VEPTR. Vertical Expandable Prosthetic Titanium Rib. Disclosures

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1 39 th National Conference on Pediatric Health Care March 19-22, 2018 CHICAGO Disclosures Standardizing VEPTR Incision Site Documentation I have no relevant disclosures. Roni Lynn Robinson, RN, MSN, CRNP Department of Orthopedic Surgery Learning Objective Gain knowledge about a novel way to assess and reduce surgical wound complications and surgical site infections (SSI) for a specific low volume, high risk surgical procedure. Vertical Expandable Prosthetic Titanium Rib VEPTR Thoracic Insufficiency Syndrome (TIS) Inability of the thorax to support normal respiration or lung growth. Thoracic Insufficiency Syndrome (TIS) What Causes TIS? Underlying Pathologies 1. Deformity of the spine causing distortion of the rib cage with both volume and function loss. 2. Primary thoracic dysplasia which can compromise chest volume and rib cage function. 3. Neuromuscular dysfunction causing secondary spine and chest deformity. CHARGE Syndrome VACTERL Congenital Scoliosis Early Onset Scoliosis Juene Syndrome Jarcho Levine Syndrome Hemihypertrophy Charcot Marie Tooth Syndrome Spina bifida Muscular dystrophy SMA Friedreich s ataxia many more 1

2 1989 Dr. Robert Campbell placed the 1 st titanium rib in a child in Texas 1994 Synthes Spine Company took over production 2004 VEPTR approved by FDA VEPTR Device History VEPTR Device VEPTR expands outward to mimic the width of a typical child s chest Attaches to the ribs and either the ribs, pelvis or the spine With permission, Campbell et.al; Thoracic insufficiency. syndrome.curr Probl Pediatr Health Care 2016 Mar; 46(3): VEPTR Device Scoliosis VEPTR can be used as a jack to straighten the spine & keep it straight as the patient grows. Post VEPTR Insertion Real life VEPTRs Background Varying, nondescript documentation of incision sites in the EHR Difficult to capture which incision is from which surgery when there are wound concerns Potential to incorrectly report Surgical Site Incisions (SSI) Could lead to difficulty with providing optimal therapy, classification, as well as proactive identification of high risk sites Parents not consistently educated on incision site nomenclature when calling or coming to the ED with a wound concern No way of identifying specific incision sites in nursing flowsheets Quality Improvement Project Goals Provide a consistent approach when communicating a VEPTR patient s incision sites across the organization Standardize SSI documentation using the Center for Thoracic Insufficiency Syndrome (CTIS) Incision Site Schematic (ISS) for all skin & wound issues related to a VEPTR procedure Educate at least 80% of the patients/families using the ISS 2

3 Incision Site Schematic Developed within the CTIS Safety Group Ability to track & monitor multiple skin incisions following a VEPTR procedure Ability to discern which specific SSI there are concerns about Allows for a standardized communication of incision sites across the board VEPTR Post Surgery PFE Patient Family Education: VEPTR Care Post Surgery When can I remove my child s dressing? Remove your child s secondary or cover dressing on (Date:) How to Care for the spine dressing When can my child shower or take a bath? How do I care for my child s incision? Signs/symptoms of infection VEPTR Incision Diagram in EHR VEPTR Incision Diagram in EHR Nurses are able to refer to ISS while documenting in flowsheet. Who will utilize the ISS? Ortho attending documents the specific sites in the CTIS physician survey (REDCap) Nursing newly created LDA specific to VEPTR incisions (active in EHR) Will allow for easy identification of which sites have concerns Nursing & Inpatient NP s complete PFE sheet (ISS) & educate families prior to discharge An image of the completed ISS sheet is uploaded into the patient s media tab Outpatient NP s & coordinators utilize the ISS (media tab) to follow up with the families post operatively Parents use the ISS sheet provided when concerned about an incision site PFE:VEPTR Care Post Surgery Quality Improvement Project Results A PFE was created for consistent education at discharge Post discharge follow up showed that 100% of families in March 2017 reported receiving the VEPTR ISS & felt comfortable using it 3

4 Quality Improvement Project Results Qlikview Accessibility Goal: To educate 80% of patients/parents using the ISS As of March, % of families had received the education 4

