Paediatric Orthopaedics - Complex Needs

Question 1

What is cerebral palsy?

Answer 1

Cerebral palsy = permanent and non-progressive motor disorder due to brain damage before birth or during first 2 years of life

Question 2

What is the aetiology of CP?

Answer 2

• Prenatal
  
  • Placental insufficiency
  • Toxaemia
  • Smoking
  • Alcohol
  • Drugs
• Perinatal
  
  • Prematurity (most common)
  • Anoxic injuries
  • Infections
• Postnatal
  
  • Infection (CMV, rubella)
  • Head trauma

Question 3

What infections can cause CP?

Answer 3

CMV, rubella

Question 4

What are the different classifications of CP?

Answer 4

• Physiological
• Spastic CP (Most Common):

Lesion in UMN

Hypertonia

Stiffness

Dyskinetic (Athetoid)CP:

Injury to basal ganglia

Involuntary movements

Dystonia

Chorea

Ataxic:

Damage to cerebellum

Unstable movement

• Anatomical
  
  • Monoplegia (one limb involved)
  • Hemiplegia (one side of body)
  • Diplopia (lower limbs)
  • Quadriplegia (total body involvement)

Question 5

What is GMFCS?

Answer 5

GMFCS (gross motor function classification system)

Question 6

What are clinical features of CP?

Answer 6

• Spasticity
• Lack of voluntary limb control
• Weakness
• Poor co-ordination
• Impaired senses

Question 7

What are the orthopaedic priorities for management of CP?

Answer 7

• Maintain sitting balance
• Improve/maintain standing posture
• Optimise gait if they can walk

Question 8

How can gait be analysed?

Answer 8

• Observation
• Video
• 3D instrumented analysis
• EMG

Question 9

What is a major complication of CP?

Answer 9

Major complication of CP is hip displacement and maybe dislocation:

• Risk proportional to GMFCS category

Question 10

What intervention can be done for children with CP at risk of dislocation?

Answer 10

• Non-surgical
  
  • Posture management
    
    • Physiotherapy
    • Seating
  • Spasticity management
    
    • Generalised
      
      • Baclofen oral
      • Diazepam
    • Localised
      
      • Botulinum toxin
      • Baclofen intra-thecal pump
• Deformity management
  
  • Soft tissue release
  • Bony realignment
    
    • Varus derotation osteotomy
    • Pelvic osteotomy
• Surgery

Question 11

What is the most common congenital deformity?

Answer 11

Congenital talipes equinovarus (Club Foor)

Question 12

What is the aetiology of congenital talipes equinovarus?

Answer 12

• Genetic
• Multifactorial
  
  • In most cases cannot specific why has occurred

Question 13

Describe the epidemiology of congenital talipes equinovarus in terms of incidence and sex?

Answer 13

• 2/1000 births
• M:F 3:1

Question 14

How is congenital talipes equinovarus often diagnosed?

Answer 14

• Often prior to birth with prenatal US

Question 15

What are the 4 deformities that cause congenital talipes equinovarus?

Answer 15

• Cavus
• Adductus (midfoot)
• Varus (hind foot)
• Equinus (hindfoot)
• Remember CAVE

Question 16

What is the treatment of congenital talipes equinovarus?

Answer 16

• Done in series of casts, from 1 to 5 in weekly intervals
• Equinus can be corrected by percutaneous tenotomy of Achilles tendon

Question 17

What is scoliosis?

Answer 17

Scoliosis = any deviation in coronal plain

Question 18

When does scoliosis have clinical significance?

Answer 18

Scoliosis = any deviation in coronal plain

Clinical significance is deviation >10^o

Question 19

What are the 2 kinds of scoliosis?

Answer 19

• Non-structural
  
  • Due to extrinsic cause such as leg length discrepancy or hip problem
  • Resolves when causal factor is addressed
• Structural
  
  • Abnormal rotation of vertebrae and is an intrinsic spinal problem
  • Can progress
    
    • Risk of progression is proportional to curve magnitude (Cobb angle) and age at presentation
  • 3 major classes
    
    • Congenital (abnormalities of formation vertebrae)
    • Idiopathic
      
      • Classified by age of presentation
        
        • Infantile <3 years
        • Juvenile 3-10 years
        • Adolescent >10 years
    • Neuromuscular
      
      • Others include post-traumatic, degenerative, infection etc

Question 20

What is the aetiology of structural scoliosis?

Answer 20

Congenital

Idiopathic (most common)

Neuromuscular

Others: (rarer)

Post traumatic

Infective

Degenerative

Question 21

What position is best to examine structural scoliosis?

Answer 21

• Structural scoliosis looks worse when bent forwards into flexion

Question 22

What investigations are done for scoliosis?

Answer 22

• AP erect whole spine x-ray with or without lateral
• MRI
  
  • Cord abnormalities
  • Vertebral abnormalities
  • Tumours

Question 23

Describe the prognosis of scoliosis?

Answer 23

• Outcomes less favourable with severe curves
• Early diagnosis matters
• Neuromuscular causes are at high risk of progression

Question 24

What is the mangement of scoliosis?

Answer 24

• Non-surgical
  
  • Bracing
    
    • Halts or minimises progression of curve
• Surgery
  
  • Complex and extensive
  • Complications
    
    • Nerve root damage
    • Cord traction injury
    • Vascular injury
    • Degenerative changes later
    • Problems of growth
    • Backache

Question 25

What are some possible complications of surgery for scoliosis?

Answer 25

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