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Paediatric Orthopaedics - Complex Needs Flashcards

1
Q

What is a child with complex needs defined as?

A

Complex needs = child with multiple and complex disabilities has at least two different types of severe or profound impairment

Complex exceptional needs include:

  • Learning and mental function
  • Communication
  • Motor skills
  • Self care
  • Hearing
  • Vision
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2
Q

What does CP stand for?

A

Cerebral palsy

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3
Q

What is cerebral palsy?

A

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

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4
Q

What is the incidence of CP?

A
  • 2/1000 births
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5
Q

What is the aetiology of CP?

A
  • Prenatal
    • Placental insufficiency
    • Toxaemia
    • Smoking
    • Alcohol
    • Drugs
  • Perinatal
    • Prematurity (most common)
    • Anoxic injuries
    • Infections
  • Postnatal
    • Infection (CMV, rubella)
    • Head trauma
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6
Q

What infections can cause CP?

A

CMV, rubella

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7
Q

What are the different classifications of CP?

A
  • Physiological
    • Spastic (pyramidal system, motor cortex)
      • Most common
    • Athetoid (extrapyramidal system, basal ganglia)
    • Ataxia (cerebellum and brainstem)
    • MIxeed (combination of spasticity and athetosis)
  • Anatomical
    • Monoplegia (one limb involved)
    • Hemiplegia (one side of body)
    • Diplopia (lower limbs)
    • Quadriplegia (total body involvement)
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8
Q

What are the different physiological classifications of CP?

A
  • Spastic (pyramidal system, motor cortex)
    • Most common
  • Athetoid (extrapyramidal system, basal ganglia)
  • Ataxia (cerebellum and brainstem)
  • Mixed (combination of spasticity and athetosis)
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9
Q

What are the different anatomical classifications of CP?

A
  • Monoplegia (one limb involved)
  • Hemiplegia (one side of body)
  • Diplopia (lower limbs)
  • Quadriplegia (total body involvement)
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10
Q

What is affected in spastic CP?

A
  • Spastic (pyramidal system, motor cortex)
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11
Q

What is affected in athetoid CP?

A
  • Athetoid (extrapyramidal system, basal ganglia)
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12
Q

What is affected in ataxia CP?

A
  • Ataxia (cerebellum and brainstem)
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13
Q

What is mixed CP?

A
  • Mixed (combination of spasticity and athetosis)
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14
Q

What physiological classification of CP is most common?

A
  • Spastic (pyramidal system, motor cortex)
    • Most common
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15
Q

What is CP that affects one limb called?

A
  • Monoplegia (one limb involved)
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16
Q

What is CP that affects one side of the body called?

A
  • Hemiplegia (one side of body)
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17
Q

What is CP that affects the lower limbs called?

A
  • Diplopia (lower limbs)
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18
Q

What is CP that affects total body movement called?

A
  • Quadriplegia (total body involvement)
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19
Q

What is GMFCS?

A

GMFCS (gross motor function classification system)

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20
Q

What is used to clinically classify CP?

A

GMFCS (gross motor function classification system) is used:

  • Level 1
    • Walks without limitations
  • Level 2
    • Walks with limitations
  • Level 3
    • Walks using hand held mobility device
  • Level 4
    • Self-mobility with limitations
  • Level 5
    • Transported in manual wheelchair
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21
Q

What are the 5 levels of GMFCS for CP?

A
  • Level 1
    • Walks without limitations
  • Level 2
    • Walks with limitations
  • Level 3
    • Walks using hand held mobility device
  • Level 4
    • Self-mobility with limitations
  • Level 5
    • Transported in manual wheelchair
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22
Q

What are clinical features of CP?

A
  • Spasticity
  • Lack of voluntary limb control
  • Weakness
  • Poor co-ordination
  • Impaired senses
23
Q

Describe the progression of CP?

A
  • Dynamic contractor
    • Increased muscle tone and hyper-reflexes
    • No fixed deformity of joints
    • Deformity can be overcome
  • Progress to fixed muscle contractures
    • Persistent spasticity and contracture
    • Shortened muscle tendon units
    • Deformity cannot be overcome
  • Can progress to joint subluxation/dislocation
    • Secondary bone changes/joint degeneration
24
Q

What are the orthopaedic priorities for management of CP?

A
  • Maintain sitting balance
  • Improve/maintain standing posture
  • Optimise gait if they can walk
25
How can gait be analysed?
* Observation * Video * 3D instrumented analysis * EMG
26
What is gait?
A persons manner of walking
27
What are the different phases of gait?
* Stance phase * Swing phase
28
Describe the gait cycle?
29
What is a major complication of CP?
Major complication of CP is hip displacement and maybe dislocation: * Risk proportional to GMFCS category
30
What intervention can be done for children with CP at risk of dislocation?
* 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
31
What medication can be used for spasticity management in CP?
* Generalised * Baclofen oral * Diazepam * Localised * Botulinum toxin * Baclofen intra-thecal pump
32
What can be done for deformity management in CP?
* Soft tissue release * Bony realignment * Varus derotation osteotomy * Pelvic osteotomy
33
What is the most common congenital deformity?
Congenital talipes equinovarus
34
What is congenital talipes equinovarus also known as?
Club foot
35
What is the aetiology of congenital talipes equinovarus?
* Genetic * Multifactorial * In most cases cannot specific why has occurred
36
Describe the epidemiology of congenital talipes equinovarus in terms of incidence and sex?
* 2/1000 births * M:F 3:1
37
How is congenital talipes equinovarus often diagnosed?
* Often prior to birth with prenatal US
38
What are the 4 deformities that cause congenital talipes equinovarus?
* Cavus * Adductus (midfoot) * Varus (hind foot) * Equinus (hindfoot) * Remember CAVE
39
What is the treatment of congenital talipes equinovarus?
* Done in series of casts, from 1 to 5 in weekly intervals * Equinus can be corrected by percutaneous tenotomy of Achilles tendon
40
Describe the normal curvature of the spine?
Spine normal curvature in sagittal plane: * Cervical lordosis * Thoracic kyphosis * Lumbar lordosis * Sacral kyphosis
41
What is scoliosis?
Scoliosis = any deviation in coronal plain
42
When does scoliosis have clinical significance?
Scoliosis = any deviation in coronal plain Clinical significance is deviation \>10o
43
What are the 2 kinds of scoliosis?
* **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
44
What is the aetiology of non-structural scoliosis?
* Due to extrinsic cause such as leg length discrepancy or hip problem
45
What is the treatment of non-structural scoliosis?
* Resolves when causal factor is addressed
46
What is the aetiology of structural scoliosis?
* Abnormal rotation of vertebrae and is an intrinsic spinal problem
47
What is the risk of progression of structural scoliosis proportional to?
* Risk of progression is proportional to curve magnitude (Cobb angle) and age at presentation
48
What are the 3 major classes of structural scoliosis?
* 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
49
What position is best to examine structural scoliosis?
* Structural scoliosis looks worse when bent forwards into flexion
50
What investigations are done for scoliosis?
* AP erect whole spine x-ray with or without lateral * MRI * Cord abnormalities * Vertebral abnormalities * Tumours
51
Describe the prognosis of scoliosis?
* Outcomes less favourable with severe curves * Early diagnosis matters * Neuromuscular causes are at high risk of progression
52
What is the mangement of scoliosis?
* 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
53
What are some possible complications of surgery for scoliosis?
* Nerve root damage * Cord traction injury * Vascular injury * Degenerative changes later * Problems of growth * Backache

Musculoskeletal (40 decks)

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