Children’s Orthopaedics - Complex Needs Flashcards
What is the criteria for an under 19 to be defined as having complex exceptional needs (CEN)?
•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
What are the categories of impairment?
- Learning and mental functions
- Communication
- Motor skills
- Self care
- Hearing
- Vision
Give some examples of complex need disorders with orthopaedic involvement
- Cerebral Palsy
- Spina Bifida
- Muscular Dystrophy
- Arthrogryposis
- Neurofibromatosis
- Syndromes – Downs, Turners etc.
What is cerebral palsy?
A permanent and non-progressive motor disorder due to brain damage before birth or during the first 2 years of life
What is the incidence of CP?
2/1000
What are the prenatal causes of CP?
- Placental insufficiency
- Toxaemia
- Smoking
- Alcohol
- Drugs
- Infection e.g. toxoplasmosis, rubella, CMS and HSV II (TORCH)
What are the perinatal causes of CP?
- Prematurity - most common
- Anoxic injuries
- Infections
- Kernicterus (caused by high levels of bilirubin in blood)
- Haemolytic disease of new born
What are the postnatal causes of CP?
- Infection - CMV, rubella
* Head trauma
What are the physiological classifications of CP?
- Spastic - pyramidal system, motor cortex
- Athetoid - extrapyramidal system, basal ganglia
- Ataxia - cerebellum and brainstem
- Mixed - combination of spasticity and athetosis
What are the anatomical classifications of CP?
- Monoplegia - one limb involved
- Hemiplegia - one side of the body
- Diplegia - lower limbs
- Quadriplegia - total body involvement
What is GMFCS for CP?
Gross Motor Function Classification System fo CP
What are the levels described by GMFCS?
•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
What are the disabilities experienced by CP sufferers?
- Spasticity
- Lack of voluntary limb control
- Weakness
- Poor co-ordination
- Impaired senses (Hearing, Vision, Taste, Touch etc)
What can happen as a result of CP?
- Dynamic contractures
- Fixed muscle contractures
- Joint subluxation/dislocation
What are dynamic contractures?
- Increased muscle tone and hyper-reflexia
- No fixed deformity of joints
- Deformity can be overcome
What are fixed muscle contractures?
- Persistent spasticity and contracture
- Shortened muscle tendon units
- Deformity cannot be overcome
What is joint subluxation/dislocation?
•Secondary bone changes/ joint degeneration
What are the orthopaedic priorities in CP?
- Maintain sitting balance
- Improve/maintain standing posture
- Optimise gait
How is gait analysed in CP?
- Observation
- Video
- 3D instrumented analysis
- ±EMG, energy expenditure
What is measured in a gait lab?
- Joint movement
- Force distribution through feet
- Timing of cycle
How are hips affected by CP?
- 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
What are the non-operative interventions used to treat posture in CP?
- Physiotherapy
* Seating
What are the non-operative interventions used to treat spasticity in CP?
- Generalised - baclofen oral (anti-spasmodic), diazepam
* Localised - baclofen (intra-thecae pump), botox
How is deformity in CP managed surgically?
•Soft tissue release
- adductors
- hamstrings
•Bony realignment
- varus derotaion osteotomy (prevents hip dislocation)
- pelvic osteotomy
What are the pros of surgical intervention?
- Reduced risk dislocation
- Reduced risk pain
- Better seating
What are the cons of surgical intervention?
- Not all would have gone on to dislocate
* BIG surgery
What is club foot also known as?
Talipes equinovarus
What is the epidemiology of talipes equinovarus?
- 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
What is the aetiology of talipes equinovarus?
•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
How well can talipes equinovarus be diagnosed prenatally?
- 60% of cases may be identified by ultra-sound
- 50% may have defects in other systems
- No relationship to ‘stiffness’ of feet
How is talipes equinovarus traditionally treated?
•Strapping (positional talipes only) •Serial casting •Dennis Browne Boots •Surgery -Postero-medial release -Ilizarov frame
What are the anatomical terms used in club foot?
•Cavus •Adductus (midfoot) •Varus (hindfoot) •Equinus (hindfoot) CAVE
How is equines corrected?
•Percutaneous tenotomy of Achilles tendon - 90% will need this
What are the outcomes of club foot?
- 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
What is scoliosis?
Any deviation in coronal plane
What degree of deviation is of clinical significance?
> 10 degrees
What are the 2 broad classes of scoliosis?
- 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.
How is scoliosis categorised by aetiology?
•Congenital (vertebral formation abnormalities)
•Idiopathic
•Neuromuscular
•Others:
-post traumatic, degenerative, infective, syndromic etc.
How is scoliosis categorised by age at presentation?
- Infantile (<3y)
- Juvenile (3-10y)
- Adolescent (>10y)
How is scoliosis categorised by region of spine primarily affected?
- Thoracic
- Lumbar
- Thoracolumbar
- Double
What are the clinical signs of scoliosis?
- Inspect posterior torso - structural scoliosis will look worse when bent forward into flexion
- Abnormal neurology or pain should be noted
What investigations are used for scoliosis?
•AP Erect Whole spine +/- Lateral (Tilting films to assess flexibility)
•MRI
*Cord abnormalities - Tethering, syrinx, diastematomyelia
*Vertebral anomalies - Failures of formation and segmentation
*Tumours
Why is early diagnosis important in scoliosis?
- Cardiorespiratory compromise
- Pain from rib/pelvic abutment
- Seating issues
- Surgical challenge
- Neuromuscluar causes are at high risk of progression
How is scoliosis managed non-surgically?
BRACING •Needs to be worn 23/24 hours to work •Delays progression of curve •Custom made •Usually used to delay surgery while spine growing
How is scoliosis managed surgically?
•Complex and extensive •Surgical approaches: -Anterior -Posterior -Both •Wake up test (Traditional) •Intra-operative spinal cord monitoring
What are the surgical complications for scoliosis?
•Nerve root damage •Cord traction injury •Vascular injury •Degenerative changes later •Problems of growth: -Growing rods -Changing rods -Crankshaft phenomenon
