | n | | | | hips. Pts | | is | | | | will | given a PCA | | | | | complain | (patient | surgery is | | | | most about | | NOT | | | | pain from | controlled | | | | | location of | analgesic) | done) | | | | bone graft) | with | | | | | | | Flat back | | | | Support | dilated or | syndrome if | | | | fused | morphine on | a | | | | | top | Harrington | | | | bones with | | rod | | | | | of the | | | | | instrumenta | medications | is used | | | | tion | | | | | | | administere | | | | | attached to | d | Flexibility | | | | the | by the | can | | | | | nurse | | | | | spine | | decrease | | | | | Pts will | post-op | | | | \*Many | lie flat | | | | | variations | for 24 | With a PCA | | | | of the | | post-op, | | | | surgery | hours, then | the nurse | | | | exist using | **sit up in | should | | | | different | bed** | monitor: | | | | approaches, | | | | | | instruments | **on POD | Pain | | | | , | 1**, be up | level | | | | and | and | | | | | | | | | | | procedures- | moving with | Constipatio | | | | the type of | assistance | n | | | | procedure | in | | | | | depends on | | Urination | | | | the cause | the | | | | | of the | following | Itching | | | | | days, and | | | | | scoliosis | will | Nausea | | | | | | | | | | | be **moving | Level of | | | | | on their | | | | | | own 1** | consciousne | | | | | | ss | | | | | **week | | | | | | post-op** | | | | | | | | | | | | Can't use | | | | | | NSAIDS for | | | | | | a period of | | | | | | time | | | | | | because | | | | | | they | | | | | | | | | | | | interfere | | | | | | with bone | | | | | | fusion | | | | | | | | | | | | **Healing** | | | | | | | | | | | | Takes | | | | | | about **3 | | | | | | months for | | | | | | the | | | | | | vertebrae | | | | | | to fuse** | | | | | | | | | | | | **substanti | | | | | | ally** | | | | | | | | | | | | Takes | | | | | | about **1-2 | | | | | | years for | | | | | | them to | | | | | | fuse | | | | | | completely* | | | | | | * | | | | | | | | | | | | | | | | | | Sports/acti | | | | | | vities | | | | | | are | | | | | | | | | | | | restricted | | | | | | for 3 | | | | | | months, | | | | | | | | | | | | then the | | | | | | provider | | | | | | will | | | | | | | | | | | | determine | | | | | | when | | | | | | certain | | | | | | | | | | | | activities | | | | | | may be | | | | | | continued | | +-------------+-------------+-------------+-------------+-------------+ **CLUBFOOT** Bone deformities and malposition with soft tissue contractures (soft tissue + bone deformities) o Aka a birth defect where the infants foot is twisted out of shape or position and affects the babies bones, muscles, tendons, and blood vessels Most frequently occurring form of clubfoot = **[Talipes Equinovarus (TEV)]** (95% of cases) o Forefoot adduction (toes point in) o Midfoot supination (midfoot turns upward- looks like a high arch) o Hindfoot varus (heel turns inward) o Ankle equinus (toes point downward) **Incidence of Clubfoot** o **1-2 newborns** out of 1,000 live births o Affects **boys** nearly **twice as often** as girls o 50% of cases are bilateral clubfoot o A positive family history = increased incidence (congenital clubfoot) **Etiology of Clubfoot** o Exact cause is unknown. Potential causes include: ▪ Intrauterine positioning ▪ Neuromuscular or muscle abnormality ▪ Genetic predisposition ▪ Arrested fetal development of skeletal and soft tissue ▪ Amniotic banding When there's a partial amniotic sac rupture, the fibrous bands that make up the amnion that should have been expelled had it been a full rupture, can get wrapped around one or both of the fetuses extremities and impair the growth of that extremity **Categories of Clubfoot** o **Positional**🡪 occurs primarily from intrauterine crowding ▪ Responds to simple stretching and casting o **Syndromic (tetralogic)** 🡪 associated with other congenital abnormalities ▪ Is a more severe form that doesn't respond well to treatment ▪ Ex: associated with spina bifida o **Congenital (idiopathic/true clubfoot)** 🡪 occurs in otherwise healthy infants ▪ Is the most common form, etiology is unknown **Symptoms of Clubfoot** o Small foot (smaller than the normal foot if unilateral) o Shortened achilles tendon o Underdeveloped calf muscle o Empty heel bed (difficult to feel bone when pressing on heel) o Transverse plantar crease o Normal leg lengths (the shortened achilles tendon may make the affected leg look shorter, but it is NOT actually shorter **Diagnosis of Clubfoot** o May be detected prenatally o Is usually diagnosed at birth with a visual inspection o X-rays will be taken to determine the degree and severity of the deformity o MRI may also be used to look at the degree of soft tissue impairment (MRIs are rarely used though) **Treatment of Clubfoot** o Early evaluation and treatment of clubfoot is very important for achieving successful correction and reducing the chances of complications ▪ Want to start treatment BEFORE the bones calcify! o Serial casting is begun immediately or shortly after birth o Successive casting every few days and then every few weeks allows for gradual stretching of the skin and tight structures on the medial side of the foot **Casting** o Initially the cast will be changed every few days for the first 1-2 weeks (cast will be put on, then removed and gentle stretching of the foot, then a new cast is put on and repeat) o Then the cast will be changed every 1-2 weeks until maximum correction is achieved ▪ Usually takes about 8-12 weeks o The casts are change and stretching occurs in order to avoid overcorrection, which can cause rocker bottom foot o If corrected successfully, the child will wear a split (Denis Browne Splint) or corrective shoes afterwards (before splint, will have ponseti method completed where they make incision in achilles that will allow achilles to heal longer over time) ▪ Worn consistently (24hr) for 3 months, then part time (overnight and during naps) until the child is about 3-4 years old ▪ Nonadherence to the splint or corrective shoes can cause a return of the clubfoot o If the deformity has not been corrected, surgical intervention must happen between 3-12 months Prognosis of Clubfoot o Outcomes are not always predictable. Depends on the severity of the deformity, the age of the child at the initial intervention, compliance with treatment, and development of bones, muscles, and nerves o Surgical intervention does NOT restore the ankle to an entirely normal state. The affected foot and leg will still remain smaller and thinner than the unaffected side o Most children after surgery are able to walk without a limp and run and play o There's a 25% chance of reoccurrence o With severe deformities, repeated surgeries are required Clubfoot Nursing Diagnoses o Impaired physical mobility o Risk for impaired skin integrity o Risk for impaired parenting o Risk for delayed motor development o Risk for altered parent/infant relationship **SPORTS INJURIES: no kid should be in the same sport all year round. Increases risk for overuse injury.** +-----------------------+-----------------------+-----------------------+ | **Type of Injury** | **Location** | **Additional Facts** | +=======================+=======================+=======================+ | **SPRAIN**🡪 severe | Ligament | | | trauma to a joint | | | | causing a ligament to | | | | be partially or | | | | completely torn | | | +-----------------------+-----------------------+-----------------------+ | **STRAIN**🡪 injury to | Muscle | | | the muscle near the | | | | musculotendinous | | | | junction, is a result | | | | of a forceful | | | | contraction of the | | | | muscle | | | +-----------------------+-----------------------+-----------------------+ | **DISLOCATION**🡪 the | Bone/joint | These conditions | | displacement of bones | | affecting the joint | | that form a joint | | most often result | | | | from trauma that | | | | causes adjoining | | | | bones to no longer | | | | align with each other | | | | | | | | The most common | | | | dislocation in | | | | younger kids is a | | | | finger (especially in | | | | kids with down | | | | syndrome) | | | | | | | | The most common | | | | dislocation in older | | | | kids is a shoulder | | | | dislocation | | | | | | | | Hip dislocation in | | | | younger children | | | | usually is caused by | | | | a fall when a child | | | | tries to do things | | | | they aren't capable | | | | of. If not corrected, | | | | can cause cut off of | | | | blood supply to | | | | femoral | +-----------------------+-----------------------+-----------------------+ | **SUBLUXATION**🡪 a | Bone/joint | | | partial or incomplete | | | | dislocation | | | +-----------------------+-----------------------+-----------------------+ | **CONTUSION**🡪 damage | Soft tissue, | | | to soft tissue, | | | | subcutaneous | subcutaneous | | | structure, and muscle | structure, | | | | | | | | muscle | | +-----------------------+-----------------------+-----------------------+ | **FRACTURE** 🡪 a | Bone | In kids they are a | | break in the bone | | result of increased | | (caused by | | mobility and/or | | trauma/sudden stress) | | immature motor and | | | | cognitive skills | | Nurses Initial | | | | Assessment: | | In infancy | | | | fractures are | | Cause of the | | **RARE**- usually | | fracture | | caused by abuse (it | | | | takes a LOT of force | | Examine fracture | | to fracture an | | site | | infants bones) | | | | Traumatic | | Neurovascular | | musculoskeletal | | evaluation | | injuries are the most | | | | frequent kinds of | | | | fractures seen in the | | | | ER | | | | | | | | The clavicle is the | | | | most frequent bone | | | | broken in children | | | | followed by the wrist | | | | (usually do to | | | | falling with an | | | | outstretched arm, | | | | which often breaks | | | | the clavicle and the | | | | wrist) | | | | | | | | Kids can't return | | | | to activity until the | | | | use of their affected | | | | extremity is equal to | | | | that of their | | | | unaffected side | | | | | | | | | +-----------------------+-----------------------+-----------------------+ | **STRESS FRACTURE** 🡪 | Bone | An overuse injury | | a break in the bone | | | | caused by repeated | | Is becoming more | | mechanical stress | | common in adolescents | | | | who limit their | | | | intake of calories | | | | and calcium to remain | | | | lean for sports | | | | | | | | Symptoms: chronic | | | | pain that changes | | | | with intensity, and | | | | focal tenderness in a | | | | singular site on the | | | | bone | | | | | | | | **Recommended daily | | | | allowance of Calcium | | | | is 1500 mg/day for | | | | adolescents** (helps | | | | prevent stress | | | | fractures) | +-----------------------+-----------------------+-----------------------+ +-----------------------+-----------------------+-----------------------+ | **EPIPHYSEAL/ | Bone | Most common in boys | | SALTER-HARRIS | | | | FRACTURE** 🡪 a break | | Can lead to | | in the bone through | | permanent growth | | the growth plate of a | | arrest in that bone | | long bone | | if not diagnosed and | | | | treated quickly | |  | | | | | | 4 types: | | | | | | | | The type of | | | | epiphyseal fracture | | | | determines if there | | | | is any future bone | | | | growth development | | | | problems | +-----------------------+-----------------------+-----------------------+ **Therapeutic Management of Sports Injuries** **RICE (rest, ice, compression, elevation)** for acute injuries o For ice: 20 mins on, 20 mins off and use a barrier between the ice and skin o Ice should be promptly applied after an acute injury as it reduces inflammation. Inflammation prevents healing because it keeps ligaments apart, increasing fibrous scarring ▪ NO HEAT- heat is used to prevent injuries (ex during stretching before a workout) not to treat acute injuries Immobilization - stress factors Nursing interventions Triad of injuries from MVA - - - **Diagnosis of Fractures** Symptoms: o Pain or tenderness at the site o Immobility or decreased ROM o Deformity of the extremity o Edema at the site, crepitus, ecchymosis, or muscle spasms X-rays o Sometimes need to be taken of both extremities **Therapeutic Management of Fractures** **Closed (simple) reduction** o Setting the bone back in place without surgery o An orthopedist usually will manipulate pieces of bone back into place by pushing on the bone through the skin without breaking the skin o Is often done in an orthopedist outpatient office and often occurs shortly after the injury o Is indicated in fractures where there is a single breakage point in the fracture as well as in epiphyseal fractures type I, II, and III (sometimes type V too) o If this is unsuccessful, an open reduction is required **Open reduction** o Surgical o Requires some instrument to be in to reset the bone o Indicated in a type IV Epiphyseal fracture and sometimes a type V depending on the severity (can also occur in normal fractures and stress fractures) **Nursing Interventions** o Assess and manage fat embolism ▪ After a crush injury of long bones ▪ Assess for dyspnea, restlessness, fever over 103, petechiae, rash, tachycardia, tachypnea, hypoxia o Teach cast care ▪ How to check neurovascular status/circulation and for skin breakdown at home ▪ Educate the patient that casts cannot get we, nothing should