Common Orthopaedic Conditions Associated with Complex Neurodisability Lindsey Hopkinson and Victoria Healey Heads of Paediatric Physiotherapy Physiocomestoyou Ltd www.physio4thekids.com
Dec 16, 2015
Common Orthopaedic Conditions Associated with
Complex NeurodisabilityLindsey 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 ConditionsGrowth 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 shortening including:
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 downwardsImage 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.