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How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014

How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014. Is he happy? Is he in pain? Am I doing everything he needs? Am I doing everything right? What if I do more? More of what? What does the future hold?. Therapy PT OT Speech Developmental

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How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014

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  1. How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014

  2. Is he happy? • Is he in pain? • Am I doing everything he needs? • Am I doing everything right? • What if I do more? • More of what? • What does the future hold? • Therapy • PT • OT • Speech • Developmental • Social work • Orthotics? • Pediatrics • Neurology • ENT • MRI ? • Genetics • Medical Diagnostics

  3. Musculoskeletal Involvement • Hypotonia- Low muscle tone • Contractures • Hip subluxation/ dislocation • Scoliosis • Polydactyly, Syndactyly

  4. Function, Function, Function … “for those who have nothing, a little is a lot”… JacquelinPerry,MD • Priorities • Communication • Activities of daily living- ADLs • Perineal care, feeding, bathing etc. • Mobility • Sitting/ Seating • Walking • Pain free

  5. Hypotonia • 92% CHOP cohort • Role of Physical Therapy • Disuse- more is better • Developmental vs age appropriate • Function • Role of Bracing • Temporary support • Prevention of contractures?

  6. Contractures • Nonambulatory children with neuromuscular involvement are prone to develop flexion contracture of the hips and knees. Equinus contracture of the ankle can occur. • Physical therapy for gentle range of motion of the joints should be instituted. • The role of surgical release of contractures is controversial as function may not be improved and recurrence is commonplace.

  7. Hip Subluxation/ Dislocation • Common in nonambulatory patients • Proximal muscle weakness predisposes to structural abnormalities which leads to uncoverage of hips.

  8. Hip Subluxation/ Dislocation • Unilateral dislocation can lead to pelvic obliquity and uneven seating pressure. • Bilateral dislocation can accentuate lumbar lordosis. • Management is controversial as pain is inconsistent and treatment is difficult.

  9. Scoliosis • More common in nonambulatory patients • Discovered at an earlier age and progresses more rapidly in nonambulatory patients. • Nonoperative treatment- Bracing • May make sitting easier but usually ineffective in preventing curve progression or altering need for surgery. • A rigid orthosis can further tax a compromised respiratory status • Role of soft TLSO may be tolerated in young children with flexible curves between 20-40 degrees to allow more time prior to surgery.

  10. Scoliosis • Surgical Treatment- spinal fusion • Goal is to balance trunk over level pelvis to facilitate seating.

  11. Scoliosis • Indications are progressive deformity with curve magnitude greater than 50-70 degrees • Preoperative traction? for low vital capacity • Posterior spinal fusion for patients who can tolerate surgery • Fusion should include entire thoracic and lumbar spine and extend to the pelvis.

  12. Polydactyly/ Syndactyly • Extra or webbed digits • Extra toes are usually not a functional concern and are only removed for shoe wear difficulties or cosmetic concerns. • Much more aggressive with extra or webbed fingers if function is altered/ decreased

  13. Thank You

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