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6 My Kid Falls ALL the Time: Common Causes of In-toeing Learning Objectives Understand the 3 most common causes of in-toeing Describe treatment for 3 the most common causes of in-toeing Understand when to refer and when to watch In-toeing Very common Most resolves spontaneously Treatment for all 3: Reassurance Reassurance 2 nd opinion for reassurance Evaluation Thorough H&P Family history Pain? Height/Weight LLD? Neuro exam Femoral Anterversion Normal anterversion 15 to 20 Increases until age 4 or 5 Resolved by age W sitting- don t worry about it Surgical treatment-rare Osteotomy if functionally limiting by early teen Physical Exam: Hip motion Increased internal rotation > 70 Decreased external rotation of < 20 Patella internally rotated when ambulating Internal Tibial Torsion Presents at walking age Most often bilateral Resolves by 7 or 8 REASSURANCE Surgical treatment-rare Derotational osteotomy Physical Exam Thigh foot angle > 15

7 Increased foot progression angle Patella faces forward, feet turn in Metatarsus Adductus Packaging problem Torticollis DDH Excessive anterversion Internal tibial torsion Treatment Diaper change stretching 90% resolve by 1-2 years REASSURANCE (no special shoes) Metatarsus Adductus Physical Exam: Normal hindfoot Medially deviated forefoot C shaped lateral border Mild, moderate, severe References The American Academy of Orthopaedic Surgeons Pediatric Orthopaedic Society of North America OrthoBullets

8 39 th National Conference on Pediatric Health Care Pediatric Fractures: A Tough Break for All March 19-22, 2018 CHICAGO Disclosures I have nothing to disclose. Kimberly R. Joo, DNP, APRN, CPNP PC, CNE Learning Objectives Define key terms Describing a fracture Review Bone Anatomy State the indications for an x ray Identify the different types of pediatric fractures Cases that require immediate referral Indicate cases that require follow up testing Splinting fractures Key Terms for Fractures Salter Harris: classification of growth plate and epiphyseal fractures Greenstick: incomplete fracture with angular deformity Buckle: compression fracture that causes the bone to bend or buckle on the damaged side Reduce: procedure to restore a fracture to original alignment Displaced: a fracture where the 2 ends of a bone are not lined up straight Angulated: a fracture with loss of alignment, the degree of rotation or change in bone length Transverse: fracture is perpendicular to the shaft Key Terms for Fractures Avulsion: a fragment of bone has torn away from the main mass of bone Effusion: abnormal accumulation of fluid in a joint Open: a broken bone that penetrates the skin Comminuted: more than 2 fracture fragments Oblique: an angulated fracture line Segmental: comminuted fracture where a completely separate segment of bone is bordered by fracture lines Torus: an incomplete buckle fracture of one cortex Key Terms for Fractures Spiral: multiplanar and complex fracture line Intra articular: the fracture line crosses the articular cartilage and enters the joint Impaction: a fracture that occurs when one bone hits an adjacent bone Compression: type of impaction fracture that occurs in the vertebrae, resulting in depression of the end plates Depression: a type of impaction fracture that occurs in the knee when the femoral condyle strikes the softer tibial plateau 1

9 Bone Anatomy Growth Plate Anatomy Indications for Imaging Injury Pain Point tenderness Deformity Decreased range of motion Edema Bruising Pain with ambulation Inability to bear weight (Slideplayer.com, 2016) What X Ray Should I Order? Describing a Fracture Anatomic Region Wrist Plain Radiograph Fracture Views All patients: AP, lateral Oblique: if fracture suspected, but AP and lateral are negative: Elbow Shoulder Knee Foot Tibia, femur, humerus, & forearm Ankle Scaphoid: if scaphoid fracture is suspected AP, lateral, and oblique AP, scapular Y AP, lateral, oblique (internal or externally rotated) Sunrise (axial, tangential): patellar injury AP, lateral Oblique: if fracture seen AP, lateral AP, lateral, and mortise (UpToDate, 2018) 2

10 Type of Fracture: Buckle (torus) Compression fracture Often at the junction between the porous metaphysis and the denser metaphysis Locations: distal radius, distal tibia, fibula and femur Stable Splint Ortho follow up Buckle (Torus) Fracture Image Type of Fracture: Plastic Deformation Bowing fracture Longitudinal force exceeds the bone s ability to recoilto it s normal position Microscopic fractures Locations: ulna, radius, and occasionally the fibula Self correcting if < 20 degrees and/or < 4 years of age Closed reduction or surgical intervention Plastic Deformation Fracture Image Type of Fracture: Greenstick Bone that is bent with a fracture line that does not extend completely through the width of the bone Risk for repeat fracture % of forearm refractures Location: forearm Greenstick Fracture Image 3

