Paediatric Orthopaedics - Complex Needs Flashcards
What is a child with complex needs defined as?
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
What does CP stand for?
Cerebral palsy
What is cerebral palsy?
Cerebral palsy = permanent and non-progressive motor disorder due to brain damage before birth or during first 2 years of life
What is the incidence of CP?
- 2/1000 births
What is the aetiology of CP?
- Prenatal
- Placental insufficiency
- Toxaemia
- Smoking
- Alcohol
- Drugs
- Perinatal
- Prematurity (most common)
- Anoxic injuries
- Infections
- Postnatal
- Infection (CMV, rubella)
- Head trauma
What infections can cause CP?
CMV, rubella
What are the different classifications of CP?
- Physiological
- Spastic (pyramidal system, motor cortex)
- Most common
- Athetoid (extrapyramidal system, basal ganglia)
- Ataxia (cerebellum and brainstem)
- MIxeed (combination of spasticity and athetosis)
- Spastic (pyramidal system, motor cortex)
- Anatomical
- Monoplegia (one limb involved)
- Hemiplegia (one side of body)
- Diplopia (lower limbs)
- Quadriplegia (total body involvement)
What are the different physiological classifications of CP?
- Spastic (pyramidal system, motor cortex)
- Most common
- Athetoid (extrapyramidal system, basal ganglia)
- Ataxia (cerebellum and brainstem)
- Mixed (combination of spasticity and athetosis)
What are the different anatomical classifications of CP?
- Monoplegia (one limb involved)
- Hemiplegia (one side of body)
- Diplopia (lower limbs)
- Quadriplegia (total body involvement)
What is affected in spastic CP?
- Spastic (pyramidal system, motor cortex)
What is affected in athetoid CP?
- Athetoid (extrapyramidal system, basal ganglia)
What is affected in ataxia CP?
- Ataxia (cerebellum and brainstem)
What is mixed CP?
- Mixed (combination of spasticity and athetosis)
What physiological classification of CP is most common?
- Spastic (pyramidal system, motor cortex)
- Most common
What is CP that affects one limb called?
- Monoplegia (one limb involved)
What is CP that affects one side of the body called?
- Hemiplegia (one side of body)
What is CP that affects the lower limbs called?
- Diplopia (lower limbs)
What is CP that affects total body movement called?
- Quadriplegia (total body involvement)
What is GMFCS?
GMFCS (gross motor function classification system)
What is used to clinically classify CP?
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
What are the 5 levels of GMFCS for CP?
- 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
What are clinical features of CP?
- Spasticity
- Lack of voluntary limb control
- Weakness
- Poor co-ordination
- Impaired senses
Describe the progression of CP?
- 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
What are the orthopaedic priorities for management of CP?
- Maintain sitting balance
- Improve/maintain standing posture
- Optimise gait if they can walk
How can gait be analysed?
- Observation
- Video
- 3D instrumented analysis
- EMG
What is gait?
A persons manner of walking
What are the different phases of gait?
- Stance phase
- Swing phase
Describe the gait cycle?
What is a major complication of CP?
Major complication of CP is hip displacement and maybe dislocation:
- Risk proportional to GMFCS category
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
- Generalised
- Posture management
- Deformity management
- Soft tissue release
- Bony realignment
- Varus derotation osteotomy
- Pelvic osteotomy
- Surgery
What medication can be used for spasticity management in CP?
- Generalised
- Baclofen oral
- Diazepam
- Localised
- Botulinum toxin
- Baclofen intra-thecal pump
What can be done for deformity management in CP?
- Soft tissue release
- Bony realignment
- Varus derotation osteotomy
- Pelvic osteotomy
What is the most common congenital deformity?
Congenital talipes equinovarus
What is congenital talipes equinovarus also known as?
Club foot
What is the aetiology of congenital talipes equinovarus?
- Genetic
- Multifactorial
- In most cases cannot specific why has occurred
Describe the epidemiology of congenital talipes equinovarus in terms of incidence and sex?
- 2/1000 births
- M:F 3:1
How is congenital talipes equinovarus often diagnosed?
- Often prior to birth with prenatal US
What are the 4 deformities that cause congenital talipes equinovarus?
- Cavus
- Adductus (midfoot)
- Varus (hind foot)
- Equinus (hindfoot)
- Remember CAVE
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
Describe the normal curvature of the spine?
Spine normal curvature in sagittal plane:
- Cervical lordosis
- Thoracic kyphosis
- Lumbar lordosis
- Sacral kyphosis
What is scoliosis?
Scoliosis = any deviation in coronal plain
When does scoliosis have clinical significance?
Scoliosis = any deviation in coronal plain
Clinical significance is deviation >10o
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
- Classified by age of presentation
- Neuromuscular
- Others include post-traumatic, degenerative, infection etc
What is the aetiology of non-structural scoliosis?
- Due to extrinsic cause such as leg length discrepancy or hip problem
What is the treatment of non-structural scoliosis?
- Resolves when causal factor is addressed
What is the aetiology of structural scoliosis?
- Abnormal rotation of vertebrae and is an intrinsic spinal problem
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
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
- Classified by age of presentation
- Neuromuscular
- Others include post-traumatic, degenerative, infection etc
What position is best to examine structural scoliosis?
- Structural scoliosis looks worse when bent forwards into flexion
What investigations are done for scoliosis?
- AP erect whole spine x-ray with or without lateral
- MRI
- Cord abnormalities
- Vertebral abnormalities
- Tumours
Describe the prognosis of scoliosis?
- Outcomes less favourable with severe curves
- Early diagnosis matters
- Neuromuscular causes are at high risk of progression
What is the mangement of scoliosis?
- Non-surgical
- Bracing
- Halts or minimises progression of curve
- Bracing
- Surgery
- Complex and extensive
- Complications
- Nerve root damage
- Cord traction injury
- Vascular injury
- Degenerative changes later
- Problems of growth
- Backache
What are some possible complications of surgery for scoliosis?
- Nerve root damage
- Cord traction injury
- Vascular injury
- Degenerative changes later
- Problems of growth
- Backache
