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MSK > Children’s Orthopaedics - Complex Needs > Flashcards

Children’s Orthopaedics - Complex Needs Flashcards

1
Q

What is the criteria for an under 19 to be defined as having complex exceptional needs (CEN)?

A

•Severe impairment in at least 4 categories + enteral/ parenteral feeding
OR
•Severe impairment in at least 2 categories + ventilation/CPAP
AND
•Impairments are sustained for more than 6 months and ongoing

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2
Q

What are the categories of impairment?

A
  • Learning and mental functions
  • Communication
  • Motor skills
  • Self care
  • Hearing
  • Vision
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3
Q

Give some examples of complex need disorders with orthopaedic involvement

A
  • Cerebral Palsy
  • Spina Bifida
  • Muscular Dystrophy
  • Arthrogryposis
  • Neurofibromatosis
  • Syndromes – Downs, Turners etc.
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4
Q

What is cerebral palsy?

A

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

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5
Q

What is the incidence of CP?

A

2/1000

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6
Q

What are the prenatal causes of CP?

A
  • Placental insufficiency
  • Toxaemia
  • Smoking
  • Alcohol
  • Drugs
  • Infection e.g. toxoplasmosis, rubella, CMS and HSV II (TORCH)
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7
Q

What are the perinatal causes of CP?

A
  • Prematurity - most common
  • Anoxic injuries
  • Infections
  • Kernicterus (caused by high levels of bilirubin in blood)
  • Haemolytic disease of new born
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8
Q

What are the postnatal causes of CP?

A
  • Infection - CMV, rubella

* Head trauma

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9
Q

What are the physiological classifications of CP?

A
  • Spastic - pyramidal system, motor cortex
  • Athetoid - extrapyramidal system, basal ganglia
  • Ataxia - cerebellum and brainstem
  • Mixed - combination of spasticity and athetosis
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10
Q

What are the anatomical classifications of CP?

A
  • Monoplegia - one limb involved
  • Hemiplegia - one side of the body
  • Diplegia - lower limbs
  • Quadriplegia - total body involvement
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11
Q

What is GMFCS for CP?

A

Gross Motor Function Classification System fo CP

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12
Q

What are the levels described by GMFCS?

A

•LEVEL I - Walks without Limitations
•LEVEL II - Walks with Limitations
•LEVEL III - Walks Using a Hand-Held Mobility Device
•LEVEL IV - Self-Mobility with Limitations (May Use Powered Mobility)
LEVEL V - Transported in a Manual Wheelchair

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13
Q

What are the disabilities experienced by CP sufferers?

A
  • Spasticity
  • Lack of voluntary limb control
  • Weakness
  • Poor co-ordination
  • Impaired senses (Hearing, Vision, Taste, Touch etc)
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14
Q

What can happen as a result of CP?

A
  1. Dynamic contractures
  2. Fixed muscle contractures
  3. Joint subluxation/dislocation
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15
Q

What are dynamic contractures?

A
  • Increased muscle tone and hyper-reflexia
  • No fixed deformity of joints
  • Deformity can be overcome
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16
Q

What are fixed muscle contractures?

A
  • Persistent spasticity and contracture
  • Shortened muscle tendon units
  • Deformity cannot be overcome
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17
Q

What is joint subluxation/dislocation?

A

•Secondary bone changes/ joint degeneration

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18
Q

What are the orthopaedic priorities in CP?

A
  • Maintain sitting balance
  • Improve/maintain standing posture
  • Optimise gait
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19
Q

How is gait analysed in CP?

A
  • Observation
  • Video
  • 3D instrumented analysis
  • ±EMG, energy expenditure
20
Q

What is measured in a gait lab?

A
  • Joint movement
  • Force distribution through feet
  • Timing of cycle
21
Q

How are hips affected by CP?

A
  • Hips are normal at birth
  • Hip displacement in 1/3 by maturity
  • Likelihood of displacement proportional to GMFCS
  • Dislocated hips are often painful
  • Dislocated hips upset sitting posture
  • Early surgical intervention leads to better long term outcome
22
Q

What are the non-operative interventions used to treat posture in CP?

A
  • Physiotherapy

* Seating

23
Q

What are the non-operative interventions used to treat spasticity in CP?

A
  • Generalised - baclofen oral (anti-spasmodic), diazepam

* Localised - baclofen (intra-thecae pump), botox

24
Q

How is deformity in CP managed surgically?

