What orthopedic conditions can be seen in newborn physical exam (buzz words that should raise suspicions)
- skin - cafe au lait - neurofibromatosis, fibrous dysplasia
- hypomelanotic macules(ash leaf)- tuberous sclerosis - neck ROM - Klippel-Feil
- congenital muscular torticolis SCM tight - clavicle - fractures - brachial plexus ijuries
- congenital pseudoarthrosis - multiple joint stiffness - arthrogryposis
- Hips - DDH (Ortalani, Barlow & Galeazzi test)
- Back & gluteal cleft - hairy patches, dimples, midline defects
- Foot - hind/forefoot longitudinal arch absent = normal
- Primative reflexes (another card)
What physical exam tests or findings can help differentiate between septic arthritis, clavicle fracture and brachial plexus injury? (2)
- gentle shake arm ( pain = fracture or infection)
2. Moro reflex - present = infection or fraccture
What is the one useful clinical or laboratory finding in ruling out infection in the newborn.
CRP has negative predictive value of 95%
positive predictive value of 60% (suggestive not diagnostic)
Fever unreliable - 15-25% infections are hypothermic
ESR - unrealiable
WBC - unreliable
leukopenia < 5,000 cells/ml more suggestive of infection.
what do you do with newborn(0-3mo) long bone fractures?
Femur fracture - Pavlik harness
humerus - pin sleeve to shirt in sling position
- stockinette sling described but be careful putting anything around their necks ( i wouldn’t)
immobilize only 7-10 days
femur - think abuse if not present at birth
multiple fractures think: OI , neonatal rickets
The principal components of a successful SEMLS program are (9)
- Planning based on the diagnostic matrix, including gait analysis.
- Preparation and education of the child and family
- Optimal perioperative care, including epidural analgesia
- Carefully planned and supervised rehabilitation
- Appropriate orthotic prescription
- Close monitoring of functional recovery
- F/U gait analysis at 12 to 24 mo after the index surgery
- Removal of fixation plates and other implants
- Follow-up until skeletal maturity, for new or recurrent deformities
What is the “Birthday Syndrome” in Spastic dysplasia children. (hint approach described by Mercer Rang)
Children spent most of their birthdays in hospital, in casts, or in rehabilitation.
Multiple Surgeries adressing the Natrual history of GMFCS level II children.
- Start with TALs for equinus gait = foot-flat but at the expense of rapidly increasing hip and knee flexion
- Lengthen hamstrings improve knee extension = resulted in increased hip flexion and anterior pelvic tilt
- Hip flexors were lengthened
- Finally, transfer of the rectus femoris was considered for knee stiffness. This approach was caricatured by Mercer Rang as the “Birthday Syndrome”
What is a green transfer (used in UE in CP)
Children with functional hand & constant flexed wrist posturing, secondary to out-of-phase FCU
(FCU) strongest wrist flexor & ulnar deviator
transferred around subcutaneous border of the ulna to extensor carpi radialis brevis (ECRB)
WE strengthened & ulnar deviation corrected
Also strengthens supination.
Alternatively transfer to extensor digitorum communis (EDC).
What is the typical upper limb deformities in CP (5)
- adduction and internal rotation of the shoulder
- pronation of the forearm
- wrist flexion and ulnar deviation
- finger flexion
- thumb in palm
What is SEMLS?
Single Event Multilevel Surgery
Current approach to surgery in spastic dysplasia.
Includes casting, botox (for pain),Epidural and local anesthesia, detailed pain management, nutrition & bowel care.
Avoids birthday syndrome
Principles of management of upper extremities in CP
- Elbow DFC - Z lengthening biceps tendon & fractional lengthening of the brachialis
- Forearm pronation
Fibrotic PT released or rerouted to be a supinator
or Green transfer FCU - ECRB
(FCU becomes secondary supinator) - Wrist - 2 most useful procedures wrist flexion deformities:
a. Green transfer (FCU-ECRB or EDC)
b. arthrodesis - Fingers & Thumb (3 main options)
Mild - Botox with casting
Moderate - lengthening at MTJ of FDS&FDP & BoNT-A splinting
Severe - gets complicated fast and poor functional outcomes - FDS to FDP - thumb-in-palm (complex) opponensplasty FDS ring or middle fingers can provide functional correction of a thumb-in-palm deformity.
What creates the Thumb-In-Palm deformity
deformity is variable (includes the following)
- Adduction of the first metacarpal
- Flexion at MCP joint
- Either flexion or extension at the IP joint
What are the differences between spastic equinovarus in diaplegia vs hemiplegia (3 main concepts)
more common in hemiplegia»_space; diplegia
Hemiplegia Varus: more severe/stiff/may be progressive
Diplegia Varus: milder/flexible/pron to over correction valgus
Varus in diplegia may be more apparent than real b/c
- excessive FNA (aneteversion) and “rollover varus.”
diplegia, overcorrection to valgus is common
hemiplegia, relapse to recurrent equinovarus is common
