EXAM 3 lecture 9: pediatric neurology and limb deficiency

Question 1

congenital limb deficiency types

Answer 1

transverse deficiency
longitudinal deficiency

Question 2

Which type of limb deficiency is more common?

Answer 2

congenital 60%

Question 3

What is the most common traumatic etiology for age 1-4?

Answer 3

lawnmower and power tools

Question 4

what is the most common traumatic etiology for older child?

Answer 4

MVA, machinery,
GSW

Question 5

___ per 10,000 live births have limb deficiency

Answer 5

2-7

Question 6

*Limb buds appear at ____ of embryonic development
and by ____completed development

Answer 6

week 4
week 7

Teratogenic factors or disruption of blood Flow

Question 7

UE Prosthesis is not necessary for transfers, crawling, sitting: T or F

Answer 7

True

can even ride bike with one hand and nubbins=crucial for sensory input

Question 8

acquired amputations:
often with what other syndromes?

Answer 8

VACTERL, TAR
*need medical check ins regularly

Question 9

How is it different from adults with acquired amputation?

Answer 9

1. other syndromes
2. skeletally immature
3. development is in process
4. congenital anatomical differences
5. psychological development (x-fix is painful –> limb salvage procedure)

Question 10

what are psychological developmental concerns for children with acquired amputations?

Question 11

What are concerns for multiple limb deficiencies in terms of wearing limb prosthesis?

Answer 11

hot
can’t disperse heat well

Question 12

Type A PFFD

Answer 12

femur is short
A: acetabulum present, femoral head present, shortened femoral
segment

Question 13

Type B PFFD

Answer 13

femur more short,
acetabulum dysplastic

B: well defined acetabulum, unossified femoral head at birth

Question 14

C

Answer 14

almost no femoral head

Question 15

Type D PFFD

Answer 15

no true acetabulum, no femoral head

Question 16

clinical findings of PFFD

Answer 16

Hip instability
◦ Malrotation (femur ER)
◦ Insufficient proximal musculature (glutes, quads, hip flexors, abductors)
◦ Short lever arm
◦ Limb length discrepancy
◦ Limb usually positioned in flexion, abduction and external
rotation
◦ 70-80% also have deficiency of the fibula = knee instability

Question 17

Most Common Gait Deviations: PFFD

Answer 17

Posterior and Lateral trunk lean during stance phase due to
poor strength of abductors and extensors

Question 18

limb deficiencies in the tibia

Answer 18

Complete or partial absence of the Tibia

clinical findings:
-abnormal articulation of knee and nakle
equinovarus foot deformity
LLD

Question 19

classifications of tibial limb deficiencies

Answer 19

◦ Type I: complete absence of tibia; no extensor mechanism
◦ Type II: Proximal tibia well formed, have quadriceps
◦ Type III: Presence of distal tibia only

Question 20

anterior bowing: what would it look like?

Answer 20

anterior bowing looks like a dimple on tibia

Question 21

Tibial Hemimelia or Amelia

Answer 21

◦If tibia is absent -> Knee Disarticulation

Question 22

how can you tell if fibula or tibia is missing?

Answer 22

Are they missing lateral toes or medial toes?
lateral - fibula

Question 23

clinical presentation of fibular hemimelia

Answer 23

May be missing lateral toes
◦ Anterior medial bowing common with dimple
◦ May have shortening of femur as well
◦ ACL deficiency or absence
◦ Varus or Valgus deformity as grow
◦ Missing lateral 2 or 3 rays

Question 24

clinical presentation of tibial hemimelia or amelia

Answer 24

• Often ACL deficient
• Anterior bowing
• Varus/Valgus deformity requiring
  growth manipulation
• Crucial to check for sufficient
  quadriceps to drive amputation
  level
• Revisions needed during growth
• Missing 1st or 2nd rays

Question 25

What are conservative interventions for limb deficiencies? Surgical?

Answer 25

Surgical: Boyd or Symes for fibular hemimelia conservative: Shoe lifts or accomodative prosthosis

Question 26

considerations for prosthesis

Answer 26

belt? how to remove it? can they put it on or put clothes on over it? how old are they? locked vs unlocked potty training? * Can they follow commands?

Question 27

Boyd or Symes for below the knee amputations

Answer 27

Take ankle off, put heel pad of calcaneus there so they can walk on it heel pad protects you from having to do multiple amputations

Question 28

At what age to you provide a prosthesis for congenital deficiency?

Answer 28

Once pulling to stand

Question 29

What should your evaluation include

Answer 29

*Double limb support (scales) *Balance *Range of motion *Strength with and without prosthesis *Sensation *Skin: scars, calluses *AmpPRO or AmpNoPRO (similar to berg, not in pediatric literature but best thing to use)

Question 30

What are general goals of PT for this population?

Answer 30

1.Full range of motion & good strength 2. Tolerance to prosthetic wear and weight bearing 3. Control of dynamic weight shifting in all planes of movement 4. Reintegrate postural control, body awareness and balance 5. Facilitate as normal a sequence of development as possible

Question 31

stump wrap vs shrinker

Answer 31

stump wrap: can take off and clean, low cost, can adjust pressure (figure 8) shrinker: pantyhose, tight, will shape limb

Question 32

what happens if stump wrapping/shrinking does not occur well

Answer 32

child will grow out of first socket in first 3-6 months and insurance will not pay for new prosthesis *If not performed, patient’s residual limb will shrink once ambulation initiated and they will outgrow the socket quickly

Question 33

methods for desensitization for children with limb deficiencies

Answer 33

Massage – soft and deep pressure all around and incision ◦ Temperatures – warm and cold water or popsicle ◦ Textures – shaving cream, toothbrush, wash cloth etc.

Question 34

Why is stretching important?

