Children's Orthopaedics - Complex needs Flashcards
What is meant by complex needs in a child?
A child with multiple and complex disabilities and at least two different types of severe impairment in which nobody has the knowledge of treatment
List some of the complex needs of a child in which orthopaedic involvement is required.
Cerebral palsy
Spina bifida
Muscular dystrophy
Arthrogryposis
Neurofibroblastomas
Syndromes e.g. Downs, Turners
Define cerebral palsy.
A permanent and non-progressive motor disorder due to brain damage before birth or during the first 2yrs of life
->the lesion is static but symptoms of the child and the clinical picture differ as the child develops
What are some of the prenatal causes of cerebral palsy?
Smoking
Placental insufficiency
Toxaemia
Alcohol
Drugs
Rubella infection
Toxoplasmosis infection
CMV
Herpes type II
->TORCH (toxoplasmosis, rubella, CMV and herpes)
What are some of the perinatal causes of cerebral palsy?
Prematurity (most common)
Anoxic injuries
Infection
Haemolytic disease of newborn
What are some of the postnatal causes of cerebral palsy?
Infection e.g. CMV, rubella
Head trauma
There are different classifications of cerebral palsy; physiologic, anatomical and GMF (gross motor function).
What are the three types of physiologic classifications of cerebral palsy?
Spastic
Athetoid
Ataxia
Where does spastic physiologic CP affect?
Pyramidal system and motor cortex
Where does athetoid physiologic CP affect?
Extrapyramidal system and basal ganglia
Where does ataxia physiologic CP affect?
Cerebellum and brainstem
->problems with balance, think of where it’s affecting
->in many there’s a combo of these different types
What is the most common type of physiological classification of cerebral palsy?
Spastic CP
There are different classifications of cerebral palsy; physiologic, anatomical and GMF (gross motor function).
What are the four types of anatomical classifications of cerebral palsy?
Monoplegia
Hemiplegia
Diplegia
Quadriplegia
Monoplegia?
One limb involved in CP
Hemiplegia?
One side of body affected by CP
Diplegia?
Lower limbs affected by CP
Quadriplegia?
Total body involvement of CP
There are different classifications of cerebral palsy; physiologic, anatomical and GMF (gross motor function).
The GMF classification has different levels. Briefly run through them so you are aware of them.
Level 1= walks w/o limitation
Level 2= walks w/ limitations
Level 3= walks using hand-held mobility device
Level 4= self-mobility w/ limitations, may use powered mobility
Level 5= transported in a manual wheelchair
What are the issues seen in a patient with cerebral palsy?
Spasticity (increased muscle tone)
Lack of voluntary limb control
Weakness
Poor coordination
Impaired senses- hearing, vision, taste, touch
As a result of the spasticity, different types of problems can occur in the limbs.
What is meant by dynamic contracture?
A limb adopts a posture due to increased tone and hyper-reflexia.
However, on passive stretching, there’s no fixed deformity in the joints
What can a dynamic contracture progress to?
A fixed contracture- persistence of spasticity and stiffness means muscle tendon unit shortens.
This cannot be overcome.
In extreme cases, a patient with cerebral palsy may develop joint sublucation/dislocation. What is meant by this?
Secondary bony changes in the joint which then leads to arthritis
Gait is assessed in CP patients. What are the two phases of the gait cycle?
Stance (weight being put through limb)
Swing
What are some of the hip conditions associated with cerebral palsy?
Hip displacement (occurs in a third of children w CP)
->these dislocations are painful and upset sitting posture
All CP patients have normal hips ay birth.
If a child with CP does develop issues with hip displacement, what helps to improve the long term outcome?
Early surgical intervention
If suspicious of a child at risk of hip displacement, what cam be done?
Posture management- physio and specialised seating
Spasticity management- med based- oral and injections
Which kind of surgical procedures can be used in the management of deformity in patients with CP which are more likely to develop hip displacements?
Soft tissue release
Bony realignment
What is the most common congenital deformity seen in orthapaedics?
Club foot (talipes)
Who tends to be more affected by club foot?
M>F
Is club foot bilateral?
50% of the time
Aetiology behind club foot?
Multifactorial and not clear- genetic component though
When can club foot be diagnosed?
During prenatal period using prenatal ultrasound- 60% of cases diagnosed at this point
Talipes, or club foot, can also be an indication of what?
Defects in other symptoms- 50%
Management of talipes/club foot?
Serial casting
->very few require surgery now
Normal curvatures of the spine?
Cervical and Lumbar lordosis
Thoracic and Sacral kyphosis
Scoliosis?
Any deviation in the coronal plane
More than what degree of deviation is abnormal?
More than 10 degrees of deviation
->less than this considered normal
Scoliosis can be structural or non-structural.
What is meant by non-structural scoliosis?
Due to extrinsic cause e.g. hip problem etc.
Problem is resolved when causal factor is addressed
Scoliosis can be structural or non-structural.
What is meant by structural scoliosis?
Abnormal rotation of the vertebrae- an intrinsic spine problems.
Has a propensity to progress
What are some of the factors which indicate a high risk of progression of the scoliosis?
< 12yrs at presentation
Size of curve at presentation
Premenarchal (before first period occurs)
Classification of structural scoliosis is based on aetiology.
What are the classifications?
Congenital
Idiopathic
Neuromuscular
Others e.g. trauma, infective, degenerative (these are rarer and tend to occur more in adults)
What is the most common type of scoliosis seen?
Idiopathic scoliosis
Idiopathic scoliosis is classified by the age at presentation.
What are the three groups and the associated ages?
Infantile- <3yrs
Juvenile 3-10yrs
Adolescent >10yrs
Upon examination of a child with scoliosis, in which movement will a structural scoliosis look worse?
When back bent over in flexion
->abnormal neurology or pain should be noted in examination as scoliosis does NOT usually cause pain
Investigations for scoliosis?
Erect whole spine x-ray
MRI for cord abnormalities, tumours or vertebral anomalies (this often determines the cause of the scoliosis)
Outcomes of scoliosis are less favourable the more severe the curvature.
What are some of the problems associated with more severe curves?
Cardiorespiratory compromise
Pain from ribs/pelvic abutment
Seating issues
Non-surgical management in used particularly in the idiopathic scoliosis patients. What may be done?
Bracing- halts or minimises progression
In which group of people is idiopathic scoliosis more common?
Teenage girls
->idk think of jokes of scoliosis made at school
Surgery can be done…what are pros and cons?
Very complex and extensive but very rewarding
Surgical complications of scoliosis surgery?
Nerve root damage
Cord traction injury
Vascular injury
Degenerative problems in the future
Problems of growth
