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Year 3 - MSK > Children’s Orthopaedics - Complex needs - CP, Talipes,Scoliosis > Flashcards

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

1
Q

what is complex needs?

A

“A child with multiple and complex disabilities has at least two different types of severe or profound impairment such that no one professional, agency or discipline has a monopoly in the assessment and management.”

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2
Q

how is someone deifnied as having complex exceptional needs?

A

learning and mental functions

communication

motor skills

self care

hearing

vision

A child or young person (< 19) is defined as having CEN if :

severe impairment in at least 4 categories together with enteral/parenteral feeding

OR

severe impairment in at least 2 categories and ventilation/CPAP

AND

impairments are sustained for more than 6 months and ongoing

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3
Q

what are some complex needs examples with orthopaedic involvement?

(Principles for looking after a complex needs child is similar for all them)

A

Cerebral Palsy (probably most common)

Spina Bifida

Muscular Dystrophy

Arthrogryposis

Neurofibromatosis (genetic tissue, benign tumours that cause neurological dysfunction)

Syndromes – Downs, Turners….

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4
Q

it is a Multidisciplinary effort looking after someone with complex needs but who is involved?

A

Wheelchair services

Orthotics

Occupational Therapy

Social work

Physiotherapy

Education support

Community paediatrics

Orthopaedics

Other specialties - Ophthalmology, Audiology, psychology

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5
Q

Cerebral Palsy - An example of a spectrum of needs

what is it?

A

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

The (brain) lesion is static but the clinical picture is not

Account for 7% of children with ‘complex needs’

Cerebral palsy is the name for a group of lifelong conditions that affect movement and co-ordination. It’s caused by a problem with the brain that develops before, during or soon after birth

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6
Q

what is the incident of CP?

A

Incidence 2 per 1000 live births

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7
Q

CP epidemiology - what are the different type of causes?

A

prenatal

perinatal

postnatal

Probably several aspects are causative

Perinatal probably most common cause

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8
Q

CP epidemiology - what are the prenatal causes?

A

placental insufficiency, toxaemia, smoking, alcohol, drugs, infection such as toxoplasmosis, rubella, CMV and herpes type II (TORCH)

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9
Q

CP epidemiology - what are the perinatal causes?

A

prematurity (most common), anoxic injuries, infections, kernicterus, Haemolytic disease of new born

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10
Q

CP epidemiology - what are the postnatal causes?

A

infection (CMV, rubella), head trauma

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11
Q

what are the 2 different types of classification for CP?

A

physiologic and anatomical

No one classification

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12
Q

what are the different physiologica classifications of CP?

A

Spastic (pyramidal system, motor cortex) -stiffness

Athetoid (extrapyramidal system, basal ganglia) - movement and cordination problems

Ataxia (cerebellum and brainstem)

Mixed (combination of spasticity and athetosis)

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13
Q

what are the different anatomical classificaitons of CP?

A

Monoplegia (one limb involved)

Hemiplegia (one side of the body)

Diplegia (lower limbs)

Quadriplegia or total body involvement

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14
Q

what is the CP Classification GMFCS? (Gross Motor Function Classification System)

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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15
Q

What are the issues in CP?

A

Spasticity

Lack of voluntary limb control

Weakness

Poor co-ordination

Impaired senses (Hearing, Vision, Taste, Touch etc)

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16
Q

What happens as a result in CP?

A

1. Dynamic contractures

Increased muscle tone and hyper-reflexia

No fixed deformity of joints

Deformity can be overcome

2. Fixed muscle contractures

Persistent spasticity and contracture

Shortened muscle tendon units

Deformity cannot be overcome

3. joint subluxation/dislocation

Secondary bone changes/joint degeneration

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17
Q

what areas are Orthopaedic Priorities in CP?

A

Spine

Hip

Feet

Torsional problems

Upper limb function

(top 3 first and most important)

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18
Q

what functions are Orthopaedic Priorities in CP?

A

Maintain Sitting balance,

Improve/maintain Standing posture

Optimise Gait

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19
Q 
Gait analysis (in CP)
An assessment and monitoring tool

How do you do it?

What are the prerequisites?

A

…by observation

…by video

…by 3D instrumented analysis

+/- EMG, energy expenditure

Compliant patient, Independent ambulator, >5yoa

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20
Q

what are the 2 different phases of gait?

A

2 main pahses:

stance

swing

21
Q

what are some hip problems in CP?

A

Hips are normal at birth

Hip displacement in 1/3 by maturity

Likelihood of displacement proportionate to GMFCS

Dislocated hips are often painful

Dislocated hips upset sitting posture

Early surgical intervention leads to better long term outcome

22
Q

The higher the GMFCS =The _______ the risk of hip dislocation

A

higher

23
Q

wha is the non-surgicsl treatment of CP?

A

Posture management - Physiotherapy, Seating

Spasticity management:

  • Generalised - Baclofen Oral, Diazepam
  • Localised - Botulinum toxin, Baclofen intra-thecal pump)
24
Q

what are some (surgical) interventions used to manage deformity?

A
  • Soft tissue release:

Adductors

Hamstrings

  • Bony realignment:

Varus Derotation Osteotomy

Pelvic Osteotomy

25
Q

what is the surgical decision on wheather to operate on soeone or not?

A

Balanced risk discussion

‘Pro’

  • Reduced risk dislocation
  • Reduced risk pain
  • Better seating

‘Con’

  • Not all would have gone on to dislocate
  • BIG surgery
26
Q

onto Club Feet also known as what?

