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0-RCPSC Shay Modified > Paeds CP (Complete) > Flashcards

Paeds CP (Complete) Flashcards

1
Q

What is the definition of cerebral palsy?

A
  1. Static encephalopathy due to injury of the immature brain
  2. The resulting nonprogressive upper motor neuron disease results in muscle imbalances that can lead to progressive musculoskeletal dysfunction
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2
Q

How can CP be classified?

A
  1. Physiologic classification
  • Spastic
  • Athetoid
  • Ataxic
  • Mixed
  • Hypotonic
  1. Anatomic
  • Quadriplegic
  • Diplegic
  • Hemiplegic
  1. GMFCS
    * Level I-V
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3
Q

What are the risk factors for CP?

A
  1. Prematurity
  2. Low birth weight
  3. Anoxic brain injuries
    * Meconium aspiration, birth asphyxia, respiratory distress syndrome
  4. Perinatal infections (ToRCH)
    * Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and Herpes
  5. Meningitis
  6. Brain trauma (NAT)
  7. Prenatal intrauterine problems
    * Placental abnormalities
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4
Q

What diagnostic imaging can be performed to confirm the diagnosis of CP?

A

MRI brain

  • Periventricular leukomalacia
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5
Q

What are the orthopedic manifestations of CP?

A
  1. Spasticity and contractures
  2. Scoliosis
  3. Hip instability and dislocations
  4. Foot deformity
    * Planovalgus, equinovarus
  5. Gait abnormalities
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6
Q

What are the preoperative considerations for a patient with CP undergoing surgery?

A
  1. Multidisciplinary consultations
    * Pediatrics, anaesthesia, ICU, PT/OT, dietician, APS (pain management team)
  2. Investigations
    * Echocardiogram, ECG, CXR
  3. Medications
    * Continue anti-spastic and anti-epileptic medication
  4. Optimize nutrition
  5. Difficult airway
    * Restricted mouth opening, poor dentition, difficult positioning, excess salivation
  6. Difficult positioning (contractures)
  7. GERD/aspiration risk
  8. Prone to hypothermia
  9. ICU post op
  10. Consider chest physio
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7
Q

What can be included in a comprehensive gait analysis?

[Orthobullets]

A
  • Physical exam
  • Kinetic analysis
  • Kinematic analysis
  • Force plate (pedobarography)
  • Dynamic EMG
  • Video
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8
Q

What are the common sagittal gait patterns seen in CP and how are they classified?

[JAAOS 2014;22:782-790]

A

1. Stance phase patterns

  • Normal
  • Jump Gait
    • Characteristics = loss of heel strike at initial contact and toe contact pattern for duration of stance phase
      • Subdivisions:
        • True equinus = plantarflexion relative to the tibia
          • Subdivisions:
            • Normal knee/hip
            • Extended knee/hip
            • Flexed knee/hip
        • Apparent equinus = normal alignment relative to the tibia with flexed knee and hip
  • Crouch Gait
    • Characteristics = flat-foot or calcaneal contact for the duration of stance phase due to ankle plantarflexion muscle group insufficiency + knee flexion
      • Subdivision:
        • Compensated = knee is offloaded in midstance by hip flexion, anterior pelvic tilt, anterior trunk tilt
        • Uncompensated = knee is not offloaded in midstance

2. Swing phase patterns

  • Normal
  • Stiff Gait
    • Characteristics = limited knee flexion during swing phase
    • Subdivisions
      • Knee source = limited knee flexion due to spasticity of the rectus femoris
      • Hip source = due to deviations at the hip (decreased flexion and internal rotation)
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9
Q

What is the management of each gait pattern in CP?