Answer 34

high risk for scarring, contractures, difficulty with ROM that impacts gait deviations

Question 35

AKA: at risk for ___ contractures

Answer 35

At risk for hip flexion, external rotation and abduction contracture | encourage sleeping prone

Question 36

BKA: at risk for ___ contractures

Answer 36

At risk for knee flexion contracture, hip flexion contracture ** Avoid sitting in wheelchair with knee always flexed * Avoid placing pillow under knee

Question 37

pre-gait training: weight shifting

Answer 37

shift forward, backwards, side to side, in circle Tip: For smaller kids have targets of where to move hips such as hoola hoop or parallel bars | they should be able to do this with noraml BOS and no UE support

Question 38

pre-gait training: WS and control exercises

Answer 38

targeted step ups ball under foot to draw picture/name *proprioception, balance, control, SLS, graded mvmt

Question 39

after they are good at: WS control now they start

Answer 39

practice stepping *step, reach up for elongation of WB side if you see trunk collapse with weight acceptance * All directions * Mass practice * Targets

Question 40

Gait training involves what components

Answer 40

1. reciprocal stepping pattern 2. maintain blaance during propulsive movement 3. able to respond to demands of environment

Question 41

history and subjective for general neurological exam?

Answer 41

◦ Birth and developmental history ◦ Any pre-morbid developmental delay? ◦ School/Day Care (what are they returning to?) ◦ What are the patient’s goals? ◦ Families goals and expectations? ◦ What does behavior management at home look like

Question 42

traumatic TBI etiology of infants

Answer 42

falls 78% near drowning in bathtubs (usually global ischemia) abuse

Question 43

traumatic TBI etiology in preschool

Answer 43

falls MVA

Question 44

5-9 year old traumatic TBI etiology

Answer 44

falls MVA sports/rec

Question 45

10+ traumatic TBI etiology

Answer 45

sports/rec | boys 2x as likely as girls to suffer a TBI

Question 46

What are kids under 3 yrs old often diagnosed with when they have a brain injury?

Answer 46

CP *more benefits *Stroke *AVM rupture *Seizure Disorders *Cancer/Tumor *Posterior Fossa Syndrome *Infection *Hypoxic Event

Question 47

__% of children with TBI have long term disability __% have severe deficits ____ % have disabiltiy

Answer 47

75-80% of children with TBI have long term disability 40% have severe deficits 15 % have disabiltiy

Question 48

concussions in children with TBI *% recovered in less than 24 hours *% within 1-7 days *% within 1-4 weeks *% in greater than 1 month

Answer 48

*20% recovered in less than 24 hours *64% within 1-7 days *11% within 1-4 weeks *2% in greater than 1 month

Question 49

secondary impairments of TBI: --% of children who sustain TBI will sustain HO

Answer 49

5-20%

Question 50

NRS: NEUROmuscular recovery scale

Answer 50

good for looking at quality of movement developed for SCI peds older than 12 years and adults

Question 51

Rancho 1-3 interventions

Answer 51

maintain ROM skin integriy positioning, splints provide sensory stimuli (auditory, visual, tactile, olfactory, vestib, kinesthetics) FAMILY EDUCATION BASED ON RANCHO LEVEL

Question 52

How to break up tone

Answer 52

both legs up is easier If extensor tone, WB into arms and support hips to get into crawling

Question 53

Rancho 4-6 interventions

Answer 53

◦ Provide structure & prevent overstimulation ◦ Engage in task specific training that is familiar ◦ Emphasize safety ◦ Relaxation techniques ◦ Encourage mobility ◦ Work on attention to task

Question 54

How can you encourage a patient to do what you want when they are Rancho 4-6?

Answer 54

*placement of toy is KEY (set up of activity is way more important than verbal cues or manual facilitation)

Question 55

Rancho 7-9 interventions

Answer 55

◦ Allow for increased independence when safe ◦ Community re-integration ◦ Dual task activities, layering tasks ◦ What all are you asking them to focus on and complete? ◦ Altered surfaces ◦ High level balance *holding ball while jumping, return to sport, etc. | walk while talking, doing math, etc.

Question 56

congenital etiology of SCI

Answer 56

spina bifida

Question 57

traumatic etiology of SCI non-traumatic etiology of SCI

Answer 57

traumatic: MVA, sports, violence non-traumatic: oncology, congenital anomalies, infection

Question 58

What is SCIWORA?

Answer 58

(Spinal Cord Injury Without Radiological Abnormalities) *need to get

Question 59

why are 55% of child SCI cases that are traumatic cause tetraplegia and 45% paraplegia

Answer 59

more instability higher up due to being a child

Question 60

before age of 5 SCI: 100% likely to get

Answer 60

scoliosis *think about that for respiratory function and other stuff

Question 61

Once signs of autonomic dysreflexia occur: what to check

Answer 61

last time bowel mvmt? last time cathed? any kinks in cath? clothing?

Question 62

SCI pressure relief education: what is important and ways to help?

Answer 62

timers watch timers or cell phone *higher level SCI will need more consistent pressure relief bc nt moving around as much

Question 63

education for all SCI

Answer 63

*Autonomic Dysreflexia *Pressure relief *Hygiene *Bowel and Bladder schedule *Sensory impairments *Signs of infection or pain or medical issue: increased spasticity, fatigue, fever *Changes to temperature regulation *Provide education age-appropriate

Question 64

What are outcome measures for SCI assessment?

Answer 64

*ASIA *ROM & MMT *Spasticity *SCIM *SCI-FAI *NRS – pediatric and adult (>12 y/o)

Question 65

why would you start mobility training in sitting or sit to stand vs bed mobility?

Answer 65

more global mm activation, demanding more of their body *bed mobility also is a full body activity, rolling, friction of bed, kinda hard