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Children’s Orthopaedics

Children’s Orthopaedics. Dr Rob Alcock, Consultant Anaesthetist Mr Nigel Kiely, Consultant Orthopaedic Surgeon Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry. Children’s Orthopaedics (The Long and Short of it). Outline. Children’s Orthopaedics Gentle Musings Case Presentations.

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Children’s Orthopaedics

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  1. Children’s Orthopaedics • Dr Rob Alcock, Consultant Anaesthetist • Mr Nigel Kiely, Consultant Orthopaedic Surgeon • Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry

  2. Children’s Orthopaedics(The Long and Short of it)

  3. Outline • Children’s Orthopaedics • Gentle Musings • Case Presentations

  4. Robert Jones & Agnes Hunt Orthopaedic Hospital

  5. Children’s Orthopaedics • Wide range of conditions • Multidisciplinary care • Generally well children • Associated conditions • Syndromes • Dysplasias • Neurological • Metabolic

  6. Children’s Orthopaedics • Hub and spoke care model • Dedicated ward staff • Consultant level of care • Paediatricians

  7. Gentle Musings • Getting the Ward on your Side • Singing from the Same Hymn Sheet • Painful But Not Ill • Blocks work Really Well

  8. Case Presentations

  9. DDH • 2 yr old child, limping • Fit and well, normal milestones • 12kg • Surgery • Anterior open reduction • Femoral & pelvic osteotomy • Spica

  10. DDH • 3 1/2 hour operation • 250mls blood loss • Drip out 48 hrs post op • Vomited, settled with oral fluids • Home day 4 post op

  11. DDH • Well Child • Prolonged Surgery • Blood loss • Caudal or Epidural? • Spica

  12. JRH Table

  13. DDH • Well Child • Prolonged Surgery • Blood loss • Caudal or Epidural? • Spica • Pain not usually a problem

  14. RECIPE ALERT!

  15. Caudal • 1ml/kg 0.2 % Bupivicaine + Ketamine 0.5mg/kg • OR • 8ml 0.25% Bupivicaine + 2ml Saline + Preservative Free Ketamine 5mg

  16. Cerebral Palsy (CP) • Variety of Causes • Non progressive neurological lesion, immature brain • prematurity • 70 % Spastic • 30% Dyskinetic, Ataxic or Mixed

  17. CP non walker • 5 yr old girl • CP spastic diplegia • standing frame, non- walker • Intellectually good, talker • Epilepsy, increasing in frequency, Valproate • Pre-op optimisation of medical conditions • Subluxed right hip • Previous soft tissue surgery

  18. CP Non Walker • Surgery delayed due to increasing fits • Stabilised • Had a fit night before surgery! • Surgery- bilat femoral osteotomies and pelvic osteotomy • Spica • Blood loss 150mls • Post op- uneventful

  19. Anaesthetic Considerations • Epilepsy • Bulbar Involvement? • Spasm • Airway

  20. CP Walker • Spastic Diplegia • 11 years old • High intelligence • No medical problems • Staged Multiple level surgery • Bilat fem derotation • Foot stabilisation • Iliac crest bone graft

  21. CP Walker • Post op pain and spasm control • Long, multiple procedures • Early mobility

  22. Anaesthetic Considerations • Understanding and Affect • Multilevel / staged • Older child

  23. RECIPE ALERT!

  24. Epidural Infusions • 0.125% Bupivicaine • 0.1 – 0.4 ml/kg/hour • Typically 0.2 ml/kg/hour

  25. Spina bifida • 12 yrs old • Ambulant, mixed level • Bladder and bowel control • Lower limb deformity • Partially sensate legs • Iliac crest graft • foot surgery, • Tibial osteotomy • Tendon transfer

  26. Spina bifida • Multiple Procedures • VP shunts • Pain control • Latex Allergy • Bladder- mitroffanof • Bowel- ACE • Pressure areas • infection

  27. Femoral fracture • 7 yr old boy • Isolated injury • Put on Thomas splint in local hospital • Admitted for flexible nailing • Traction table • Distal femoral incisions • Early mobility

  28. Femoral fracture • Caudal • NCA / Oral Analgesia

  29. Clubfoot • Ponseti treatment • Hub and spoke model of care • 6 week old child • Minimum weight 4kg • Percutaneous tenotomy and plaster • Can be done under LA?

  30. Clubfoot • Small Infants • Well • Small procedure • Simple Analgesia

  31. Foot deformity and frame • Fixed foot deformity • Frame and osteotomy • gradual distraction of deformity • Frame on for several months

  32. Foot frame • Pain • Compartment syndrome • Dressing changes • Psychology • compliance

  33. SUFE • 12 yr old • Obese child • Fit and well • Pain and limping • Treatment- bilateral pinning in situ • Percutaneous • Traction table

  34. SUFE • Co-morbidites – uncommon • Post op- pain usually resolves quickly • Early mobility

  35. Thank you for your attention! • Final tip- always open cefuroxime boxes from the bottom! • Avoids the annoying patient information leaflet.

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