Sei sulla pagina 1di 10

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations O RTHOPAEDIC P AEDIATRIC P ATIENT : N EUROVASCULAR C

ORTHOPAEDIC PAEDIATRIC PATIENT:

NEUROVASCULAR CONSIDERATIONS

PRACTICE GUIDELINE ©

 

DOCUMENT SUMMARY/KEY POINTS

Definition of neurovascular assessment

Criteria for neurovascular assessment

The general principles of neurovascular assessment to upper and lower extremities:

o

Sensory function

o

Motor Function

o

Pain

o

Swelling

o

Capillary refill

o

Presence of peripheral pulses

o

Temperature

o

Colour

o

Muscle Strength

o

Documentation

Potential complication associated with peripheral circulation and peripheral neurologic integrity

Management of neuromuscular impairment

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to each individual presentation.

Approved by:

CHW Policy and Procedure Committee

Original endorsed by SMG July 1999

Date Effective:

Immediate

Review Period: 3 years

Team Leader:

Clinical Nurse Consultant

Area/Dept: Orthopaedics

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 1 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations CHANGE SUMMARY • Section 3 General principles

CHANGE SUMMARY

Section 3 General principles

Reference List

READ ACKNOWLEDGEMENT

Training/Assessment Required – Nursing staff to complete competency in Orthopaedic Education program (in orthopaedic clinical areas). Inservice provided to ED

Read Acknowledge Only – Medical, Nursing, Allied health

This document reflects what is currently regarded as safe practice. However, as in any clinical situation, there may be factors which cannot be covered by a single set of guidelines. This document does not replace the need for the application of clinical judgement to each individual presentation.

Approved by:

CHW Policy and Procedure Committee

Original endorsed by SMG July 1999

Date Effective:

Immediate

Review Period: 3 years

Team Leader:

Clinical Nurse Consultant

Area/Dept: Orthopaedics

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 2 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations TABLE OF CONTENTS 1 Rationale 4 1.1

TABLE OF CONTENTS

1

Rationale

4

1.1

Definition 4

2

Criteria for Neurovascular Observations

4

3

General Principles - Neurovascular Assessment 5

3.1

Peripheral Neurologic Integrity Upper Extremities Lower Extremities

5

5

6

3.2

Pain

6

3.3

Peripheral Vascular Integrity

7

4

Documentation

7

5

Complications 8

5.1

Compartment Syndrome

8

Definition: 8 Signs and Symptoms of Compartment Syndrome 8 Management: 8

5.2

Peripheral Nerve Injury

8

5.3

Vascular Injuries

9

6

References

9

Management of orthopaedic patient post-operatively/post injury

10

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 3 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc

This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations 1 Rationale To ensure that neurovascular status of the

1 Rationale

To ensure that neurovascular status of the child is not compromised, and prevent permanent damage to the affected limb, thus promoting maximal healing. Delayed recognition of neurovascular compromise can result in permanent muscle and nerve damage. 1,2,3,4

1.1

Definition

Neurovascular assessment includes the assessment of the peripheral circulation and the peripheral neurologic integrity. Neurovascular impairment is usually caused by pressure on the nerve or altered vascular supply to the extremity. 1,2

2 Criteria for Neurovascular Observations

Neurovascular observations are taken HOURLY for 24 hours, however the child needs to be monitored until the stability of the extremity is attained and maintained. 1,2,3,4

Hourly neurovascular observations are performed for the first 24hours (and monitored until the stability of the extremity is attained in the following situations. Additional observations/notes are mentioned below:

Trauma to an extremity

o

Suspected Fractures / Fractures

o

Crush injuries

Application of traction

o Bucks traction requires 6 hours of observation.

Application of plasters/back slabs

o Observations to continue for duration of POP in situ.

Post operatively

o

Application of External fixation device.

o

If tourniquet applied in theatre for over 20 minutes.

Spinal surgery

o Observations to continue 4 th hourly.

Burns patient

o Doppler to be used to check pulses.

Cardiac Catheterisation

o Hourly wound checks for 24 hours.

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 4 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc

This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations 3 General Principles - Neurovascular Assessment Note:

3 General Principles - Neurovascular Assessment

Note: Always compare affected limb with unaffected limb when assessing neurovascular status. Take into account child's history, eg Spina Bifida or existing nerve damage. 2,3

Refer to also to flowchart.

3.1 Peripheral Neurologic Integrity

Upper Extremities

Sensation Function

Movement Function

Radial Nerve:

Radial Nerve : Radial Nerve:

Radial Nerve:

Radial Nerve : Radial Nerve:

Able to feel touch the web space between the Thumb and index finger

Able to extend fingers at the MCP joints (1 st knuckle) and extension of the wrist

Ulnar Nerve:

Ulnar Nerve: Ulnar Nerve: Able to abduct all fingers

Ulnar Nerve: Able to abduct all fingers

Ulnar Nerve: Ulnar Nerve: Able to abduct all fingers

Able to feel touch at the distal fat pad of the small finger

Median Nerve:

Median Nerve: Median Nerve:

Median Nerve:

Median Nerve: Median Nerve:

Able to feel touch at the distal surface of the index finger, palm up

1) Able to oppose thumb and small finger/flex wrist

2) Flex thumb at IP joint

Table adapted from and cited in Maher, A.B., Salmond, S. W., & Pellino, T. A. 2002. Orthopaedic Nursing. 3rd edition. Chapter 8. p.201. W.B. Saunders, Philadelphia.

