Paediatric Orthopaedics - Complex Needs

Question 1

What is a child with complex needs defined as?

Answer 1

multiple and complex disabilities and has at least two different types of severe or profound impairment

complex exceptional needs include:

• learning and mental function
• communication
• motor skills
• self care
• hearing
• vision

Question 2

What does CP stand for?

Answer 2

Cerebral palsy

Question 3

What is cerebral palsy?

Answer 3

permanent and non-progressive motor disorder due to brain damage before birth or during first 2 years of life

Question 4

What is the incidence of CP?

Answer 4

• 2/1000 births

Question 5

What is the aetiology of CP?

Answer 5

• Prenatal
  
  • Placental insufficiency
  • Toxaemia
  • Smoking
  • Alcohol
  • Drugs
• Perinatal
  
  • Prematurity (most common)
  • Anoxic injuries
  • Infections
• Postnatal
  
  • Infection (CMV, rubella)
  • Head trauma

Question 6

What infections can cause CP?

Answer 6

CMV, rubella

Question 7

What are the different classifications of CP?

Answer 7

• physiological
• anatomical

Question 8

What are the different physiological classifications of CP?

Answer 8

• spastic (pyramidal system, motor cortex)
• athetoid (extrapyramidal system, basal ganglia)
• ataxia (cerebellum and brainstem)
• mixed (combination of spasticity and athetosis)

Question 9

What are the different anatomical classifications of CP?

Answer 9

• Monoplegia (one limb involved)
• Hemiplegia (one side of body)
• Diplopia (lower limbs)
• Quadriplegia (total body involvement)

Question 10

What is affected in spastic CP?

Answer 10

• Spastic (pyramidal system, motor cortex)

Question 11

What is affected in athetoid CP?

Answer 11

• Athetoid (extrapyramidal system, basal ganglia)

Question 12

What is affected in ataxia CP?

Answer 12

• Ataxia (cerebellum and brainstem)

Question 13

What is mixed CP?

Answer 13

• Mixed (combination of spasticity and athetosis)

Question 14

What physiological classification of CP is most common?

Answer 14

• Spastic (pyramidal system, motor cortex)
  
  • Most common

Question 15

What is CP that affects one limb called?

Answer 15

• Monoplegia (one limb involved)

Question 16

What is CP that affects one side of the body called?

Answer 16

• Hemiplegia (one side of body)

Question 17

What is CP that affects the lower limbs called?

Answer 17

Diplegia (lower limbs)

Question 18

What is CP that affects total body movement called?

Answer 18

• Quadriplegia (total body involvement)

Question 19

What is GMFCS?

Answer 19

GMFCS (gross motor function classification system)

Question 20

What is used to clinically classify CP?

Answer 20

GMFCS (gross motor function classification system)

Question 21

What are the 5 levels of GMFCS for CP?

Answer 21

• Level 1
  
  • Walks without limitations
• Level 2
  
  • Walks with limitations
• Level 3
  
  • Walks using hand held mobility device
• Level 4
  
  • Self-mobility with limitations
• Level 5
  
  • Transported in manual wheelchair

Question 22

What are clinical features of CP?

Answer 22

• Spasticity
• Lack of voluntary limb control
• Weakness
• Poor co-ordination
• Impaired senses

Question 23

Describe the progression of CP?

Answer 23

dynamic contractures

• increased muscle tone and hyper-reflexes
• no fixed deformity of joints
• deformity can be overcome

Progress to fixed muscle contractures

• persistent spasticity and contracture
• shortened muscle tendon units
• deformity cannot be overcome

Can progress to joint subluxation/dislocation

• secondary bone changes/joint degeneration

Question 24

What are the orthopaedic priorities for management of CP?

Answer 24

• maintain sitting balance
• maintain standing posture
• optimise gait if they can walk

Question 25

How can gait be analysed?