A

•Soft tissue release

  • adductors
  • hamstrings

•Bony realignment

  • varus derotaion osteotomy (prevents hip dislocation)
  • pelvic osteotomy
25
Q

What are the pros of surgical intervention?

A
  • Reduced risk dislocation
  • Reduced risk pain
  • Better seating
26
Q

What are the cons of surgical intervention?

A
  • Not all would have gone on to dislocate

* BIG surgery

27
Q

What is club foot also known as?

A

Talipes equinovarus

28
Q

What is the epidemiology of talipes equinovarus?

A
  • Most common congenital deformity
  • 1 to 2 in 1000 live births (variable)
  • 3 Male : 1 Female
  • 50% bilateral
  • Risk for 2nd child 1 in 35
29
Q

What is the aetiology of talipes equinovarus?

A 
•Pressure theories
-Oligohydramnios
-Abnormal fetal position
-Unstretched uterus
•Placental insufficiency
•Constriction bands
•Toxin
•Temperature
•Infective pathogen (enterovirus)
•Drugs
•EM radiation
•Chromosomal abnormality
•Sex-linked
•Single dominant
•Single recessive
•Polygenic
MULTIFACTORIAL
30
Q

How well can talipes equinovarus be diagnosed prenatally?

A
  • 60% of cases may be identified by ultra-sound
  • 50% may have defects in other systems
  • No relationship to ‘stiffness’ of feet
31
Q

How is talipes equinovarus traditionally treated?

A 
•Strapping (positional talipes only)
•Serial casting
•Dennis Browne Boots
•Surgery
-Postero-medial release
-Ilizarov frame
32
Q

What are the anatomical terms used in club foot?

A 
•Cavus 
•Adductus (midfoot)
•Varus (hindfoot)
•Equinus (hindfoot)
CAVE
33
Q

How is equines corrected?

A

•Percutaneous tenotomy of Achilles tendon - 90% will need this

34
Q

What are the outcomes of club foot?

A
  • 95% of club feet successfully treated
  • 45 year results show that feet are mobile, pain free and plantigrade
  • Results reproduced at major centres around the world
  • Level 1 RCT evidence
  • Majority of recurrences due to failure of compliance with splints
35
Q

What is scoliosis?

A

Any deviation in coronal plane

36
Q

What degree of deviation is of clinical significance?

A

> 10 degrees

37
Q

What are the 2 broad classes of scoliosis?

A
  • Non-structural = due to extrinsic cause – a leg length discrepancy, a 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.
38
Q

How is scoliosis categorised by aetiology?

A

•Congenital (vertebral formation abnormalities)
•Idiopathic
•Neuromuscular
•Others:
-post traumatic, degenerative, infective, syndromic etc.

39
Q

How is scoliosis categorised by age at presentation?

A
  • Infantile (<3y)
  • Juvenile (3-10y)
  • Adolescent (>10y)
40
Q

How is scoliosis categorised by region of spine primarily affected?

A
  • Thoracic
  • Lumbar
  • Thoracolumbar
  • Double
41
Q

What are the clinical signs of scoliosis?

A
  • Inspect posterior torso - structural scoliosis will look worse when bent forward into flexion
  • Abnormal neurology or pain should be noted
42
Q

What investigations are used for scoliosis?

A

•AP Erect Whole spine +/- Lateral (Tilting films to assess flexibility)
•MRI
*Cord abnormalities - Tethering, syrinx, diastematomyelia
*Vertebral anomalies - Failures of formation and segmentation
*Tumours

43
Q

Why is early diagnosis important in scoliosis?

A
  • Cardiorespiratory compromise
  • Pain from rib/pelvic abutment
  • Seating issues
  • Surgical challenge
  • Neuromuscluar causes are at high risk of progression
44
Q

How is scoliosis managed non-surgically?

A 
BRACING
•Needs to be worn 23/24 hours to work
•Delays progression of curve
•Custom made
•Usually used to delay surgery while spine growing
45
Q

How is scoliosis managed surgically?

A 
•Complex and extensive
•Surgical approaches:
-Anterior
-Posterior
-Both
•Wake up test (Traditional)
•Intra-operative spinal cord monitoring
46
Q

What are the surgical complications for scoliosis?

A 
•Nerve root damage
•Cord traction injury
•Vascular injury
•Degenerative changes later
•Problems of growth:
-Growing rods
-Changing rods
-Crankshaft phenomenon

MSK (28 decks)

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