Children Orthopaedics: Complex needs - CP, clubfoot, scoliosis

Question 1

Define complex needs

Answer 1

Child w/ multiple + complex disabilities that causes at least 2 different types of severe impairment. Requires different specialties to manage (no one discipline).

Question 2

What is cerebral palsy?

Answer 2

Permanent and non-progressive motor disorder due to brain damage before birth or during the first 2 yrs of life.

Question 3

What are some causes of cerebral palsy?

Answer 3

Prenatal – placental insufficiency, toxaemia, smoking/alcohol/drugs, infections (toxoplasmosis/rubella/CMV/Herpes type II)
Perinatal (before+ up to yr after born) – prematurity (most common), anoxic injuries, infections, haemolytic disease of new born
Postnatal: infection (CMV, rubella), head trauma.

Question 4

How is CP classified anatomically?

Answer 4

Monoplegia (one limb involved)
Hemiplegia (one side of body)
Diplegia (LL)
Quadriplegia or total body involvement

Question 5

What clinical classification system is used for CP and detail it

Answer 5

Gross Motor Function Classification System (GMFC):
Level I – walks w/o limitations
Level II – walks with limitations
Level III – walks using hand-held mobility device
Level IV – Self-mobility with limitations (may use powered mobility)
Level V – Transported in a manual wheelchair

Question 6

What are the issues in CP and what happens as a result?

Answer 6

Issues – spasticity, lack of voluntary limb control, weakness, poor co-ordination, impaired senses
Results – 1) Dynamic contractures 2) Fixed muscle contractures 3) Joint subluxation/dislocation

Question 7

What does likelihood of hip displacement in CP correlate with?

Answer 7

The higher GMFC – the higher the risk of hip dislocation. Due to spasticity (muscles tightening/stiffening)

Question 8

What symptoms does hip dislocation (CP) cause?

Answer 8

Often painful

Upset sitting posture

Question 9

What leads to better long term outcome in hip dislocation (CP)?

Answer 9

Early surgical intervention

Question 10

What are non-surgical interventions for CP?

Answer 10

Posture management – physiotherapy, seating.
Spasticity management:
Generalised – baclofen oral, diazepam
Localised – botulinum toxin, baclofen

Question 11

What operative management options are there for CP deformities?

Answer 11

Soft tissue release – adductor, hamstrings
Bony realignment
- Varus derotation osteotomy
- Pelvic osteotomy

Question 12

What is the most common congenital deformity?

Answer 12

Congenital Talipes Equinovarus Clubfoot (TEV)

Question 13

Describe the anatomical features of clubfoot

Answer 13

Muscle contractures contribute to CAVE deformity

Cavus [high arch]
Adductus (midfoot)
Varus (hindfoot) [angulation toward midline]
Equinus (hindfoot) [upward bending limited, foot held downwards]

Question 14

What conservative method is usually used to treat clubfoot?

Answer 14

Ponseti method – manipulation

Series of usually 5 casts, correcting CAVE deformities

Question 15

What surgical correction is usually used for equinus (in Clubfoot)?

Answer 15

Percutaneous tenotomy of Achilles tendon. 90% will need this. Allows ankle to dorsiflex.

Question 16

Describe the normal sagittal spine shape

Answer 16

Cervical Lordosis
Thoracic Kyphosis
Lumbar Lordosis
Sacral Kyphosis

Question 17

What is a scoliosis and when does it becomes clinically significant?

Answer 17

Any deviation of spine in the coronal plane is a scoliosis (sideway curvature). Clinical significance > 10-degree deviation.

Question 18

Describe what is meant by non-structural and structural scoliosis

Answer 18

Non-structural – due to extrinsic cause, e.g. leg length discrepancy, hip problem etc. Resolves when causal factor is addressed.

Structural scoliosis = abnormal rotation of the vertebrae and is an intrinsic spinal problem. It has a propensity to progress

Question 19

How is scoliosis classified?

Answer 19

By…
Aetiology,
Age at presentation (infantile, juvenile, adolescent),
Region primarily affected (thoracic (usually R), lumbar (L), thoracolumbar (R), double (R thoracic, L lumbar))

Question 20

What is the aetiology of scoliosis?

Answer 20

Congenital (Abnormalities of formation vertebra)
Idiopathic
Neuromuscular

Others: post traumatic, degenerative, infective, syndromic etc.

Question 21

Describe the examination of scoliosis

Answer 21

Inspect posterior torso. Structural scoliosis will look worse bent forward in flexion.
Abnormal neurology or pain should be noted.

Question 22

What are the risk factors for scoliosis progression?

Answer 22

Age / Skeletal maturity – younger age
Gender – girls
Pattern of curve – thoracic, double major

Question 23

How do you investigate scoliosis?

Answer 23

XR - AP erect Whole Spine +/- lateral (tilting films to assess flexibility)
MRI
- Cord abnormalities – tethering, syrinx
- Vertebral anomalies – failures of formation and segmentation
- Tumours

Question 24

Describe the significance of early diagnosis in scoliosis

Answer 24

Severe curves give less favourable outcomes:
- Cardiorespiratory compromise
- Pain from rib/pelvic abutment
- Seating issues
- Surgical challenge
Neuromuscular causes (esp. cerebral palsies + muscular dystrophy) are at high risk of progression.

Question 25

Outline the non-surgical treatment of scoliosis

Answer 25

Bracing – needs to be worn 23/24hrs/day to work, delays progression of curve, custom made, usually to delay surgery while spine growing.

Question 26

Describe surgical treatment of scoliosis

Answer 26

Complex and extensive
Fusion
Surgical approaches: anterior, posterior, both
Intra-operative SC monitoring.

Question 27

What are surgical complications for scoliosis surgery?

Answer 27

Nerve root damage
Cord traction injury 
Vascular injury 
Degenerative changes later 
Growth problems