Paediatric Orthopaedics - Complex Needs, CTEV and Scoliosis

Question 1

What are some complex exceptional needs?

Answer 1

Learning and mental functions, communication, motor skills, self care, hearing and vision

Question 2

When is a child or young person (<19) defined as having CEN?

Answer 2

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

Question 3

What are some complex needs examples that need orthopaedic involvement?

Answer 3

Cerebral palsy, spina bifida, muscular dystrophy, arthrogryposis, neurofibromatosis, and syndrome (Downs and Turners)

Question 4

What is cerebral palsy?

Answer 4

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

Question 5

What are the prenatal causes of CP?

Answer 5

Placental insufficiency, toxaemia, smoking, alcohol, drugs, and infections like toxoplasmosis, rubella, CMV and herpes type II

Question 6

What are some perinatal causes of CP?

Answer 6

Prematurity, anoxic injuries, infections, kernicterus, and haemolytic diseases

Question 7

What are some postnatal causes of CP?

Answer 7

Infection like CMV and rubella, and head trauma

Question 8

What are the CP classifications - physiological?

Answer 8

Spastic - pyramidal system and motor cortex
Athetoid - extrapyramidal system and basal ganglia
Ataxia - cerebellum and brainstem
Mixed - combinations of spastic and athetoid

Question 9

What is the anatomical classification of CP?

Answer 9

Monoplegia - one limb involved
Hemiplegia - one side of body involved
Diplegia - lower limbs
Quadriplegia - 4 limbs or total body involvement

Question 10

Describe the gross motor function classification system (GMFCS)

Answer 10

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

Question 11

What are the issues in CP?

Answer 11

Spasticity (increased tone in muscles), lack of voluntary limb control, weakness, poor coordination and impaired senses

Question 12

What happens as a result of spasticity in CP?

Answer 12

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

Question 13

What are orthopaedic priorities in CP?

Answer 13

Spine, hip, feet, torsional problems and upper limb function
Maintain sitting balance, improve standing posture and optimise gait

Question 14

How is gait analysed in CP?

Answer 14

Observation, video, 3D instrumental analysis, and EMG
Need to be complaint, independent ambulator and more than 5 years old

Question 15

What are the phases of gait?

Answer 15

60% stance phase and 40% swing phase
Stance - weight acceptance and single limb support
Swing - limb advancement

Question 16

What are some hip problems in CP?

Answer 16

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

Question 17

What are the non surgical interventions used for posture management?

Answer 17

Physio and seating

Question 18

What are the non-surgical interventions for spasticity management?

Answer 18

Generalised - Baclofen oral and Diazepam
Localised - Botulinum toxin and Baclofen intra-thecal pump

Question 19

What is the deformity management?

Answer 19

Soft tissue release - adductors and hamstrings
Bony realignment - varus derotation osteotomy and pelvic osteotomy

Question 20

What is the pros and cons of surgical intervention?

Answer 20

Pros - reduced risk dislocation, risk pain and better seating
Cons - not all patients go on to dislocate and its a big surgery

Question 21

What is the incidence of Congenital Talipes Equinovarus (club foot)?

Answer 21

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

Question 22

What is the aetiology of club foot?

Answer 22

Multifactorial
Pressure theories, placental insufficiency, constriction bands, toxin, temp., infective pathogen, drugs, polygenic…

Question 23

How is club foot diagnosed in prenatal stage?

Answer 23

60% of cases may be identified by US
50% may have other system defects

Question 24

What is the traditional treatment options for club foot?

Answer 24

Strapping, serial casting, Dennis Browne boots, and surgery - postero-medial release and Ilizarov frame

Question 25

What is the anatomy of club foot?

Answer 25

Cavus
Adductus - midfoot
Varus - hindfoot - midline
Equinus - hindfoot

Question 26

What is the treatment progression of club foot?

Answer 26

Series of casts - above knee
Changed weekly
Correct adductus, then varus then equinus

Question 27

How is the equinus corrected in club foot?

Answer 27

Percutaneous tenotomy of Achilles tendon

Question 28

What is the outcomes of club foot?

Answer 28

95% of club feet successfully treated
Feet are mobile, pain free ad plantigrade
Majority of recurrences due to failure with compliance of splints

Question 29

Describe the normal sagittal spine shape

Answer 29

Cervical lordosis, thoracic kyphosis, lumbar lordosis, and sacral kyphosis

Question 30

What is the definition of scoliosis?

Answer 30

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

Question 31

What is high risk progression for scoliosis?

Answer 31

Premenarchal
Under 12 at presentation
Size of curve at presentation

Question 32

How is scoliosis classified?

Answer 32

Congenital - formation of vertebrae
Idiopathic
Neuromuscular
Others - post traumatic, degenerative, infective and syndromes

Question 33

What is the classification of idiopathic scoliosis?

Answer 33

Infantile (under 3 yrs), juvenile (3-10yrs) and adolescent (over 10 yrs)

Question 34

How is scoliosis classified by region of spine?

Answer 34

Thoracic, lumbar, thoracolumbar and double

Question 35

How is scoliosis examined?

Answer 35

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

Question 36

What investigations are used for scoliosis?

Answer 36

AP erect whole spine and lateral films sometimes required
MRI - cord abnormalities, vertebral abnormalities and tumours

Question 37

Why is early diagnosis important in scoliosis?

Answer 37

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

Question 38

What is the non-surgical management of scoliosis?

Answer 38

Bracing - needs to be worn 23/24 hrs a day, delays progression of curve and delays surgery

Question 39

What is the surgical management of scoliosis?

Answer 39

Complex and extensive
Surgical approaches - anterior, posterior or both
Wake up test
Intra-operative spinal cord monitoring

Question 40

What are the scoliosis surgical complications?

Answer 40

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)