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PT 862 > CP Pathology and Surgeries > Flashcards

CP Pathology and Surgeries Flashcards

1
Q

Review: Define CP

A

An inclusive term to describe a group of nonprogressive disorders occurring in young children in which disease of the brain causes impairment of motor function.
- Secondary changes in the musculoskeletal system
may progress throughout growth

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2
Q

What can spasticity cause?

A

Spasticity ->
Inability to stretch muscles during normal play ->
Muscle contractures ->
Abnormal skeletal forces

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3
Q

What are some orthopedic problems for children with CP?

A

Spastic hip disease
Spinal deformity
Ankle/Foot deformities

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4
Q

What are the four priorities for CP patients?

A
  1. Communication
  2. ADL’s
  3. Mobility
  4. Walking
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5
Q

What are some oral interventions and what do they address?

A

Diazepam, Baclofen, Tizanidine
- Decreases tone
SE: Sedation, weakness, hypotonia

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6
Q

What are the secondary problems for patients with MS that can be changed/impacted?

A

Muscle contracture/Bony abnormalities ->
PT/Orthotics ->
Orthopedic surgery ->
Muscle lengthening, Muscle transfer, Osteotomy/Arthrodesis

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7
Q

What are some injectable interventions and what do they address?

A

Botulinim toxin A (botox)
- Irreversibly blocks acetylcholine release by nerves at motor end point (Reversible chemical denervation)

Phenol/Alcohol nerve block
- Similar to Botox but lasts longer

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8
Q

Who is a good candidate for botox and how long does it last?

A

Lasts ~4-6 months

Patient selection
- Dynamic muscle contracture
- Limited number of muscles involved (< 4)

Goals
- Delay surgical intervention
- Facilitate stretching
- Adjunct to PT, casting
- Simulates surgery

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9
Q

What is a surgical intervention and what does it address?

A

Dorsal Rhizotomy
Decreases stimulation from muscle spindles – section of sensory rootlets
- Weakens muscle
- Prevents need for
orthopaedic surgery ~ 50%

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10
Q

Who is a good candidate for Dorsal Rhizotomy surgery?

A

Patient selection is critical to success
- Pure spasticity
- No fixed contractures
- Good selective motor control
- 4-8 years old
- Adequate cognition to cooperate with rehab

Ideal SDR Candidate
- 3-8 y/o spastic diplegic
- Former preemie, LBW, with severe, pure spasticity
- Extensive postop rehab required

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11
Q

What is the result of Dorsal Rhizotomy surgery and what are some side effects?

A

Results
- Permanent decrease in spasticity
- Supraspinal effects
- Upper extremity function
- Bladder function
- Speech, swallowing

Complications
- Dysesthesias, weakness, neurogenic bladder, sensory loss

Effects on musculoskeletal system
- Effect the need for orthopaedic surgery?
- Spinal deformity
- Scoliosis, spondylolisthesis, hyperlordosis
- ? Hip subluxation

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12
Q

What is an Intrathecal Baclofen and why would one have that surgery?

A

Neurosurgical procedure
- Local delivery to spinal cord
- Intrathecal catheter
- Subcutaneous pump
- Complications in up to 25%

Indications
- Spasticity
- Interferes with function or ease of care

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13
Q

When does PT intervene for CP patients?

A

Children < 3 (early intervention)
Post-operative PT
Targeted interventions
“Primary care”

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14
Q

When would a serial cast be used and how often are they changed?

A

Mild spasticity/contractures
Dynamic deformities
Casts every 1-2 weeks for 6-8 weeks
Recurrence a problem

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15
Q

When would an orthotic be used and what can they help?

A

Prevent deformity
Stabilize joints
Substitute for weak muscles
Rarely go above knee

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16
Q

What are the primary problems in orthopedic treatment of CP?

A

Loss of selective motor control
Balance
Spasticity - leads to secondary problems
(permanent)

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17
Q

What are the secondary problems in orthopedic treatment of CP?

A

Soft tissue contracture
Bony deformities
(may be corrected)

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18
Q

What are the tertiary problems in orthopedic treatment of CP?

A

Compensation for primary and secondary problems

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19
Q

What is “Lever arm dysfunction”?

A

Alteration in the leverage relationships necessary for normal gait
Correction increases magnitude of moment acting on joint

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20
Q

What is included in a preoperative evaluation?

A

Collect data
- Functional level
- ROM, strength, selectivity
- Observational Gait Analysis
- Radiographs
Generate problem list
Instrumented motion analysis

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21
Q

What are the goals for a multiple LE procedure?

A

Correct lever arm problems
Lengthen muscles that are short
Transfer muscles that are out of phase or creating deformities
Adequate rehabilitation

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22
Q

Describe muscle-tendon lengthening and what are some issues that may occur?

A

For dynamic and static soft tissue contractures
- Multiple techniques
- Weakens muscle
- May decrease tone elsewhere

23
Q

Describe tendon transfers and what are some issues that may occur?

A

Substitutes for weak muscles
- Changes pull of overactive muscles
- Weakens muscle
- Complete vs. Split transfers

24
Q

Describe bony surgeries and what do they provide?

