Paediatric Orthopaedics - Complex Needs, CTEV and Scoliosis Flashcards
What are some complex exceptional needs?
Learning and mental functions, communication, motor skills, self care, hearing and vision
When is a child or young person (<19) defined as having CEN?
Severe impairment in at least 4 categories together with parenteral feeding
Or severe impairment in 2 categories and ventilation
And impairments are sustained for 6 months and ongoing
What are some complex needs examples that need orthopaedic involvement?
Cerebral palsy, spina bifida, muscular dystrophy, arthrogryposis, neurofibromatosis, and syndrome (Downs and Turners)
What is cerebral palsy?
A permanent and non-progressive motor disorder due to brain damage before birth or during first 2 years of life
Lesion is static but clinical picture is not
What are the prenatal causes of CP?
Placental insufficiency, toxaemia, smoking, alcohol, drugs, and infections like toxoplasmosis, rubella, CMV and herpes type II
What are some perinatal causes of CP?
Prematurity, anoxic injuries, infections, kernicterus, and haemolytic diseases
What are some postnatal causes of CP?
Infection like CMV and rubella, and head trauma
What are the CP classifications - physiological?
Spastic - pyramidal system and motor cortex
Athetoid - extrapyramidal system and basal ganglia
Ataxia - cerebellum and brainstem
Mixed - combinations of spastic and athetoid
What is the anatomical classification of CP?
Monoplegia - one limb involved
Hemiplegia - one side of body involved
Diplegia - lower limbs
Quadriplegia - 4 limbs or total body involvement
Describe the gross motor function classification system (GMFCS)
Level I - walks without limitations
Level 2 - Walks with limitations
Level 3 - walks using a hand held mobility device
Level 4 - self-mobility with limitations
Level 5 - transported in manual wheelchair
What are the issues in CP?
Spasticity (increased tone in muscles), lack of voluntary limb control, weakness, poor coordination and impaired senses
What happens as a result of spasticity in CP?
Dynamic contractures - increased muscle tone and hyper-reflexia, no fixed deformity in joints and can be overcome
Fixed muscle - persistent spasticity, shortened muscle tendon units, and deformity can’t be overcome
Joint subluxation - secondary bone changes
What are orthopaedic priorities in CP?
Spine, hip, feet, torsional problems and upper limb function
Maintain sitting balance, improve standing posture and optimise gait
How is gait analysed in CP?
Observation, video, 3D instrumental analysis, and EMG
Need to be complaint, independent ambulator and more than 5 years old
What are the phases of gait?
60% stance phase and 40% swing phase
Stance - weight acceptance and single limb support
Swing - limb advancement
What are some hip problems in CP?
Hip displacement in 1/3 by maturity
Likelihood of displacement is proportional to GMFCS
Dislocated hips causing upset to sitting posture
Early surgical intervention leads to better outcome in future
What are the non surgical interventions used for posture management?
Physio and seating
What are the non-surgical interventions for spasticity management?
Generalised - Baclofen oral and Diazepam
Localised - Botulinum toxin and Baclofen intra-thecal pump
What is the deformity management?
Soft tissue release - adductors and hamstrings
Bony realignment - varus derotation osteotomy and pelvic osteotomy
What is the pros and cons of surgical intervention?
Pros - reduced risk dislocation, risk pain and better seating
Cons - not all patients go on to dislocate and its a big surgery
What is the incidence of Congenital Talipes Equinovarus (club foot)?
Most common congenital deformity
1 in 2 in 1000 live births
3 male : 1 female
50% bilateral
Risk for second child is 1 in 35
What is the aetiology of club foot?
Multifactorial
Pressure theories, placental insufficiency, constriction bands, toxin, temp., infective pathogen, drugs, polygenic…
How is club foot diagnosed in prenatal stage?
60% of cases may be identified by US
50% may have other system defects
What is the traditional treatment options for club foot?
Strapping, serial casting, Dennis Browne boots, and surgery - postero-medial release and Ilizarov frame
What is the anatomy of club foot?
Cavus
Adductus - midfoot
Varus - hindfoot - midline
Equinus - hindfoot
What is the treatment progression of club foot?
Series of casts - above knee
Changed weekly
Correct adductus, then varus then equinus
How is the equinus corrected in club foot?
Percutaneous tenotomy of Achilles tendon
What is the outcomes of club foot?
95% of club feet successfully treated
Feet are mobile, pain free ad plantigrade
Majority of recurrences due to failure with compliance of splints
Describe the normal sagittal spine shape
Cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis
What is the definition of scoliosis?
Any deviation in coronal plane
Clinical significance if 10 degrees deviation
Structural - extrinsic cause (leg length discrepancy) - resolves as causative factor addressed
Non-structural - abnormal rotation of vertebrae and intrinsic problem
What is high risk progression for scoliosis?
Premenarchal
Under 12 at presentation
Size of curve at presentation
How is scoliosis classified?
Congenital - formation of vertebrae
Idiopathic
Neuromuscular
Others - post traumatic, degenerative, infective and syndromes
What is the classification of idiopathic scoliosis?
Infantile (under 3 yrs), juvenile (3-10yrs) and adolescent (over 10 yrs)
How is scoliosis classified by region of spine?
Thoracic, lumbar, thoracolumbar and double
How is scoliosis examined?
Inspect posterior torso
Structural scoliosis will look worse when bent forward into flexion
Abnormal neurology and pain is noted
Look for skeletal maturity and immaturity - signs of progression
What investigations are used for scoliosis?
AP erect whole spine and lateral films sometimes required
MRI - cord abnormalities, vertebral abnormalities and tumours
Why is early diagnosis important in scoliosis?
Outcomes less favourable from severe curves - cardiorespiratory compromise, pain from rib/ pelvic, seating issues and surgical challenge
Neuromuscular causes are at high risk of progression
What is the non-surgical management of scoliosis?
Bracing - needs to be worn 23/24 hrs a day, delays progression of curve and delays surgery
What is the surgical management of scoliosis?
Complex and extensive
Surgical approaches - anterior, posterior or both
Wake up test
Intra-operative spinal cord monitoring
What are the scoliosis surgical complications?
Nerve root damage, cord traction injury, vascular injury, degenerative changes later and problems in growth (growing rods, changing rods and crankshaft phenomenon which causes twisting of spine)