11 Type of Fracture: Physeal (Growth Plate) Growth plates are susceptible to fracture Weak point in pediatric bones Tensile strength of pediatric bone is less than that of ligaments 21 30% of pediatric long bone fractures Locations: distal radius and distal ulna Girls: 9 12 years Boys: years 30% cause bone growth disturbance Once the physis closes, fractures follow adult patterns Type of Fracture: Physeal Salter Harris Classification Type I: Disrupts the physis Type II: Break from the growth plate into the metaphysis Type III: Intraarticular through the epiphysis and extend across the physis Type IV: Cross the epiphysis, physis, and metaphysis Type V: Compression to the physis Types of Fractures: Physeal Salter Harris Classification Salter Harris Ankle Fracture Images Green = growth plate Red = fracture (UpToDate, 2018) (Epomedicine, 2016) Salter Harris Humor Type of Fracture: Apophyseal Avulsion Fibrocartilage physes instead of columnar cartilage Prone to overuse traction avulsions Osgood Schlatter disease: tibial tuberosity Sinding Larsen Johnsson syndrome: inferior pole of the patella Self limited Do not interfere with growth Adolescent athletes (Wordpress, 2014) 4

12 Apophyseal Avulsion Fracture Image Special Circumstance Fracture: Stress Fracture Overuse injuries Accumulated microtrauma from repetitive strain Small but progressive cracks in the periosteum Adolescents Female > males Locations: tibia, fibula, pars interarticularis (spondylolysis) and femur Radiographic findings don t present until 1 2 weeks of symptoms MRI is more sensitive (Science Direct, 2012) (KoreamedSynapse, 2009) Stress Fracture Sports and Sites Stress Fracture Images Sport Baseball Basketball Gymnastics Ice Skating Running Soccer Swimming Volleyball Fracture Site Tibia Anterior cortex of tibia, tarsal navicular Tibia, fibula Distal fibula Proximal tibial metaphysis, distal tibial metaphysis, fibula, tarsal navicular, midshaft of femur, distal femur, femoral neck Patella Proximal tibia Tibia (UpToDate, 2018) Special Circumstance Fracture: Child Abuse Fracture in a child < 1 year Lower extremity fracture in a non ambulatory child Posterior rib fractures Metaphyseal lesions (bucket handle or corner fractures) Bilateral long bone fractures Complex skull fractures Spinous process fractures Repeat fracture in an unusual location Stage of healing that is inconsistent with injury description Multiple fractures in various stages of healing Mandatory reporter Child Abuse Fracture Image 5

13 Special Circumstance Fracture: Pathologic Fracture Fracture in a bone that is weakened by an underlying abnormality Bone tumors Rickets McCune Albright syndrome Juvenile osteoporosis Chronic renal insufficiency Osteogenesis imperfecta Osteopetrosis Location: proximal femur and humerus Pathologic Fracture Image (Radiopaedia, 2018) Special Circumstance Fracture: Repeat Fractures 1 in 1, % of forearm fractures Risk: Incomplete bony union Residual angulation Early cast removal Radial or ulnar diaphyseal fracture Greenstick fracture Immediate Referral Open fractures Deformed/angulated fractures Rotated fractures Displaced fractures Fractures with dislocations Joint/articular surface involvement Any fracture with neurovascular compromise Consult orthopedics whenever you have a question Immobilization Guidelines 1. Document vascular, sensory, and motor function before and after immobilization. Immobilize above and below the site of injury, generally in a position of function. 2. Immediate consultation with orthopedics for all findings on previous slide. 3. Consult orthopedics whenever you have a question. If you consult an attending physician, follow up with that physician. 4. With any fracture (except torus), the fracture could progress (even in a cast). 5. True buckle/torus fractures should not demonstrate completion of fracture through volar cortex and should not have angulation. Immobilization Guidelines 6. Elbows: for children < 6 years, consider obtaining comparative lateral film of contralateral elbow; for condyle fractures, consider obtaining oblique view to more clearly delineate amount of displacement. 7. Any displacement at a growth plate should prompt a consult to ortho. 8. Ensure good after care instructions, pain control, and specify follow up (ortho or PCP and timing). 9. These guidelines are very generalized. Care must be taken to alter treatment according to individualized patient situation. 6

