Cortex - Paediatric orthopaedics 2

Question 1

What is cerebral palsy?

Answer 1

It is a neuromuscular condition with onset before 2-3yrs old due to an insult to the immature brain before, during or after birth.

Question 2

List some of the causes of cerebral palsy

Answer 2

1. Antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV)
2. Intrapartum (10%): birth asphyxia/trauma
3. Postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma

Question 3

What are the 3 main types of CP and the area of the nervous system they affect

Answer 3

1. Spastic CP (80% of cases) caused by injury to the motor cortex, UMN’s or corticospinal tract - resulting in weakness and spasticity which may worsen as the child grows.
2. Ataxic (which affects the cerebellum) - reduces co‐ordination and balance
3. Athetoid (affecting the extrapyramidal motor system, the pyramidal tract and basal ganglia) - results in an uncontrolled writhing motion, sudden changes in tone and difficulties controlling speech.

Question 4

Describe the different distribution patterns of CP

Answer 4

1. Affect one limb = monoplegic
2. One ipsilateral upper and lower limb = hemiplegic – the most common
3. Both legs only = diplegic
4. All 4 limbs = quadraplegia

Question 5

Describe the presentation of cerebral palsy

Answer 5

Expression and severity varies

• muscle stiffness or floppiness (hypotonia)
• muscle weakness
• random and uncontrolled body movements
• balance and co-ordination problems
• repeated fits or seizures
• drooling problems and swallowing difficulties (dysphagia)
• Common to have communication and learning difficulties

Question 6

What are some of the treatment options for CP ?

Answer 6

Non‐surgical tx:

• Physio and splintage (orthotics) to prevent contractures.
• Baclofen to reduce spasticity and Botox injection into spastic muscles.

Surgical tx:

• Hip excision or replacement to treat painful hip dislocation and subsequent problems with wheelchair sitting
• Surgical release of joint contractures
• Correction of severe scoliosis
• Joint fusions
• Tendon transfers.

Question 7

What is spina bifida ?

Answer 7

• Where two halves of the posterior vertebral arch fail to fuse
• Can result in the contents of the vertebral canal herniate through the defect with either hernmiation of the meninges alone (a meningocele) or with the spinal cord or cauda equina.

Question 8

What is polio ?

Answer 8

• A viral infection which affects motor anterior horn cells in the spinal cord or brainstem resulting in a lower motor neurone deficit.
• A variable degree of paralysis usually affecting a group of muscles of one limb within 2‐3 days. Some affected motor neurons recover with recovery of weakness however residual paralysis can occur.

Question 9

What does the term limb malformations encompass?

Answer 9

• Extra bones,
• Absent bones,
• Short (hypoplastic) bones
• Fusions of bones and/or skin and soft tissues.

Question 10

What is syndactyly ?

Answer 10

Congenital malformation of the limbs where two digits (fingers or toes) are fused due to failure of separation of the skin/soft tissues or phalanges of adjacent digits either partially or along the entire length of the digits

Question 11

What is polydactyly ?

Answer 11

An extra digit is formed and can be treated by amputating the extra digit

Question 12

What is fibular hemimelia ?

Answer 12

Partial or complete absence of the fibula leading to a shortened limb, bowing of the tibia and ankle deformity

Question 13

What is the most common congenital fusion (e.g. bones fusing together)

Answer 13

Tarsal coalition where the two tarsal bones of the foot fuse together which can cause painful flat feet

Question 14

What is Obstetric Brachial Plexus Palsy and who does it often occur in?

Answer 14

Injury to the brachial plexus during vaginal delivery

Most commonly in:

• Large babies
• twin deliveries
• Shoulder dystocia (difficult delivery of the shoulder after the head with compression of the shoulder on the pubic symphysis).

Question 15

What are the two main types of obstetric brachial plexus palsy ?

Answer 15

Erbs palsy (most common one) and Klumpke’s palsy

Question 16

Damage to what part of the brachial plexus results in erbs palsy ?

Answer 16

C5&6

Question 17

Describe the typical presentation and sign of erbs palsy

Answer 17

There is loss of motor innervation of the deltoid, supraspinatus, infraspinatus, biceps and brachilais muscles.

This causes internal rotation of the humerus causing the classic waiters tip posture (shown in pic)

Question 18

What is the treatment of erbs palsy ?

Answer 18

Physio

Question 19

Injury to what part of the brachial plexus results in klumpkes palsy ?

Answer 19

C8& T1 roots

Question 20

Describe the typical presentation of Klumpke’s palsy and the associated muscles affected causing this presentation

Answer 20

• It is caused by forceful adduction causing paralysis to the intrinsic muscles of the hand +/‐ finger and wrist flexors
• The fingers are typically flexed

Question 21

What condition is horners syndrome associated with ?

Answer 21

Horners syndrome - characterized by a constricted pupil (miosis), drooping of the upper eyelid (ptosis), absence of sweating of the face (anhidrosis), and sinking of the eyeball into the bony cavity

Question 22

Describe normal lower limb development (in terms of aligment)

Answer 22

• At birth kids usually have have varus knees (bow legs)
• Progressing to 10-15 degress of valgus (knock knees) at age 3
• Gradually regress to the physiologic valgus of 6° by around the age of 7‐9

Question 23

What is pathological valgus or varus ?

Answer 23

Where alignment is considered outside the normal range (+/‐ 6° from mean value for age).

Question 24

Describe the appearance of valgus and varus aligment

Answer 24

A varus deformity will result in a larger gap between the knees

Valgus deformity at the knee will result in a more of a knock knee appearance with a larger gap than normal between the feet/ankles