Children Orthopaedics: Complex needs - CP, clubfoot, scoliosis Flashcards
Define complex needs
Child w/ multiple + complex disabilities that causes at least 2 different types of severe impairment. Requires different specialties to manage (no one discipline).
What is cerebral palsy?
Permanent and non-progressive motor disorder due to brain damage before birth or during the first 2 yrs of life.
What are some causes of cerebral palsy?
Prenatal – placental insufficiency, toxaemia, smoking/alcohol/drugs, infections (toxoplasmosis/rubella/CMV/Herpes type II)
Perinatal (before+ up to yr after born) – prematurity (most common), anoxic injuries, infections, haemolytic disease of new born
Postnatal: infection (CMV, rubella), head trauma.
How is CP classified anatomically?
Monoplegia (one limb involved)
Hemiplegia (one side of body)
Diplegia (LL)
Quadriplegia or total body involvement
What clinical classification system is used for CP and detail it
Gross Motor Function Classification System (GMFC):
Level I – walks w/o limitations
Level II – walks with limitations
Level III – walks using hand-held mobility device
Level IV – Self-mobility with limitations (may use powered mobility)
Level V – Transported in a manual wheelchair
What are the issues in CP and what happens as a result?
Issues – spasticity, lack of voluntary limb control, weakness, poor co-ordination, impaired senses
Results – 1) Dynamic contractures 2) Fixed muscle contractures 3) Joint subluxation/dislocation
What does likelihood of hip displacement in CP correlate with?
The higher GMFC – the higher the risk of hip dislocation. Due to spasticity (muscles tightening/stiffening)
What symptoms does hip dislocation (CP) cause?
Often painful
Upset sitting posture
What leads to better long term outcome in hip dislocation (CP)?
Early surgical intervention
What are non-surgical interventions for CP?
Posture management – physiotherapy, seating.
Spasticity management:
Generalised – baclofen oral, diazepam
Localised – botulinum toxin, baclofen
What operative management options are there for CP deformities?
Soft tissue release – adductor, hamstrings
Bony realignment
- Varus derotation osteotomy
- Pelvic osteotomy
What is the most common congenital deformity?
Congenital Talipes Equinovarus Clubfoot (TEV)
Describe the anatomical features of clubfoot
Muscle contractures contribute to CAVE deformity
Cavus [high arch]
Adductus (midfoot)
Varus (hindfoot) [angulation toward midline]
Equinus (hindfoot) [upward bending limited, foot held downwards]
What conservative method is usually used to treat clubfoot?
Ponseti method – manipulation
Series of usually 5 casts, correcting CAVE deformities
What surgical correction is usually used for equinus (in Clubfoot)?
Percutaneous tenotomy of Achilles tendon. 90% will need this. Allows ankle to dorsiflex.
Describe the normal sagittal spine shape
Cervical Lordosis
Thoracic Kyphosis
Lumbar Lordosis
Sacral Kyphosis
What is a scoliosis and when does it becomes clinically significant?
Any deviation of spine in the coronal plane is a scoliosis (sideway curvature). Clinical significance > 10-degree deviation.
Describe what is meant by non-structural and structural scoliosis
Non-structural – due to extrinsic cause, e.g. leg length discrepancy, hip problem etc. Resolves when causal factor is addressed.
Structural scoliosis = abnormal rotation of the vertebrae and is an intrinsic spinal problem. It has a propensity to progress
How is scoliosis classified?
By…
Aetiology,
Age at presentation (infantile, juvenile, adolescent),
Region primarily affected (thoracic (usually R), lumbar (L), thoracolumbar (R), double (R thoracic, L lumbar))
What is the aetiology of scoliosis?
Congenital (Abnormalities of formation vertebra)
Idiopathic
Neuromuscular
Others: post traumatic, degenerative, infective, syndromic etc.
Describe the examination of scoliosis
Inspect posterior torso. Structural scoliosis will look worse bent forward in flexion.
Abnormal neurology or pain should be noted.
What are the risk factors for scoliosis progression?
Age / Skeletal maturity – younger age
Gender – girls
Pattern of curve – thoracic, double major
How do you investigate scoliosis?
XR - AP erect Whole Spine +/- lateral (tilting films to assess flexibility)
MRI
- Cord abnormalities – tethering, syrinx
- Vertebral anomalies – failures of formation and segmentation
- Tumours
Describe the significance of early diagnosis in scoliosis
Severe curves give less favourable outcomes:
- Cardiorespiratory compromise
- Pain from rib/pelvic abutment
- Seating issues
- Surgical challenge
Neuromuscular causes (esp. cerebral palsies + muscular dystrophy) are at high risk of progression.
Outline the non-surgical treatment of scoliosis
Bracing – needs to be worn 23/24hrs/day to work, delays progression of curve, custom made, usually to delay surgery while spine growing.
Describe surgical treatment of scoliosis
Complex and extensive
Fusion
Surgical approaches: anterior, posterior, both
Intra-operative SC monitoring.
What are surgical complications for scoliosis surgery?
Nerve root damage Cord traction injury Vascular injury Degenerative changes later Growth problems
