Children’s Orthopaedics - Complex needs - CP, Talipes,Scoliosis

Question 1

What is a child with complex needs defined as?

Answer 1

A child with at least two different types of severe or profound impairments, such that no one discipline has the monopoly on assessment and management

Question 2

What are some complex needs syndromes that may require orthopaedic involvement?

Answer 2

• Cerebral palsy
• Spina Bifida
• Muscular dystrophies
• Arthrogryposis
• Neurofibromatosis
• Syndromes (Downs / Turners)

Question 3

What is cerebral palsy?

Answer 3

A disorder of movement and posture associated with fixed lesion of the developing brain

Question 4

What are the three possible orthopaedic related outcomes of the brain lesion acquired in cerebral palsy?

Answer 4

1. Dynamic contractures: increased muscle tone & hyper-reflexia but any deformity can be overcome
2. Fixed muscle contractures: persistent spasticity and contracture, deformity cannot be overcome
3. Joint subluxation / dislocation: secondary bone changes & joint degeneration.

Question 5

What are the two main phases of gait?

Answer 5

Stance phase - when weight is being pushed through the limb

Swing phase - as the limb swings to reassume forward position

Question 6

What are some common examples of skeletal pathologies in individuals with cerebral palsy?

Answer 6

• Hip dislocation

- Scoliosis

Question 7

What are some management options for cerebral palsy patients at risk of hip dislocation / orthopaedic problems due to bad posture?

Answer 7

• Physiotherapy / seating (wheelchair)
• Diazepam / Bo-tox / Baclofen (management of spasticity - to reduce tone)

Surgery:

• Soft tissue release
• Bone realignment

Question 8

What is Talipes Equinovarus? How common is it? Who tends to get it?

Answer 8

Congenital deformity of the feet - club feet

• Quite common: 1-2 / 1000 births
• More common in males
• 50% cases are bilateral

Question 9

Can talipes equinovarus be identified prenatally?

Answer 9

• 60% of cases may be detected prenatally

- 50% of cases tend to have other associated defects

Question 10

What are the anatomical deformities associated with club foot?

Answer 10

CAVE:
- Cavus (high arch)

• Adductus (midfoot adducted onto hindfoot)
• Varus (heel tilted towards midline)
• Equinus (toes pointing down)

Question 11

What is the treatment progression for clubfoot?

Answer 11

Series of casts (5 of them)

• Given at weekly intervals
• Each cast to correct the different deformities associated with clubfoot

Question 12

Prognosis for clubfoot? Major reason of recurrence?

Answer 12

• 95% treated successfully
• Some feet relapse
• Lack of compliance to splints causes recurrence

Question 13

What is scoliosis? What are the different types of scoliosis and a brief description of each?

Answer 13

Any deviation of the spinal curvature in the coronal plain

• Non-structural: due to extrinsic cause, eg. leg length discrepancy. Resolves when underlying issue treated
• Structural: abnormal rotation of the vertebrae themselves, has a propensity to progress

Question 14

What are some factors that indicate poor prognosis in scoliosis patients?

Answer 14

• Premenarchal (periods haven’t started yet)

< 12 yrs at presentation

• Size of curve at presentation (larger = worse)

Question 15

What are the most common causes of scoliosis?

Answer 15

• congenital
• Idiopathic
• Neuromuscular (muscle imbalance)
• Post traumatic
• Degenerative
• Infective etc.

Question 16

How are different types of scoliosis classified?

Answer 16

By the area of the spine affected:

• Thoracic
• Lumbar
• Thoracolumbar
• Double

Question 17

Symptoms / signs of scoliosis?

Answer 17

Adams forward flexion test: getting the patient to lean forwards on back inspection greatly highlights deformity

Look for underlying neuromuscular issues or pain (pain not usually a feature of scoliosis)

Question 18

Investigations for scoliosis?

Answer 18

X-Ray

MRI (underlying cause? cord abnormalities?)

Question 19

When is conservative, non-surgical bracing used to manage scoliosis? How effective is it?

Answer 19

When the scoliosis is in a child that is still growing, operating will stunt growth

• Is effective at halting the progression of the abnormal curvature but is not a cure

Question 20

How hectic can scoliosis surgery be?

Answer 20

Hectic man

In some cases they have to operate from the anterior and posterior aspects of the patient to get the straightener instrumentation in properly

Question 21

What are some possible complications of scoliosis surgical management?

Answer 21

• Nerve root damage
• Cord traction injury
• Vascular injury
• Degenerative changes later
• Problems of growth

Question 22

Why may repeated operations be required in the treatment of scoliosis?

Answer 22

Because the spine grows but the rods in place to straighten the spine don’t

If you don’t exchange the rods can cause anterior growth of the spine which leads to abnormal twisting