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Common Orthopaedic Conditions Associated with Complex Neurodisability. Lindsey Hopkinson and Victoria Healey Heads of Paediatric Physiotherapy Physiocomestoyou Ltd. www.physio4thekids.com. Contents. Complex Neurodisability At risk of developing: Hip displacement
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Common Orthopaedic Conditions Associated with Complex Neurodisability Lindsey Hopkinson and Victoria Healey Heads of Paediatric Physiotherapy Physiocomestoyou Ltd www.physio4thekids.com
Contents • Complex Neurodisability At risk of developing: • Hip displacement • Scoliosis (spinal curve) • Lower limb contractures • Hamstring Muscles • Adductors Muscles • Hip flexor Muscles • Calf muscle
Complex Neurodisability • Cerebral Palsy • Neuromuscular Disease • Stroke • Acquired Head Injury • Brain Tumour • Metabolic Diseases • Genetic Syndromes
Neurodisability and Orthopaedic Conditions • Growth of the musculoskeletal system • Weight • Muscle strength • Altered tone • Active volitional movement / wheelchair bound Image from www.rch.org.au
Hip Development • The hip joint can be described as a ball and a socket • The ball is the head of the thigh bone and sits in the socket of the pelvis • At birth the socket is shallow and the head of the thigh bone is not placed deep within the socket • Normal motor development causes changes within the hip joint resulting in a mature adult stable hip joint over time • Children with neurodisability can have hip joint problems resulting in hip displacement
Hip Displacement • Displacement is when part of the ball is uncovered by the socket (migration percentage) • Reasons : • Decreased weight-bearing forces altering the remodeling of the femur with growth • Reduced ambulation / ability to walk (motor function) • Muscle weakness • Abnormal tone in the muscles around the hip Image from www.hipchicksunite.com
How to monitor your child’s hips as they Grow • Hip Surveillance (Active screening programme) DISCUSS with your PHYSIOTHERAPIST • X-ray from 30 months unless clinical indication for x-ray prior to this for all children with a neurological disability
Possible indications for parents / carers of hip displacement Pain on movement (rotation / abduction) Leg length Tightness within thigh muscles Change in sitting posture Pain / change in walking pattern of ambulant children Windswept posture Image from www.besbiz.eu.com
Scoliosis / spinal curve • Your child’s therapist should monitor your child’s spine as they grow • Muscle weakness / abnormal muscle tone increases the risk of scoliosis • Differing diagnosis will affect the risk of scoliosis for your child • Growth results in progression of pre existing spinal curves • Mobility
How to monitor your child’s spine • Lead healthcare professional to monitor EARLY as your child grows with Clinical examination • X-ray – Orthopaedic Consultant SPINAL • Observations • Skin Creases • Rib hump back and front • Pelvis alignment in sitting / posture in sitting LEANING OVER • Pain • Loss of sitting balance
Lower Limb Contractures - Hamstrings Hamstrings: • 3 muscles are on located at the back of the thigh.
Signs of shorteningHow to monitor for shortening: Ambulant • Crouch gait • Unable to straighten knees • Growth spurts • Feel Non ambulant • Tilting pelvis backwards in wheelchair • Unable to sit with pelvis neutral and legs bent at 90 degrees so feet on foot plates • Feel ** Physiotherapist clinical examination and observation of gait / sitting posture
Lower Limb Contractures – Hip Flexors Hip Flexors (non ambulant children most at risk) Muscles located at the front of the hip Signs of shortening include: • Raised buttocks when lay on tummy • Unable to lie on their back with leg straight • Crouch / anterior tilted pelvis Image from www.edoszkop.com
ADDUCTOR MUSCLES Muscles located between your child’s inner thigh Signs of shorteningincluding: • Scissoring • Difficulty with dressing and hygiene • Sitting posture • Windswept posture Image from www.wikipedia.org
CALF MUSCLES Soleus and gastrocnemius muscles – back of lower leg How to monitor for shortening: • Difficulty tolerating Splints Ambulant: • Walking on toes • Heels flat but feet rolling inwards Non ambulant: • Feet pointing downwards Image from www.oandp.com
When we refer to Orthopaedic Consultants Walking Children: • Unable to straighten knee(s) • Unable to bring ankle to neutral • Asymmetric abduction of hip • Foot deformities (foot turning in or out - varus / valgus) • Unable to straighten hip fully to neutral (< 10⁰) • Tight hamstring – popliteal angle < 50⁰ degrees
When we refer to Orthopaedic Consultants Non walking children: • Reduced hip abduction <40⁰ • Pain • Hamstring tightness 60⁰ < • Unable to extend hips – hip flexion contracture < 20⁰ • Unable to straighten knees <20⁰ • If toes pointing down more than 20⁰ • In line with hip surveillance • ANY at risk patients re spine / sign of scoliosis EVEN if flexible
Conclusion • Ensure as a parent you have discussed orthopaedic monitoring with a member of your healthcare team and discussed hip and spine surveillance to ensure timely and optimal referral to the correct team.