A

Osteotomies
- cutting and realigning bones
- corrects deformity
(Hip)

Fusions
- joining bones together
- decreases motion
- stabilizes
(Spine, Foot)

25
What are interventions for ambulatory (hemiplegia/diplegia) CP patients?
Both soft tissue and bony pathology may occur at hip, knee, and ankle Address all components at once - Lengthen muscles that are short - Transfer muscles that are out of phase or creating deformities - Correct lever arm problems Have realistic goals Adequate rehabilitation Will still need orthotic support Will still have problems with selectivity, balance, and spasticity!
26
What are some common gait deviations for the hip?
Internal rotation gait - Femoral torsion - Muscular forces (Glut Min, TFL) Flexion deformity
27
What are some surgical interventions for internal rotation gait hip?
Intramuscular Psoas lengthening Derotational Osteotomy: - Internal femoral torsion +/- coxa valga
28
What are some common gait deviations for the knee?
Excessive flexion in stance phase - Hamstring contracture - Torsional deformity Impaired clearance in swing phase - Spastic rectus femoris
29
What is a surgical interventions for knee gait deviations?
Fractional Hamstring lengthening: for "functional" HS contracture Rectus femoris transfer: for spastic RF Medial Hamstring Lengthening Tibial derotational osteotomy: torsional deformity
30
What are some common gait deviations for the foot/ankle?
Loss of Stance phase stability Impaired clearance in swing phase Impaired prepositioning
31
What is a surgical interventions for equinus?
Preferably using a gastroc soleus recession technique Avoid Z-lengthening if possible - Soleus essential for stance phase support and power generation
32
What is Equinovalgus and what causes it?
Muscle imbalance of gastroc - make foot move into valves Most common in diplegia
33
What is the surgical treatment for Equinovalgus ?
Treat equinus first Lateral column lengthening - Gastrocsoleus lengthening - Calcaneal osteotomy - Forefoot varus (bone block for lengthening) OR Triple Arthrodesis (fusion surgery)
34
What is the surgical treatment for FLEXIBLE Equinovalgus? (club foot)
Tibialis Posterior, Tibialis Anterior, both Intramuscular Tibialis Posterior lengthening Gastrocsoleus lengthening Split tendon transfer
35
What is the surgical treatment for FIXED Equinovalgus? (club foot)
Hindfoot (Calcaneal osteotomy) - Lateral closing wedge - Sliding Midfoot - Dorsolateral closing wedge of cuboid Forefoot - Dorsiflexion osteotomy medial column Triple arthrodesis
36
What results from a crouch gait?
Loss of PF/KE Couple. (Lever-arm dysfunction, Soleus insufficiency) 2 degree Contractures of hip & knee flexors Contracture of posterior knee capsule Quadriceps insufficiency/Patella alta
37
How can crouch gait be treated?
Serial casting Hamstring lengthening “Guided growth” with Plate or staples Hamstring lengthening + posterior capsulotomy Distal femoral extension osteotomy and patellar ligament advancement
38
What are the priorities for Quadriplegia/non-ambulatory CP patients?
Communication Activities of daily living Mobility Only ~20% Ambulate
39
What are the goals for Quadriplegia/non-ambulatory CP patients?
Wheelchair to maximize function Spine: straight enough to sit Hips: located, mobile, painless Knee: motion for sitting and transfers Feet: plantigrade
40
What are some issues that result if a patient has hip displacement?
Pain Sitting difficulty Pelvic obliquity/scoliosis Ease of care
41
What causes spastic hip disease?
Soft tissues - Spasticity/muscle imbalance - Adduction contracture
42
How do we screen for spastic hip disease?
Imaging, using Reimer’s Migration Index CP Normal: < 30% Subluxation: >30% Dislocation: >90%
43
How to screen for dislocation potential?
Clinical = hip abduction Baseline AP pelvis at 18 months AP pelvis every 6 mos if “at risk”
44
What are the treatment options for hip subluxation in each phase?
Early = Soft tissue lengthening (preventative) Bony changes = Reconstruction End stage = Salvage
45
What are some surgical treatments for hip subluxation?
Soft tissue lengthening (early) Femoral Osteotomy Pelvic Osteotomy Open reduction Acetabuloplasty
46
What % of CP patients with spastic Quadriplegia will have scoliosis?
39-75% Gets worse with skeletal maturity
47
What are treatment options for scoliosis?
Observation - Small or nonprogressive curves Nonoperative - Wheelchair modifications (controls pelvis, trunk, head/neck) - Bracing (does not prevent progression, improves function) Operative - Spinal arthrodesis (fusion)
48
What are the indications/considerations for surgical interventions for scoliosis?
Curve magnitude/progression > 40 - 50° Sitting imbalance (loss of UE use) Visceral problems or pain Degree of intellectual disability?
49
What are the benefits for spinal fusion to address scoliosis?
Sitting balance/endurance Use of upper extremities Pulmonary function Feeding/nutrition Ease of care, transportation Decreased pain
50
What are the complications for spinal fusion to address scoliosis?
Occurs in 48-81% Respiratory (Atelectasis, Pneumonia) Gastrointestinal (Reflux/aspiration, Ileus, SMA syndrome) Skin/Wound Infection (Superficial, Deep [5-8%]) Implant Related Pseudarthrosis
51
What is athetoid CP?
Abnormal tone and tension Increases with activity Squirming or writhing motion Constant Disappears during sleep
52
Complications and considerations for athetoid CP?
Kernicterus Many are non ambulators Soft tissue surgery unpredictable Scoliosis Cervical spine disease in adults
53
What is the orthopedic treatment process (summary)?
Define problem list Address all components at once Have realistic goals Adequate rehabilitation Pts will still need orthotic support and will have problems with selectivity, balance, and spasticity!

PT 862 (13 decks)

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