[JAAOS 2014;22:782-790]

A
  1. Jump gait, true equinus, normal knee/hip
  • Single level management
    • Botox or TAL or gastroc recession
  1. Jump gait, true equinus, hyperextended knee/hip
    * Same as above (spontaneous resolution of knee/hip extension)
  2. Jump gait, true equinus, flexed knee/hip
  • Tone management (Botox or intrathecal Baclofen) and single event multilevel surgery (SEMLS)
  • Management summary [European Journal of Neurology 2001;8 (Suppl. 5), 98-108]:
    • Spasticity management
      • Botox injections to calf, hamstrings, (hip)
      • Selective dorsal rhizotomy
    • Contracture management
      • SEMLS – gastroc, hamstring, psoas lengthening
        4. Jump gait, apparent equinus
  • Direct management of knee/hip deviations (do not address the ankle)
  • Management summary [European Journal of Neurology 2001;8 (Suppl. 5), 98-108]:
    • Spasticity management
      • Botox injections to hamstrings, iliopsoas
    • Contracture management
      • SEMLS – hamstring, psoas lengthening
  • Inappropriate TAL or gastroc recession will result in crouch gait
  1. Crouch gait, compensated
    * Often tolerated in younger, smaller, lighter and stronger patient
  2. Crouch gait, uncompensated
  • SEMLS, orthotics, physical therapy
  • Management summary [European Journal of Neurology 2001;8 (Suppl. 5), 98-108]:
    • Spasticity management
      • Botox injections to hamstrings, hip
    • Contracture management
      • SEMLS – hamstring, psoas lengthening, osteotomies for torsional abnormalities or distal femur extension osteotomy
  1. Stiff gait, knee source
    * Single level surgical management (rectus femoris to medial hamstring)
  2. Stiff gait, hip source
    * Do not address the knee
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10
Q

What are the common transverse plane gait patterns and the management of each pattern?

[JAAOS 2014;22:782-790]

A
  1. Internal, single level
    * Single level surgical management (eg. tibial rotation osteotomy)
  2. Internal multilevel
    * SEMLS
  3. External, single level
    * Single level surgical management
  4. External, multilevel
    * Rarely surgery (often due to obesity that cannot be corrected)
  5. Neutral, off-setting (miserable malalignment)
    * SEMLS
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11
Q

What is the spectrum of hip disorders in patients with CP?

[JAAOS 2002;10:198-209]

A
  1. Hip at risk
  2. Subluxation
  3. Dislocation
  4. Dislocation with degeneration and pain
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12
Q

What are the differences between CP hip disorders and DDH?

[JAAOS 2002;10:198-209]

A
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13
Q

With progressive hip involvement what are the resulting difficulties for patients with CP?

[JAAOS 2002;10:198-209]

A

Difficulties with hygiene, sitting, gait and pain

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14
Q

What patients are most affected by spastic hip disorders?

[JAAOS 2002;10:198-209]

A

Severity of neurological involvement (increasing GMFCS level)

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15
Q

What is the femoral deformity in spastic hip disorders?

[JAAOS 2002;10:198-209]

A
  1. Femoral anteversion
  2. Coxa valga
  3. Focal deformation of femoral head (erosion from acetabular margin)
  4. Epiphysis becomes wedge shaped and displaces superolaterally
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16
Q

What is the acetabular deformity in spastic hip disorders?

[JAAOS 2002;10:198-209]

A
  1. Increased acetabular index
  2. Posterosuperior acetabular deficiency
17
Q

What should be evaluated on radiographs in spastic hip disorders?

[JAAOS 2002;10:198-209]

A
  1. Reimer’s Migration Index
  • Vertical drawn from the lateral acetabular margin
  • Width of the uncovered head (lateral to the vertical) divided by the total width of the femoral head
  • Normal = <25% at age 4
  1. Acetabular index
  • Angle formed between Hilgenreiner’s line and line along Sourcil
  • Normal = <25° in child <5, <20° in adult
  1. Sourcil shape
  • Type 1 = lateral corner is sharp and below the level of the weightbearing dome
  • Type 2 = lateral corner is blunted and above the level of the weightbearing dome
18
Q

What is the recommended monitoring of spastic hip disorders in children with CP?

