Children's orthopaedics: Cerebral palsy, Club foot and Scoliosis Flashcards
When is a child defined as having complex needs?
- 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.
Who is involved within MDT caring for a child with complex needs?
- OT
- Social work
- Orthotics
- Physio
- Wheelchair services
- Education support
- Community paediatrics
- Orthopaedics
- Others - opthalmology, audiology, psychology
What is Cerebral Palsy (CP)?
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
What are some causes of CP?
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
What are 3 main classifications of CP?
- Physiological - how the condition manifests itself
- Anatomical
- GMFCS
Physiological classification of CP
- 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
Anatomical classification of CP (4)
- Monoplegia - one limb involved (upper or lower)
- Hemiplegia - one side of the body
- Diplegia - lower limbs
- Quadriplegia - total body involvement
What is the GMFCS classification system for CP?
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
What issues do CP patients face? (5)
- 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)
What 3 problems can arise in the limbs as a result of spasticity?
- 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
What 3 things are priorities in cerebral palsy patients?
Maintain Sitting balance - if in a chair
Improve/maintain Standing posture - if able to walk
Optimise Gait - help maintain muscle strenght + tone
How is Gait analysed?
- Observation
- Video
- 3D instrumented analysis
- +/- Electromyogram
Patient needs to be compliant, able to walk independently and over 5 years old.
What is the Gait Cycle?
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
What is a major problem seen in severly handicapped children?
Hip problems i.e dislocation
The higher the GMFCS level, the higher the risk of hip displacement.
What non-surgical interventions can be done if a child with CP is thought to be at risk of hip dislocation?
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.
What surgical interventions can be carried out if a child with CP is thought to be at risk of hip dislocation?
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
Pros and cons for surgery in CP children
Pro
- Reduced risk dislocation
- Reduced risk pain
- Better seating
Con
- Not all would have gone on to dislocate
- BIG surgery
What is club foot (talipes)?
- 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
How can a pre-natal diagnosis of club foot be made?
USS - 60% of cases can be identified
What are the 4 deformities in a club foot? (CAVE)
Cavus - high arch foot particularly on medial aspect of foot
Adductus (midfoot)
Varus (hindfoot) - tilted towards the midline
Equinus (hindfoot) - toes are pointing down
How is club foot treated?
- 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.
Normal sagittal spine shape
Cervical Lordosis
Thoracic Kyphosis
Lumbar Lordosis
Sacral Kyphosis
What is Scoliosis?
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.
What is the ‘Cobb angle’?
A radiological measurement that’s made to assess the severity of the curve.