14 Immobilization/Splinting: Upper Extremity Site of Injury Immobilization Follow Up Timing Clavicle 1. Clavicle strap with sling or cuff & collar 7 15 days ortho or PCP 2. Sling & swath *ortho if athlete/teen Humerus proximal Sling & swath 5 7 days Humerus shaft Sugar tong splint with sling & swath 5 7 days Elbow lateral condyle <2mm displacement Elbow medial condyle <2mm displacement Supracondylar Type 1 Non angulated Type 2 Supracondylar Angulated Type 2 All Type 3 1. Long Arm posterior splint (elbow 90) with cuff & collar (simple sling for older kids) 2. Long Arm cast (elbow 90) with C&C or SS only with mild edema Long Arm posterior splint with C&C 3 7 days Immediate consult with ortho Immobilization/Splinting: Upper Extremity Site of Injury Immobilization Follow Up Timing Scaphoid (other carpal) Radial Head/Neck Thumb Spica 1. Long Arm posterior splint with C&C or SS 2. Long Arm cast with C&C or SS if mild edema Radius and Ulna Shaft Long Arm cast with C&C 7 10 days Radius and Ulna Distal Long Arm cast with C&C (if mild edema) Long Arm posterior splint or Reserve Sugar Tong with C&C 7 10 days Radius and Ulna Buckle or Torus Long Arm cast Short Arm cast for simple buckle 3 5 days (actual fracture) 7 10 days (suspected) 5 7 days Immediate consult with ortho if displaced days Olecranon 1. Long Arm posterior splint with C&C or SS 3 7 days 2. Long Arm cast with C&C or SS if mild edema (partial elbow Immediate consult if complete extension ) fracture Immobilization/Splinting: Upper Extremity Immobilization/Splinting: Lower Extremity Site of Injury Immobilization Follow Up Timing 1 st Metacarpal Thumb Spica splint 5 7 days 2 nd Metacarpal Radial Gutter splint 5 7 days 3 rd Metacarpal Volar splint 5 7 days 4 th & 5 th Metacarpals Ulnar Gutter splint 5 7 days Fingers Splint and/or buddy tape PCP for minor fractures Ortho if: 1. Intra articular 2. Displaced 3. Angulated 4. Rotational deformity Site of Injury Immobilization Follow Up Timing Femur Position of comfort Immediate consult Knee x ray negative Knee immobilizer (KI) Long Leg Sugar Tong splint (LLST) 3 7 days with ortho or sports med Long Leg Posterior splint (LLPS) Tibial Spine/Plateau LLST Immediate consult Proximal Fibula KI or Schantz wrap with crutches Consult ortho Tibia/Fibula: Toddler s fracture Long Leg Cast (LLC) 7 10 days Distal Fibula fracture LLC, LLPS, Short Leg Sugar Tong (SLST), Short Leg Posterior Splint (SLPS) 3 7 days if splinted 7 10 days if casted Distal Tibia fracture LLPS / SLST, LLC if minimal displacement 3 7 days if splinted 7 10 days if casted Immobilization/Splinting: Lower Extremity References Site of Injury Immobilization Follow Up Timing Ankle: Tri planar fracture LLPS Immediate consult Ankle: Tibia fracture LLPS Immediate consult Ankle: Tillaux < 2mm displacement LLPS or LLC (if mild edema) 5 7 days Ankle: Tillaux >/= 2mm displacement LLPS Immediate consult Salter Harris I Fibula fracture SLPS, SLST or air cast 7 10 days Foot: Tarsal fracture SLPS 5 7 days Single Schantz Reese shoe Foot: Metatarsal fracture Reese shoe or SLPS 7 10 days Toe (angulated may require reduction Reese shoe and/or buddy tape days with PCP or ortho if angulated Great toe open or with nail bed disturbance Reese shoe and/or buddy tape Antibiotics for 10 days 5 7 days with ortho Mathison, D.J., & Aggrawal, D. (2017). General principles of fracture management: Fracture patterns and description in children. In R.G. Bachur (Ed.), UpToDate. Watham, Mass.: UpToDate. Retrieved from Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B., Blosser, C.G. & Garzon, D. L.(2017). Pediatric primary care: A handbook for nurse practitioners (6 th Ed). Philadelphia: W.B. Saunders Company. 7