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Manchester Hip Surveillance Pathway for Children with Cerebral Palsy. 13 th June 2011 Greater Manchester Cerebral Palsy Network Meeting Dr Wendy Rankin, Consultant Paediatrician. Hip displacement (MP >30%) by GMFCS level Soo et al 2006. Does hip surveillance work?.
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Manchester Hip Surveillance Pathway for Children with Cerebral Palsy 13th June 2011 Greater Manchester Cerebral Palsy Network Meeting Dr Wendy Rankin, Consultant Paediatrician
Does hip surveillance work? Haggalund [2005] showed results of first 10 years of a hip surveillance programme with early intervention surgery. From 1992, only 2 children had dislocated hips out of 251 children with CP.. This compared to 8 in previous control group of 103 children Dobson et al [ 2002] reported on first 3 years of Orthopaedic clinic based on early detection and surgery [total 133 children] They showed elimination of hip dislocation and salvage surgery, at expense of rise in preventive surgery.
Liverpool - Current recommendations for hip screening Should start at 18 months [Dobson,2002, Hagglund,2005, Thomason,2002 ] Should be repeated every 6 months in severely affected children and yearly in others children [Dobson,2002, Haggalund, 2005] How can this be rationalised ? All children age 18 months with bilateral spastic CP with high tone who are estimated to be in GMFCS 1V or V should have a hip radiograph in the standard position to measure migration percentage. [These children will have poor trunk and head control at this age]. This should be repeated 6 monthly. Others in GMFCS 111 with these features should have a hip radiograph at 30 months and then at yearly intervals until 8 years of age.
Hip Surveillance Clinical Indicators: • All children with Cerebral Palsy* to have a standardised clinical hip assessment at every examination following diagnosis. Results to be recorded in patient’s notes. • A hip x-ray is required for: • Children with CP* not walking independently by 30 months of age or not able to sit without support at 18 months. • Children with CP* under 30 months of age presenting with: • Significant tonal abnormality • Reduction of abduction range < 30 degrees • Asymmetry of range of movement especially abduction • Leg length discrepancy/ scoliosis • Asymmetrical posterior skin crease • Hip pain/ persistent disturbed sleep • Parents report problem with cares • DDH • Children with CP* over 30 months showing clinical signs as above and not having had a hip x-ray previously, or last x- ray older than 6 months
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy Standard Who Date Child diagnosed Paediatrician or date of diagnosis with CP and notified Physiotherapist to pathway co-ordinator Classification Paediatrician with date completed completed (Appendix 1); Physiotherapist copy to co-ordinator, main record and physiotherapy record Examination of hips at each Paediatrician or (table) assessment; hip x-ray if Physiotherapist Cause for concern (Appendix 2)
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy Standard Who Date Routine hip x-ray Paediatrician or (table) according to severity Physiotherapist level (appendix 3) and X-ray protocol (appendix 4) MP > or = 30 degrees Paediatrician (table) refer to orthopaedic surgeon
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy Standard Who Date 24 hour postural Physiotherapist management to be implemented within 3 months of referral – (i) Sleep support for GMFCS Date provided Level III – V (can be used from birth) (ii) Home seat for GMFCS Date provided Level III – V (can be used from age 3 months) (iii) Standing frame for all bilateral Date provided CP (can be used from age 12 months)
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy
Appendix 1 – CP classification • CP Classification form • Name of child Dob M/F NHS No • Classification of cerebral palsy • CP sub-type (see classification tree from SCPE) • Function • Motor GMFCS • MACs • Cognitive • Vision • Hearing • Epilepsy • Neuroimaging • Cause / timing • Classification under previous terminology • Date completed by • References • 1. Revised classification. Dev Med Child Neurol 49 (2007) Supplement109 • 2. Surveillance of Cerebral Palsy in Europe (SCPE). Dev Med Child Neurol 42 (2000) 816-824
Appendix 2 – cause for concern suggesting need for hip x-ray • Significant tonal abnormality • Reduction of abduction range < 30 degrees • Asymmetry of range of movement especially abduction • Leg length discrepancy/ scoliosis • Asymmetrical posterior skin crease • Hip pain/ persistent disturbed sleep • Parents report problem with cares • DDH
Appendix 3 –routine hip x-rays Unilateral Bilateral Others Severe* IV + V III I + II X age 30/12 age 18/12 age 30/12 X X annual hip x-ray until skeletal maturity X • extensive plantar flexion of the ankle with limited ROM at the knee and hip during swing and stance phase • X = only x-ray if cause for concern
Appendix 4 – x-ray protocolmigration percentage Migration percentage = (AC x 100)/AB