Paediatric Orthopaedics - Complex Needs Flashcards
What is a child with complex needs defined as?
multiple and complex disabilities and 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?
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
- anatomical
What are the different physiological classifications of CP?
- spastic (pyramidal system, motor cortex)
- 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?
Diplegia (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)
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 contractures
- 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
- 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?
hip displacement and maybe dislocation
What intervention can be done for children with CP at risk of dislocation?
non-surgical
- posture management: physiotherapy, seating
- spasticity management
- deformity management
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 specify 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)
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?
when deviation is >10o
What are the 2 kinds of scoliosis?
- non-structural: due to an extrinsic cause
- structural: intrinsic spinal problem
What is the aetiology of non-structural scoliosis?
due to extrinsic cause
- leg length discrepancy
- 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?
- curve magnitude (Cobb angle)
- age at presentation
What are the 3 major classes of structural scoliosis?
- congenital: abnormalities of formation vertebrae
- idiopathic
- neuromuscular
- others: post-traumatic, degenerative, infection…
What position is best to examine structural scoliosis?
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)
surgery: complex and extensive
What are some possible complications of surgery for scoliosis?
- backache
- nerve root damage
- vascular or cord traction injury
- degenerative changes later
- problems of growth
