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3RD YEAR SYSTEMS: MSK > Children's orthopaedics: Cerebral palsy, Club foot and Scoliosis > Flashcards

Children's orthopaedics: Cerebral palsy, Club foot and Scoliosis Flashcards

1
Q

When is a child defined as having complex needs?

A
  • learning and mental functions
  • communication
  • motor skills
  • self care
  • hearing
  • vision

Severe impairment in at least 4 categories^ together with enteral/ parenteral feeding

OR

Severe impairment in at least 2 categories and ventilation/CPAP

AND impairments are sustained for more than 6 months and ongoing.

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2
Q

Who is involved within MDT caring for a child with complex needs?

A
  • OT
  • Social work
  • Orthotics
  • Physio
  • Wheelchair services
  • Education support
  • Community paediatrics
  • Orthopaedics
  • Others - opthalmology, audiology, psychology
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3
Q

What is Cerebral Palsy (CP)?

A

A permanent and non-progressive motor disorder due to brain damage before birth or during the first 2 years of life.

  • Most common motor and movement disability of childhood - 2 per 1000 live births
  • It is an umbrella term, referring to a group of symptoms and disabilities. They are all related but each child will have a unique and individual experience of CP.
  • The lesion is static but the clinical picture is not
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4
Q

What are some causes of CP?

A

Pre-natal

  • Placental insufficiency
  • Pre-eclampsia
  • Smoking, alcohol or drugs
  • TORCH infection i.e toxoplasmosis, rubella

At birth

  • Prematurity (most common)
  • Anoxic injuries
  • Infection

Post-natal

  • Infection (Cytomegalovirus, rubella)
  • Head trauma
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5
Q

What are 3 main classifications of CP?

A
  • Physiological - how the condition manifests itself
  • Anatomical
  • GMFCS
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6
Q

Physiological classification of CP

A
  • Spastic - most common type of CP - pyramidal system and motor cortex involved - causes high tone and stiffness
  • Athetoid - extrapyramidal system and basal ganglia involved - movement disorders and coordination problems
  • Ataxia - cerebellum and brainstem involved - balance problems

Mixed - combination of spasticity and athetosis - common in severely handicapped children

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7
Q

Anatomical classification of CP (4)

A
  • Monoplegia - one limb involved (upper or lower)
  • Hemiplegia - one side of the body
  • Diplegia - lower limbs
  • Quadriplegia - total body involvement
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8
Q

What is the GMFCS classification system for CP?

A

GMFCS = Gross Motor Function Classification system categorises children with CP into 5 different levels.

Level 1 - Walks without Limitations – fairly normal life

Level 2 - Walks with Limitations

Level 3 - Walks Using a Hand-Held Mobility Device

Level 4 - Self-Mobility with Limitations +/- use Powered Mobility

Level 5 - Transported in a Manual Wheelchair

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9
Q

What issues do CP patients face? (5)

A
  • Spasticity – esp in spastic type of CP – increased tone in muscles
  • Lack of voluntary limb control
  • Weakness of muscle groups
  • Poor co-ordination
  • Impaired senses (Hearing, Vision, Taste, Touch etc)
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10
Q

What 3 problems can arise in the limbs as a result of spasticity?

A
  • Dynamic contractures - where the limb adopts a posture due to increased muscle tone and hyper-reflexia. This deformity is not fixed though and can be overcome.
  • Fixed muscle contractures - due to persistent spasticity and contracture. Results in shortened muscle tendon units and this deformity cannot be overcome.
  • Joint subluxation / dislocation in extreme cases - eventually in the older child or adult this leads to bony changes or arthritis
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11
Q

What 3 things are priorities in cerebral palsy patients?

A

Maintain Sitting balance - if in a chair

Improve/maintain Standing posture - if able to walk

Optimise Gait - help maintain muscle strenght + tone

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12
Q

How is Gait analysed?

A
  • Observation
  • Video
  • 3D instrumented analysis
  • +/- Electromyogram

Patient needs to be compliant, able to walk independently and over 5 years old.

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13
Q

What is the Gait Cycle?

A

The typical walk consists of a repeated gait cycle. The cycle is divided into 2 sections:

  • Stance (60%) - this is when weight is being put through the limb
  • Swing (40%) - when the leg is swung forward
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14
Q

What is a major problem seen in severly handicapped children?

A

Hip problems i.e dislocation

The higher the GMFCS level, the higher the risk of hip displacement.

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15
Q

What non-surgical interventions can be done if a child with CP is thought to be at risk of hip dislocation?

A

Posture management

  • Physio
  • Seating - to allow for correct posture

Spasticity management

  • Generalised spasticity - Oral medication to reduce tone - i.e Baclofen oral, diazepam
  • Localised - Botulinum toxin can be injected into specific muscle groups. A pump infusing Baclofen in and around the spinal cord can also be used.
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16
Q

What surgical interventions can be carried out if a child with CP is thought to be at risk of hip dislocation?