Answer 25

* Observation * Video * 3D instrumented analysis * EMG

Question 26

What is gait?

Answer 26

A persons manner of walking

Question 27

What are the different phases of gait?

Answer 27

* Stance phase * Swing phase

Question 28

Describe the gait cycle?

Answer 28

Question 29

What is a major complication of CP?

Answer 29

hip displacement and maybe dislocation

Question 30

What intervention can be done for children with CP at risk of dislocation?

Answer 30

non-surgical - posture management: physiotherapy, seating - spasticity management - deformity management surgery

Question 31

What medication can be used for spasticity management in CP?

Answer 31

generalised - baclofen oral - diazepam localised - botulinum toxin - baclofen intra-thecal pump

Question 32

What can be done for deformity management in CP?

Answer 32

- soft tissue release - bony realignment: varus derotation osteotomy, pelvic osteotomy

Question 33

What is the most common congenital deformity?

Answer 33

Congenital talipes equinovarus

Question 34

What is congenital talipes equinovarus also known as?

Answer 34

Club foot

Question 35

What is the aetiology of congenital talipes equinovarus?

Answer 35

- genetic - multifactorial: in most cases cannot specify why has occurred

Question 36

Describe the epidemiology of congenital talipes equinovarus in terms of incidence and sex?

Answer 36

* 2/1000 births * M:F 3:1

Question 37

How is congenital talipes equinovarus often diagnosed?

Answer 37

* Often prior to birth with prenatal US

Question 38

What are the 4 deformities that cause congenital talipes equinovarus?

Answer 38

- **C**avus - **A**dductus (midfoot) - **V**arus (hind foot) - **E**quinus (hindfoot)

Question 39

What is the treatment of congenital talipes equinovarus?

Answer 39

* Done in series of casts, from 1 to 5 in weekly intervals * Equinus can be corrected by percutaneous tenotomy of Achilles tendon

Question 40

Describe the normal curvature of the spine?

Answer 40

Spine normal curvature in sagittal plane: * Cervical lordosis * Thoracic kyphosis * Lumbar lordosis * Sacral kyphosis

Question 41

What is scoliosis?

Answer 41

Scoliosis = any deviation in coronal plain

Question 42

When does scoliosis have clinical significance?

Answer 42

when deviation is \>10^o

Question 43

What are the 2 kinds of scoliosis?

Answer 43

- non-structural: due to an extrinsic cause - structural: intrinsic spinal problem

Question 44

What is the aetiology of non-structural scoliosis?

Answer 44

due to extrinsic cause - leg length discrepancy - hip problem

Question 45

What is the treatment of non-structural scoliosis?

Answer 45

* Resolves when causal factor is addressed

Question 46

What is the aetiology of structural scoliosis?

Answer 46

* Abnormal rotation of vertebrae and is an intrinsic spinal problem

Question 47

What is the risk of progression of structural scoliosis proportional to?

Answer 47

- curve magnitude (Cobb angle) - age at presentation

Question 48

What are the 3 major classes of structural scoliosis?

Answer 48

- congenital: abnormalities of formation vertebrae - idiopathic - neuromuscular - others: post-traumatic, degenerative, infection...

Question 49

What position is best to examine structural scoliosis?

Answer 49

bent forwards into flexion

Question 50

What investigations are done for scoliosis?

Answer 50

* AP erect whole spine x-ray with or without lateral * MRI * Cord abnormalities * Vertebral abnormalities * Tumours

Question 51

Describe the prognosis of scoliosis?

Answer 51

* Outcomes less favourable with severe curves * Early diagnosis matters * Neuromuscular causes are at high risk of progression

Question 52

What is the mangement of scoliosis?

Answer 52

non-surgical: bracing (halts or minimises progression of curve) surgery: complex and extensive

Question 53

What are some possible complications of surgery for scoliosis?

Answer 53

- backache - nerve root damage - vascular or cord traction injury - degenerative changes later - problems of growth