A

Congenital Talipes Equinovarus

27
Q

how common is club foot and who does it occur in?

A

Most common congenital deformity

  • 1 to 2 in 1000 live births (variable)
  • 3 Male : 1 Female (different from DDH which is more common in females)
  • 50% bilateral
  • Risk for 2nd child 1 in 35
28
Q

what is the aetiologyof club foot?

A

Multifactorial

Pressure theories - Oligohydramnios, Abnormal fetal position, Unstretched uterus

Placental insufficiency

Constriction bands

Toxin

Temperature

Infective pathogen (enterovirus)

Drugs

Chromosomal abnormality

Sex-linked

Single dominant

Single recessive

Polygenic

EM radiation

29
Q

how is a prenatal diagnosis of club foot made?

A

Often can be diagnosed using pre-natal ultrasound prior to birth

Parents can be counselled before delivery on treatment and the likely outcome

60% of cases may be identified by ultra-sound

50% may have defects in other systems

No relationship to ‘stiffness’ of feet

30
Q

what are the Traditional Treatment Options?

A

Strapping - Positional talipes only

Serial casting

Dennis Browne Boots

Surgery:

  • Postero-medial release
  • Ilizarov frame
31
Q

than anatomy of club foot - what different things occur?

A

Cavus - high arch foot

Adductus (midfoot) - mid foot is adducted on the hind foot

Varus (hindfoot) - heal tilted towards midline

Equinus (hindfoot) - toes pointing down

This is the sequence of correction

32
Q

pictures showing treatment progression

A

avergae of 5 casts

Applied at weekly intervals above knee

Fix cavus first then adductus then varus then equinus

33
Q

how is correction of equinus done?

A

Percutaneous tenotomy (the surgical cutting of a tendon, especially as a remedy for club foot) of Achilles tendon

Tight achillies tendon and foot cant be dorsiflexion

May be divided using small knife under sedation

34
Q

what are trhe outcomes of club foot?

A

95% of club feet successfully treated

45 year results show that feet are mobile, pain free and plantigrade (90 degrees to the tibia so walking possible)

Results reproduced at major centres around the world

Level 1 RCT (random control trial) evidence

Majority of recurrences due to failure of compliance with splints

35
Q

onto scoliosis - What is the normal sagittal spine shape?

A

Cervical Lordosis

Thoracic Kyphosis

Lumbar Lordosis

Sacral Kyphosis

36
Q

what is the epdemiology and cause of scoliosis?

A

Any deviation in coronal plane is a scoliosis

Clinical significance >10 degree deviation (Up to 10 degrees of deviation is normal and is called a scoliotic tilt)

Structural vs non-structural:

non-structural = due to extrinsic cause – a leg length discrepancy (commonest non-structurl cause), 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

37
Q

in scoliosis, first need to decide if structural or non-structural and this is done through __________

A

examination

38
Q

in scoliosis, what is the % risk of progression with magnitude and age at presentation

A

Cobb angle is a radiological measurement made to assess the severity of the curve

39
Q

in scoliosis what things indicate a high risk of progession?

A

Premenarchal (before period)

< 12yoa at presentation

Size of curve at presentation

40
Q

what ar ethe different classifications by aetiologyof scoliosis?

A

Congenital (Abnormalities of formation vertebra)

Idiopathic (largest group)

Neuromuscular

Others post traumatic, degenerative, infective, syndromic etc

41
Q

what is the Classification of Idiopathic scoliosis?

A

By age at presentation:

Infantile (<3y)

Juvenile (3-10y)

Adolescent (>10y) (probably biggest group and most common in girls)

42
Q

ho is scoliosis classified by region of spine primarily affected?

A
43
Q

what is done on examination of scoliosis?

A

Inspect posterior torso. Structural scoliosis will look worse when bent forward into flexion

Abnormal neurology or pain should be noted (Pain not normally a feature of scoliosis)

Risk factors for progression:

44
Q

How is Investigation of scoliosis done?

A

AP Erect Whole spine +/- Lateral (Tilting films to assess flexibility)

MRI:

Cord abnormalities - Tethering, syrinx (fluid filled cavity), diastematomyelia (bar of bone placed sagittally and transfixes the spinal cord)

Vertebral anomalies - failures of formation and segmentation

Tumours

45
Q

Early diagnosis …matters because…..

A

outcomes less favourable from severe curves:

  • Cardiorespiratory compromise
  • Pain from rib/pelvic abutment
  • Seating issues
  • Surgical challenge

Neuromuscular causes (esp Cerebral Palsy & Muscular Dystrophy) are at high risk of progression

46
Q

what is the non-surgical management of scoliosis?

A

Bracing

Older types Poorly tolerated

Needs to be worn 23/24 hours to work

Delays progression of curve

Custom made

Usually used to delay surgery while spine growing

Particularly idiopathic group - Most common in teenage girls

47
Q

what is the surgical management of scoliosis?

A

Complex and extensive

Surgical approaches - Anterior, Posterior, Both

Wake up test (Traditional)

Intra-operative spinal cord monitoring

48
Q

what are some surgical complications in scoliosis?

A

Nerve root damage

Cord traction injury

Vascular injury

Degenerative changes later (back ache)

Problems of growth

  • Growing rods
  • Changing rods
  • Crankshaft phenomenon (spine in younger child has been instrumented posteriorly but continues to grow anteriorly and this can cause twisting of the spine as the child grows older

Year 3 - MSK (45 decks)

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