Children’s Orthopaedics - Complex needs - CP, Talipes,Scoliosis Flashcards
What is a child with complex needs defined as?
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
What are some complex needs syndromes that may require orthopaedic involvement?
- Cerebral palsy
- Spina Bifida
- Muscular dystrophies
- Arthrogryposis
- Neurofibromatosis
- Syndromes (Downs / Turners)
What is cerebral palsy?
A disorder of movement and posture associated with fixed lesion of the developing brain
What are the three possible orthopaedic related outcomes of the brain lesion acquired in cerebral palsy?
- Dynamic contractures: increased muscle tone & hyper-reflexia but any deformity can be overcome
- Fixed muscle contractures: persistent spasticity and contracture, deformity cannot be overcome
- Joint subluxation / dislocation: secondary bone changes & joint degeneration.
What are the two main phases of gait?
Stance phase - when weight is being pushed through the limb
Swing phase - as the limb swings to reassume forward position
What are some common examples of skeletal pathologies in individuals with cerebral palsy?
- Hip dislocation
- Scoliosis
What are some management options for cerebral palsy patients at risk of hip dislocation / orthopaedic problems due to bad posture?
- Physiotherapy / seating (wheelchair)
- Diazepam / Bo-tox / Baclofen (management of spasticity - to reduce tone)
Surgery:
- Soft tissue release
- Bone realignment
What is Talipes Equinovarus? How common is it? Who tends to get it?
Congenital deformity of the feet - club feet
- Quite common: 1-2 / 1000 births
- More common in males
- 50% cases are bilateral
Can talipes equinovarus be identified prenatally?
- 60% of cases may be detected prenatally
- 50% of cases tend to have other associated defects
What are the anatomical deformities associated with club foot?
CAVE:
- Cavus (high arch)
- Adductus (midfoot adducted onto hindfoot)
- Varus (heel tilted towards midline)
- Equinus (toes pointing down)
What is the treatment progression for clubfoot?
Series of casts (5 of them)
- Given at weekly intervals
- Each cast to correct the different deformities associated with clubfoot
Prognosis for clubfoot? Major reason of recurrence?
- 95% treated successfully
- Some feet relapse
- Lack of compliance to splints causes recurrence
What is scoliosis? What are the different types of scoliosis and a brief description of each?
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
What are some factors that indicate poor prognosis in scoliosis patients?
- Premenarchal (periods haven’t started yet)
< 12 yrs at presentation
- Size of curve at presentation (larger = worse)
What are the most common causes of scoliosis?
- congenital
- Idiopathic
- Neuromuscular (muscle imbalance)
- Post traumatic
- Degenerative
- Infective etc.
How are different types of scoliosis classified?
By the area of the spine affected:
- Thoracic
- Lumbar
- Thoracolumbar
- Double
Symptoms / signs of scoliosis?
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)
Investigations for scoliosis?
X-Ray
MRI (underlying cause? cord abnormalities?)
When is conservative, non-surgical bracing used to manage scoliosis? How effective is it?
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
How hectic can scoliosis surgery be?
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
What are some possible complications of scoliosis surgical management?
- Nerve root damage
- Cord traction injury
- Vascular injury
- Degenerative changes later
- Problems of growth
Why may repeated operations be required in the treatment of scoliosis?
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