Anterior Interosseous Nerve: Injury is associated with extension-type supracondylar fractures. The child should be able to flex the interphalangeal joint of the thumb.

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 5 of 10

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Lower Extremities

Sensation Function

Considerations Lower Extremities Sensation Function Movement Function Peroneal Nerve: Peroneal Nerve:

Movement Function

Peroneal Nerve:

Peroneal Nerve: Peroneal

Peroneal

Peroneal Nerve: Peroneal

Nerve:

Able to feel touch at the web space between the great toe and second toe

Able to dorsiflex ankle and extend toes at the metatarsal phalangeal joints

Tibial Nerve:

Tibial Nerve: Tibial Nerve:  

Tibial Nerve:

 

Able to feel touch at the medial and lateral surfaces of the sole of the foot

Able to plantar flex ankle and toes

Able to feel touch at the medial and lateral surfaces of the sole of the foot

Table adapted from and cited in Maher, A.B., Salmond, S. W., & Pellino, T. A. 2002. Orthopaedic Nursing. 3rd edition. Chapter 8. p.201. W.B. Saunders, Philadelphia.

Important notes on movement and sensation of an extremity

Active Movement = able to voluntarily extend and flex an extremity, digit.

Passive Movement = parent/nurse/doctor is able to extend and flex an extremity, digit

A child should be able to demonstrate active movement of an extremity

If a child has increased pain on passive extension or flexion of fingers or toes this may indicate compartment syndrome. 3,4,5,6

Always check affected limb for hardness and swelling. It maybe assumed that there is also high pressure within the muscle compartment. 4,7

Not all children can verbally express variations in sensation, such as numbness and pins and needles. Assess other neurovascular parameters closely especially pain, movement and swelling. Monitor child for increased anxiety, agitation and analgesic requirements. 7

3.2

Pain

Pain is a crucial indicator that there is a potential problem associated with a child’s neurovascular status. Be alert if the pain experienced by the child is out of proportion to the injury. 4,5,6,7,8 An increasing need for analgesics for pain management is an indicator of possible compartment syndrome. 4,5,6,7,8

Pain that is greater on passive extension and flexion of an extremity needs to be further investigated. 4,5,6,7,8

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 6 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc

This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

3.3 Peripheral Vascular Integrity

Considerations 3.3 Peripheral Vascular Integrity Parameters Normal Inadequate Arterial Supply

Parameters

Normal

Inadequate Arterial Supply

Inadequate Venous Return

 

Pink

   

Colour

(natural)

Pale or white

Blue, mottled

Temperature

Warm

Cool

Hot

Capillary refill

1-2 seconds

>2 seconds

Immediate

Swelling

Full

Hollow or prune like

Distended or tense, tissues feel hard

 

Check for presence of peripheral pulses, especially children with fractures involving the elbow

Pulses

If pulses are not palpable due to plaster casts, assess closely above parameters.

If pulse is not present, document and notify medical officer, observe colour, capillary refill and temperature.

Table adapted from and cited in Maher, A.B., Salmond, S. W., & Pellino, T. A. 2002. Orthopaedic Nursing. 3rd edition. Chapter 8. p.200. W.B. Saunders, Philadelphia.

4

Documentation

Neurovascular observations are documented hourly on the paper / electronic chart.

Documentation of the child’s neurovascular status needs to be also described in the child’s medical records.

Altered neurovascular status requires written documentation in the child’s medical records and immediate notification to the Orthopaedic Registrar.

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 7 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc

This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations 5 Complications 5.1 Compartment Syndrome Definition: Is

5

Complications

5.1 Compartment Syndrome

Definition:

Is an increase of pressure within a muscle compartment, there is an increase of interstitial pressure within the osseofascial compartments. If the pressure is not relieved, necrosis of the soft tissues will occur, leading to permanent contracture deformities. 4,5,6

Signs and Symptoms of Compartment Syndrome

Pain: not relieved by simple analgesics (non-narcotic) and excessive pain on passive extension and flexion of extremity 3,4,5,6,7,8 . Narcotics can mask pain from compartment syndrome. This should not preclude appropriate analgesia, but rather indicate a need for a higher index of suspicion.

Paresthesia: abnormal sensations eg, numbness, tingling of extremity 4,5,6,7,8

Pressure: skin is tight and shiny, pressure in muscle compartment is greater then 30- 40mmHg ( pressures are measured in theatres) 3,4,5,6,7,8

Pallor: can indicate an arterial injury, is a late sign 4,5,6,7,8

Paralysis: caused by prolonged nerve compression or muscle damage, is a late sign

4,5,6,7

Pulselessness: Can indicate death of a tissue, check general colour of the extremity

4,5,6,7

Management:

Elevate limb above the level of the heart

Notify orthopaedic medical staff as a matter of urgency

Split plaster backslab or full plaster

Place child on Nil By Mouth

Temporarily cease narcotic infusion to assess neurovascular status especially flexion and extension of extremity.

