Children’s Orthopaedics - Complex Needs Flashcards by Lucy McLean

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

How well did you know this?

Not at all

Perfectly

What are the categories of impairment?

Learning and mental functions
Communication
Motor skills
Self care
Hearing
Vision

How well did you know this?

Not at all

Perfectly

Give some examples of complex need disorders with orthopaedic involvement

Cerebral Palsy
Spina Bifida
Muscular Dystrophy
Arthrogryposis
Neurofibromatosis
Syndromes – Downs, Turners etc.

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is the incidence of CP?

2/1000

How well did you know this?

Not at all

Perfectly

What are the prenatal causes of CP?

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the postnatal causes of CP?

Infection - CMV, rubella

* Head trauma

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What are the anatomical classifications of CP?

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

How well did you know this?

Not at all

Perfectly

What is GMFCS for CP?

Gross Motor Function Classification System fo CP

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

What can happen as a result of CP?

Dynamic contractures
Fixed muscle contractures
Joint subluxation/dislocation

How well did you know this?

Not at all

Perfectly

What are dynamic contractures?

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

How well did you know this?

Not at all

Perfectly

What are fixed muscle contractures?

Persistent spasticity and contracture
Shortened muscle tendon units
Deformity cannot be overcome

How well did you know this?

Not at all

Perfectly

What is joint subluxation/dislocation?

•Secondary bone changes/ joint degeneration

How well did you know this?

Not at all

Perfectly

What are the orthopaedic priorities in CP?

Maintain sitting balance
Improve/maintain standing posture
Optimise gait

How well did you know this?

Not at all

Perfectly

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 ```