[JAAOS 2002;10:198-209]

A

Between ages 2 and 8 have two orthopedic examinations per year including:

  • AP pelvis radiographs
    • Assess AI and MI
  • Hip abduction ROM
19
Q

What is a hip at risk (in context of CP)?

[JAAOS 2002;10:198-209]

A
  1. <45° abduction
  2. MI >25%
20
Q

What is the critical migration index?

[JAAOS 2002;10:198-209]

A

50%

  • Femoral epiphysis begins to lose the support of the bony pelvis
  • Will not spontaneously reduce
21
Q

What are the 3 main surgical treatment options for spastic hip disorders?

[JAAOS 2002;10:198-209]

A
  1. Soft tissue lengthening
  • ‘Preventative’
    • Can also consider nonop including Botox, bracing, therapy
  1. Reconstruction
    * Soft tissue lengthening, shortening VDRO, acetabuloplasty, +/- capsulotomy
  2. Salvage
  • Castle procedure
  • McHale procedure
  • Arthrodesis
  • Arthroplasty
22
Q

What are the indications for the above treatment options in CP hip?

[JAAOS 2002;10:198-209]

A
  1. Soft tissue lengthening
  • Indications:
    • <8 years with hip abduction <30° and MI 25-60%
  • Contraindications:
    • No contractures or spasticity
    • >4 years with MI >60%
      1. Reconstruction
  • Indications:
    • >4 years with MI >60% and no degeneration
    • <8 years with failed soft tissue lengthening (MI >40% 1 year postoperative)
    • >8 years with MI >40% and no degeneration
  1. Salvage
  • Indications:
    • Painful dislocated hips with degeneration

**Simplified 1 [Curr Rev Musculoskelet Med (2012) 5:126–134]

  • Preventative (Soft tissue lengthening)
    • MI >40%
    • Increase in MI >10% in the last year
    • Abduction <30°
  • Reconstruction
    • MI >50%
    • Evidence of hip subluxation /early dislocation
    • No evidence of degenerative changes in the femoral head
  • Salvage
    • Painful degenerative dislocated hips
    • Previously failed reconstructions

***Simplified 2 [Orthopaedics & Traumatology: Surgery & Research 105 (2019) S133–S141]

  • MI 10-30%
    • Botox and positioning
  • MI 30-40%
    • Soft tissue release
  • MI >40%
    • Painless = reconstruction
    • Painful
      • Triradiate open = salvage
      • Triradiate closed = salvage or THA
23
Q

What are the techniques for each treatment option in CP hip?

A
  1. Soft tissue lengthening
  • Transverse incision 1-3cm distal to inguinal crease
  • Adductor longus tenotomy
  • Gracilis myotomy
  • +/- adductor brevis lengthening
  • Iliopsoas tenotomy in nonambulators
  • Psoas tenotomy in ambulators
  1. Reconstruction
  • Soft tissue lengthening (as above to achieve >45° abduction)
  • Shortening VDRO
    • Shortening is the most important component (functionally lengthens the muscles)
      • Subtrochanteric osteotomy is performed
      • Femoral head is reduced into acetabulum (capsulotomy performed if reduction not achieved closed – typically not needed)
      • Amount of femoral shortening is then judged based on overlap between proximal and distal segments (usually 1-3cm)
  • Acetabuloplasty
    • Triradiate open
      • Dega is preferred as the deficiency is posterosuperior
      • Salter is contraindicated as it does not alter posterior coverage
    • Triradiate closed
      • PAO, triple, (shelf/chiari)
        3. Salvage
  • Castle procedure
    • Femoral head is resected distal to LT
    • Rectus and vastus lateralis are sewn over the femur
    • Abductors, psoas and capsule are sewn over the acetabulum
  • McHale procedure (valgus support osteotomy)
    • Femoral head is resected and a subtrochanteric valgus osteotomy is used to direct the lesser trochanter into the acetabulum and the remaining femoral shaft away from the pelvis

0-RCPSC Shay Modified (29 decks)

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