Organise theatre time for measurement of muscle compartments and or fasciotomy

5.2 Peripheral Nerve Injury

Can result from fractures, and insertion of hardware such as pins and wires that have the potentially to stretch or sever the nerve. 9

Fractures to the elbow can frequently affect nerve function. The anterior interosseous nerve is the most common nerve injured with extension type supracondylar fractures. 9

Most peripheral nerve injuries will improve over an 8 to 12 week period. 9

Close monitoring of a nerve injury in outpatients is required. If nerve function does not improve within 8 to 12 weeks a nerve conduction study needs to considered. 9

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 8 of 10

K:\CHW P&P\ePolicy\Sept 10\Orthopaedic Paediatric Patient - Neurovascular Considerations.doc

This Guideline may be varied, withdrawn or replaced at any time.

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

5.3 Vascular Injuries

tient: Neurovascular Considerations 5.3 Vascular Injuries • Can result from severely displaced fractures. 3 •

Can result from severely displaced fractures. 3

Ischemic limbs associated with fractures require immediate closed reduction to remove tension on the neurovascular structures - usually circulation to the limb is restored. 3

If circulation does not return the child needs to be taken to theatres for fracture stabilisation and vascular exploration. 3

Revascularisation should be achieved within 6 to 8 hours. 3

6

References

1. Maher, A. B., Salmond, S. W., & Pellino, T. A., (2002). Orthopaedic Nursing. Chapter 8. Philadelphia: W.B. Saunders.

2. Altizer, L., (2002). Neurovascular assessment. Orthopaedic Nursing. Vol. 20. (4), 48-50.

3. Herring, J. A. (2002). Compartment Syndrome: Vascular Injuries. Tachdjian’s pediatric orthopaedics, from the Texas Scottish Rite Hospital for Children. Vol 3, (3rd ed., pp. 2075-2078.

4. Wright, E., (2009). Neurovascular impairment and compartment syndrome. Paediatric Nursing. Vol. 21.(3).

26-29.

5. Bae, D. S., Kadiyala, K. R., & Waters, P. M., (2001). Acute compartment syndrome in children:

contemporary diagnosis, treatment, and outcome. Journal of Pediatric Orthopaedics Vol 21(5). 680-688

6. Harvey, C. (2001). Compartment syndrome: when it is least expected. Orthopaedic Nursing. Vol. 20 (3).

15-23.

7. Noonan, K. L., McCarthy, J. J., (2010). Compartment syndrome in the pediatric patient. Journal Pediatric Orthopaedics. Vol. 30. (2). S96-S101.

8. Walls, M. (2002). Orthopaedic trauma. RN. Vol 65. (7). 52-58.

9. Herring, J. A. (2002). Upper extremity injuries. Tachdjian’s pediatric orthopaedics, from the Texas Scottish Rite Hospital for Children. Vol 3, (3rd ed.), pp. 2163-2166.

Copyright notice and disclaimer:

The use of this document outside The Children's Hospital at Westmead (CHW), or its reproduction in whole or in part, is subject to acknowledgement that it is the property of CHW. CHW has done everything practicable to make this document accurate, up-to-date and in accordance with accepted legislation and standards at the date of publication. CHW is not responsible for consequences arising from the use of this document outside CHW. A current version of this document is only available electronically from the Hospital. If this document is printed, it is only valid to the date of printing.

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 9 of 10

Guideline No: 0/C/06:8038-01:02

Guideline: Orthopaedic Paediatric Patient: Neurovascular Considerations

Paediatric Pa tient: Neurovascular Considerations Management of orthopaedic patient post-operatively/post

Management of orthopaedic patient post-operatively/post injury

Pain Management

Patient Assessments

Patient Assessments

Patient Assessments
Patient Assessments

Neurovascular Assessment

Pain Assessment Neurovascular assessment for 24hrs Administer Increased Excessive analgesia as swelling Pain
Pain Assessment
Neurovascular assessment for 24hrs
Administer
Increased
Excessive
analgesia as
swelling
Pain
charted
Sensory & motor
function e.g. pain
on extension &
flexion of
extremities
Normal
status – no
deviations
Assess patient
to determine
focus of pain
Contact Medical
staff immediately
for review
Note: If POP
in situ, neuro
observations
and circulation
observations
to continue for
the duration of
casting
Continue
neurovascular
observations until
stable
Note: If POP in situ,
neurovascular observations and
circulation observations to
continue for duration of casting
Neurovascular
observations are
within normal
limits and stable
– CEASE formal
observations
after 24 hours

Note

If a cylindrical immobiliser/cast is in-situ, then neurovascular observations should continue to occur every 4-6 hours while the child is in hospital.

Date of Publishing: 20 September 2010 10:07 AM

Date of Printing:

Page 10 of 10