EXAM 3 lecture 9: pediatric neurology and limb deficiency Flashcards
Dr. Melissa Howard
congenital limb deficiency types
transverse deficiency
longitudinal deficiency
Which type of limb deficiency is more common?
congenital 60%
What is the most common traumatic etiology for age 1-4?
lawnmower and power tools
what is the most common traumatic etiology for older child?
MVA, machinery,
GSW
___ per 10,000 live births have limb deficiency
2-7
*Limb buds appear at ____ of embryonic development
and by ____completed development
week 4
week 7
Teratogenic factors or disruption of blood Flow
UE Prosthesis is not necessary for transfers, crawling, sitting: T or F
True
can even ride bike with one hand and nubbins=crucial for sensory input
acquired amputations:
often with what other syndromes?
VACTERL, TAR
*need medical check ins regularly
How is it different from adults with acquired amputation?
- other syndromes
- skeletally immature
- development is in process
- congenital anatomical differences
- psychological development (x-fix is painful –> limb salvage procedure)
what are psychological developmental concerns for children with acquired amputations?
What are concerns for multiple limb deficiencies in terms of wearing limb prosthesis?
hot
can’t disperse heat well
Type A PFFD
femur is short
A: acetabulum present, femoral head present, shortened femoral
segment
Type B PFFD
femur more short,
acetabulum dysplastic
B: well defined acetabulum, unossified femoral head at birth
C
almost no femoral head
Type D PFFD
no true acetabulum, no femoral head
clinical findings of PFFD
Hip instability
◦ Malrotation (femur ER)
◦ Insufficient proximal musculature (glutes, quads, hip flexors, abductors)
◦ Short lever arm
◦ Limb length discrepancy
◦ Limb usually positioned in flexion, abduction and external
rotation
◦ 70-80% also have deficiency of the fibula = knee instability
Most Common Gait Deviations: PFFD
Posterior and Lateral trunk lean during stance phase due to
poor strength of abductors and extensors
limb deficiencies in the tibia
Complete or partial absence of the Tibia
clinical findings:
-abnormal articulation of knee and nakle
equinovarus foot deformity
LLD
classifications of tibial limb deficiencies
◦ Type I: complete absence of tibia; no extensor mechanism
◦ Type II: Proximal tibia well formed, have quadriceps
◦ Type III: Presence of distal tibia only
anterior bowing: what would it look like?
anterior bowing looks like a dimple on tibia
Tibial Hemimelia or Amelia
◦If tibia is absent -> Knee Disarticulation
how can you tell if fibula or tibia is missing?
Are they missing lateral toes or medial toes?
lateral - fibula
clinical presentation of fibular hemimelia
May be missing lateral toes
◦ Anterior medial bowing common with dimple
◦ May have shortening of femur as well
◦ ACL deficiency or absence
◦ Varus or Valgus deformity as grow
◦ Missing lateral 2 or 3 rays
clinical presentation of tibial hemimelia or amelia
- Often ACL deficient
- Anterior bowing
- Varus/Valgus deformity requiring
growth manipulation - Crucial to check for sufficient
quadriceps to drive amputation
level - Revisions needed during growth
- Missing 1st or 2nd rays
What are conservative interventions for limb deficiencies? Surgical?
Surgical: Boyd or Symes for fibular hemimelia
conservative: Shoe lifts or accomodative prosthosis
considerations for prosthesis
belt? how to remove it?
can they put it on or put clothes on over it?
how old are they? locked vs unlocked
potty training?
* Can they follow commands?
Boyd or Symes for below the knee amputations
Take ankle off, put heel pad of calcaneus there so they can walk on it
heel pad protects you from having to do multiple amputations
At what age to you provide a
prosthesis for congenital
deficiency?
Once pulling to stand
What should your evaluation include
*Double limb support (scales)
*Balance
*Range of motion
*Strength with and without prosthesis
*Sensation
*Skin: scars, calluses
*AmpPRO or AmpNoPRO (similar to berg, not in pediatric literature but best thing to use)
What are general goals of PT for this population?
1.Full range of motion & good strength
2. Tolerance to prosthetic wear and weight
bearing
3. Control of dynamic weight shifting in all
planes of movement
4. Reintegrate postural control, body
awareness and balance
5. Facilitate as normal a sequence of
development as possible
stump wrap vs shrinker
stump wrap: can take off and clean, low cost, can adjust pressure (figure 8)
shrinker: pantyhose, tight, will shape limb
what happens if stump wrapping/shrinking does not occur well
child will grow out of first socket in first 3-6 months and insurance will not pay for new prosthesis
*If not performed,
patient’s residual limb
will shrink once
ambulation initiated and
they will outgrow the
socket quickly
methods for desensitization for children with limb deficiencies
Massage – soft and deep pressure all
around and incision
◦ Temperatures – warm and cold water
or popsicle
◦ Textures – shaving cream, toothbrush,
wash cloth etc.
