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14. Year 2: Musculoskeletal > Paediatric Orthopaedics - Complex Needs > Flashcards

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
Q

How can gait be analysed?

A
  • Observation
  • Video
  • 3D instrumented analysis
  • EMG
26
Q

What is gait?

A

A persons manner of walking

27
Q

What are the different phases of gait?

A
  • Stance phase
  • Swing phase
28
Q

Describe the gait cycle?

A
29
Q

What is a major complication of CP?

A

Major complication of CP is hip displacement and maybe dislocation:

  • Risk proportional to GMFCS category
30
Q

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

A
  • 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
Q

What medication can be used for spasticity management in CP?

A
  • Generalised
    • Baclofen oral
    • Diazepam
  • Localised
    • Botulinum toxin
    • Baclofen intra-thecal pump
32
Q

What can be done for deformity management in CP?

A
  • Soft tissue release
  • Bony realignment
    • Varus derotation osteotomy
    • Pelvic osteotomy
33
Q

What is the most common congenital deformity?

A

Congenital talipes equinovarus

34
Q

What is congenital talipes equinovarus also known as?

A

Club foot

35
Q

What is the aetiology of congenital talipes equinovarus?

A
  • Genetic
  • Multifactorial
    • In most cases cannot specific why has occurred
36
Q

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

A
  • 2/1000 births
  • M:F 3:1
37
Q

How is congenital talipes equinovarus often diagnosed?

A
  • Often prior to birth with prenatal US
38
Q

What are the 4 deformities that cause congenital talipes equinovarus?

A
  • Cavus
  • Adductus (midfoot)
  • Varus (hind foot)
  • Equinus (hindfoot)
  • Remember CAVE
39
Q

What is the treatment of congenital talipes equinovarus?

A
  • Done in series of casts, from 1 to 5 in weekly intervals
  • Equinus can be corrected by percutaneous tenotomy of Achilles tendon
40
Q

Describe the normal curvature of the spine?

A

Spine normal curvature in sagittal plane:

  • Cervical lordosis
  • Thoracic kyphosis
  • Lumbar lordosis
  • Sacral kyphosis
41
Q

What is scoliosis?

A

Scoliosis = any deviation in coronal plain

42
Q

When does scoliosis have clinical significance?

A

Scoliosis = any deviation in coronal plain

Clinical significance is deviation >10o

43
Q

What are the 2 kinds of scoliosis?

A
  • 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
Q

What is the aetiology of non-structural scoliosis?

A
  • Due to extrinsic cause such as leg length discrepancy or hip problem
45
Q

What is the treatment of non-structural scoliosis?

A
  • Resolves when causal factor is addressed
46
Q

What is the aetiology of structural scoliosis?

A
  • Abnormal rotation of vertebrae and is an intrinsic spinal problem
47
Q

What is the risk of progression of structural scoliosis proportional to?

A
  • Risk of progression is proportional to curve magnitude (Cobb angle) and age at presentation
48
Q

What are the 3 major classes of structural scoliosis?

A
  • 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
Q

What position is best to examine structural scoliosis?

A
  • Structural scoliosis looks worse when bent forwards into flexion
50
Q

What investigations are done for scoliosis?

A
  • AP erect whole spine x-ray with or without lateral
  • MRI
    • Cord abnormalities
    • Vertebral abnormalities
    • Tumours
51
Q

Describe the prognosis of scoliosis?

A
  • Outcomes less favourable with severe curves
  • Early diagnosis matters
  • Neuromuscular causes are at high risk of progression
52
Q

What is the mangement of scoliosis?

A
  • 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
Q

What are some possible complications of surgery for scoliosis?

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

14. Year 2: Musculoskeletal (40 decks)

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