be stuck down the cast (even if they are itchy), and to elevate their limb after getting a cast **Complications of fractures** o Infection o Neurovascular injury o Vascular injury o Mal-union or delayed healing (very unusual in kids, look for other reasons that healing may be delayed such as metabolic problems of low calcium...) - o Leg length discrepancy **The five stages of bone healing include:** 1\. **Hematoma** 🡪 a collection of blood that pools outside of the blood vessel a\. Within the first 24 hours of injury 2\. **Cellular proliferation** 🡪 cells grow and divide, producing more cells 3\. **Callus formation**🡪 soft bone replaces the hematoma 4\. **Ossification** 🡪 bone formation a\. Soft tissues become calcified and hardened 5\. **Consolidation and remodeling** 🡪 the strengthening of the bone to convert to normal bone with satisfactory weight bearing ability a\. longest stage of bone remodeling **COMPARTMENT SYNDROME** **An increase in pressure within a closed space that causes compression of vessels and nerves at that site, reducing blood flow and sensation** Results from swelling caused by **trauma** or use of an **immobilizing device** Symptoms: o Severe pain unrelieved by analgesics o Pain more intense than what would be expected from a fracture o **Pallor, paresthesia, weak or lack of pulse distal to the trauma,** skin cold to touch o Pain with extending fingers or toes Most common in lower extremities or lower arms (tibial, fibial, radial, or ulnar fractures) Go to the ER RIGHT AWAY!! o This is an emergency that requires surgical intervention **OSTEOMYELITIS** **Infection of a bone** Occurs in the metaphyseal region of long bones o Most commonly in the distal portion of the femur Is most frequent in kids aged **5-14 years old** o Still can occur at any age **Exogenous** 🡪 direct inoculation from outside bone o Ex: child required a surgical reset of a bone and then developed a subsequent bone infection **Hematogenous** 🡪 spread of an organism from a pre-existing infection (acute and subacute) o Acute ▪ Begins abruptly ▪ Most intense in the first few days after the infection ▪ Doesn't have to be an infection due to skin impairment or surgery, could be caused by an upper respiratory infection ▪ Is considered acute if it occurs WITHIN the first 2 weeks after they had the initial infection o Subacute ▪ Occurs AFTER 2 weeks post infection ▪ Is present for longer than acute ▪ May have already been treated with antibiotics that weren't specific for the organism or the patient didn't complete the full course of antibiotics **Organisms that could be behind the infection** o Staphloccus aureus 🡪 most common over 5 years ▪ Usually due to a skin infection, procedure, or surgery o Haemophilus influenzae, strep, pneumonia, o Salmonella and Staph aureus 🡪 Sickle Cell Disease o Community acquired MRSA ▪ Is becoming more common and is much more serious and difficult to treat o E coli and B strep 🡪 most common in neonates o Pseudomonas 🡪 puncture wounds over 6 years o Nisseria gonorrhea 🡪 sexually active adolescents **Diagnosis of Osteomyelitis** o Symptoms: ▪ Vague and non specific ▪ Infant: **fever, irritability, poor feeding** ▪ Older child: **pain, warmth and tenderness over site of infection, fever, lethargy, decreased ROM** o Lab data ▪ **Leukocytosis and elevated ESR** ▪ Blood cultures ▪ Bone cultures ▪ CT scan and MRI Because X-rays may not be able to see it ▪ All of these need to be done for a differential diagnosis because all of the symptoms could also be a tumor Therapeutic Management of Osteomyelitis o **Long term IV antibiotics** ▪ 7-14 days, then do lab work and check symptoms: ▪ If better, can change them to oral antibiotics for up to 6 weeks (afebrile, wbc decreased, CRP/ESR decrease) ▪ If not better, the patient will stay on the IV antibiotics and go home with a PICC line ▪ \*Monitor for side effects! ▪ Take probiotics - o **Complete bed rest → AT RISK FOR FRACTURE.** o **Immobilization of affected limb** o May require surgical drainage o Nursing Interventions: ▪ Positioning🡪 careful and gentle moving of the limb as it is very painful ▪ Pain control 🡪 usually oral (take temp before giving NSAID so you know if they have a fever before) ▪ Monitor vital signs ▪ Antibiotic therapy ▪ May require isolation, may require casting ▪ Nutrition ▪ Non-weight bearing ▪ Physical therapy o \*non-adherence can cause further deterioration of bone and turns into chronic osteomyelitis