Why is stretching important?
high risk for scarring, contractures, difficulty with ROM that impacts gait deviations
AKA: at risk for ___ contractures
At risk for hip flexion, external rotation and
abduction contracture
encourage sleeping prone
BKA: at risk for ___ contractures
At risk for knee flexion contracture, hip
flexion contracture
** Avoid sitting in wheelchair with knee always flexed
* Avoid placing pillow under knee
pre-gait training: weight shifting
shift forward, backwards, side to side, in circle
Tip: For smaller kids have targets of
where to move hips such as hoola
hoop or parallel bars
they should be able to do this with noraml BOS and no UE support
pre-gait training: WS and control exercises
targeted step ups
ball under foot to draw picture/name
*proprioception, balance, control, SLS, graded mvmt
after they are good at:
WS
control
now they start
practice stepping
*step, reach up for elongation of WB side if you see trunk collapse with weight acceptance
- All directions
- Mass practice
- Targets
Gait training involves what components
- reciprocal stepping pattern
- maintain blaance during propulsive movement
- able to respond to demands of environment
history and subjective for general neurological exam?
◦ Birth and developmental history
◦ Any pre-morbid developmental delay?
◦ School/Day Care (what are they returning to?)
◦ What are the patient’s goals?
◦ Families goals and expectations?
◦ What does behavior management at home look like
traumatic TBI etiology of infants
falls
78% near drowning in bathtubs (usually global ischemia)
abuse
traumatic TBI etiology in preschool
falls
MVA
5-9 year old traumatic TBI etiology
falls
MVA
sports/rec
10+ traumatic TBI etiology
sports/rec
boys 2x as likely as girls to suffer a TBI
What are kids under 3 yrs old often diagnosed with when they have a brain injury?
CP
*more benefits
*Stroke
*AVM rupture
*Seizure Disorders
*Cancer/Tumor
*Posterior Fossa Syndrome
*Infection
*Hypoxic Event
__% of children with TBI have long term disability
__% have severe deficits
____ % have disabiltiy
75-80% of children with TBI have long term disability
40% have severe deficits
15 % have disabiltiy
concussions in children with TBI
*% recovered in less than 24 hours
*% within 1-7 days
*% within 1-4 weeks
*% in greater than 1 month
*20% recovered in less than 24 hours
*64% within 1-7 days
*11% within 1-4 weeks
*2% in greater than 1 month
secondary impairments of TBI:
–% of children who sustain TBI will sustain HO
5-20%
NRS: NEUROmuscular recovery scale
good for looking at quality of movement
developed for SCI peds older than 12 years and adults
Rancho 1-3 interventions
maintain ROM
skin integriy
positioning, splints
provide sensory stimuli (auditory, visual, tactile, olfactory, vestib, kinesthetics)
FAMILY EDUCATION BASED ON RANCHO LEVEL
How to break up tone
both legs up is easier
If extensor tone, WB into arms and support hips to get into crawling
Rancho 4-6 interventions
◦ Provide structure & prevent overstimulation
◦ Engage in task specific training that is familiar
◦ Emphasize safety
◦ Relaxation techniques
◦ Encourage mobility
◦ Work on attention to task
How can you encourage a patient to do what you want when they are Rancho 4-6?
*placement of toy is KEY (set up of activity is way more important than verbal cues or manual facilitation)
Rancho 7-9 interventions
◦ Allow for increased independence
when safe
◦ Community re-integration
◦ Dual task activities, layering tasks
◦ What all are you asking them to focus
on and complete?
◦ Altered surfaces
◦ High level balance
*holding ball while jumping, return to sport, etc.
walk while talking, doing math, etc.
congenital etiology of SCI
spina bifida
traumatic etiology of SCI
non-traumatic etiology of SCI
traumatic: MVA, sports, violence
non-traumatic: oncology, congenital anomalies, infection
What is SCIWORA?
(Spinal Cord Injury Without Radiological Abnormalities)
*need to get
why are 55% of child SCI cases that are traumatic cause tetraplegia and 45% paraplegia
more instability higher up due to being a child
before age of 5 SCI: 100% likely to get
scoliosis
*think about that for respiratory function and other stuff
Once signs of autonomic dysreflexia occur: what to check
last time bowel mvmt?
last time cathed?
any kinks in cath?
clothing?
SCI pressure relief education: what is important and ways to help?
timers
watch timers or cell phone
*higher level SCI will need more consistent pressure relief bc nt moving around as much
education for all SCI
*Autonomic Dysreflexia
*Pressure relief
*Hygiene
*Bowel and Bladder schedule
*Sensory impairments
*Signs of infection or pain or medical issue: increased spasticity, fatigue, fever
*Changes to temperature regulation
*Provide education age-appropriate
What are outcome measures for SCI assessment?
*ASIA
*ROM & MMT
*Spasticity
*SCIM
*SCI-FAI
*NRS – pediatric and adult (>12 y/o)
why would you start mobility training in sitting or sit to stand vs bed mobility?
more global mm activation, demanding more of their body
*bed mobility also is a full body activity, rolling, friction of bed, kinda hard