A

It is difficult to identify those children who would benefit from surgery but if so the following option may be used:

  • Soft tissue releases - adductors of the hips, hamstrings
  • Bony realignment - Osteotomy of the proximal femur or pelvic osteotomy
17
Q

Pros and cons for surgery in CP children

A

Pro

  • Reduced risk dislocation
  • Reduced risk pain
  • Better seating

Con

  • Not all would have gone on to dislocate
  • BIG surgery
18
Q

What is club foot (talipes)?

A
  • A common orthopaedic problem that affects the lower limbs
  • Congenital deformity
  • 1 to 2 in 1000 live births (variable)
  • 3 Male : 1 Female
  • It has a genetic component and is multi-factorial however they cannot specify why it happens yet
19
Q

How can a pre-natal diagnosis of club foot be made?

A

USS - 60% of cases can be identified

20
Q

What are the 4 deformities in a club foot? (CAVE)

A

Cavus - high arch foot particularly on medial aspect of foot

Adductus (midfoot)

Varus (hindfoot) - tilted towards the midline

Equinus (hindfoot) - toes are pointing down

21
Q

How is club foot treated?

A
  • Serial casting - Series of 5 above-the-knee casts applied at weekly intervals. The casts aim to treat CAVE in order so the first cast addresses Cavus and so on.
  • Tenotomy of Achilles tendon - around 80% of children will have a tight Achilles tendon even after the serial casting that means it cannot be dorsiflexed (flexed towards the sky) A tiny operation is carried out under sedation to allow for dorsiflexion. It should regrow normally after this
  • This is followed by the use of foot abduction brace/splint to prevent the occurrence of relapse.
22
Q

Normal sagittal spine shape

A

Cervical Lordosis

Thoracic Kyphosis

Lumbar Lordosis

Sacral Kyphosis

23
Q

What is Scoliosis?

A

Deviation of the spine in the coronal plane. Over 10 degrees deviation is indicative of scoliosis.

It can be structural or non-structural

  • Structural - underlying vertebral abnormality - intrinsic spinal problem
  • Non-structural - most common cause is a limb length discrepancy which causes a tilt in the spine. This can resolve if the causal factor is addressed.
24
Q

What is the ‘Cobb angle’?

A

A radiological measurement that’s made to assess the severity of the curve.

25
Q

Which 3 factors put a child at a higher risk of progressive scoliosis?

A

Size of curve at presentation - bigger curve

Presenting before 12 years of age

Females that haven’t started their period yet

26
Q

Classification of structural scoliosis based on aetiology (3)

A
  • Congenital - abnormalities in the vertebrae
  • Idiopathic - most commonly seen
  • Neuromuscular diseases - muscular dystrophy, CP - muscular imbalance tilts the spine
27
Q

How can idiopathic scoliosis be classified?

A

Age of presentation -

  • Infantile (<3y)
  • Juvenile (3-10y)
  • Adolescent (>10y)

Region of spine primarily affected - thoracic, lumbar, thoracolumbar etc

28
Q

What does examination of a child with suspected scoliosis involve?

A
  • Adam’s forward flexion test - Inspect posterior torso. Structural scoliosis will look worse when bent forward into flexion.
  • Abnormal neurology or pain should be noted (pain is not normally a feature of scoliosis)
  • Look for RF that are associated with progression i.e skeletal immaturity or maturity
29
Q

Investigations carried out for scoliosis

A
  • Erect whole spine x-ray usually Anteroposterior but sometimes lateral
  • Sometimes tilting films are done too
  • MRI scan - helps determine cause of scoliosis and also if there are problems that may arise if surgery is needed i.e an MRI scan may uncover cord abnormalitis, vertebral anomalies (failure of formation and segmentation) or tumours
30
Q

Why is an early diagnosis of scoliosis important?

A

The outcomes are less favourable from severe curves:

  • If the curve is over 70ºc then there can be cardiorespiratory compromise
  • In children who are wheelchair bound with severe curves they can start to get pain from the ribs digging in to the pelvis
  • This may cause seatinng issues
31
Q

Non-surgical management for Scoliosis

A

Bracing

  • The Brace is custom made for the patient.
  • It needs to be worn 23/24 hours to work and delay the progression of the curve.
  • Modern braces can fit under clothing but are still not every popular.
  • Usually used to delay surgery while spine growing
32
Q

Surgical management of Scoliosis

A
  • Very complex but rewarding
  • Surgical approach depends on age of presentation and what requires to be done
  • Surgical approach can be anterior, posterior or both
  • Scarring can be extensive and can lead to psychological issues
  • Spinal cord function may be altered - worst scenario is that the child might be paralysed
  • Intra-operative spinal cord monitoring is carried out throughout surgery to prevent interference with the spinal cord
33
Q

Complications with Scoliosis surgery

A
  • Nerve root damage
  • Cord traction injury
  • Vascular injury
  • Degenerative changes later - back ache etc
  • Problems of growth
    • Growing rods or changing rods can be inserted for this

3RD YEAR SYSTEMS: MSK (36 decks)

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