1. Manchester Hip Surveillance Pathway for Children with Cerebral Palsy 13 th June 2011 Greater Manchester Cerebral Palsy Network Meeting Dr Wendy Rankin, Consultant Paediatrician

2. Hip displacement (MP >30%) by GMFCS level Soo et al 2006

5. 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.

7. 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.

8. 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

10. Manchester Hip Surveillance Pathway for Children with Cerebral Palsy StandardWhoDate Child diagnosedPaediatrician ordate of diagnosis with CP and notifiedPhysiotherapist to pathway co-ordinator ClassificationPaediatrician withdate completed completed (Appendix 1);Physiotherapist copy to co-ordinator, main record and physiotherapy record Examination of hips at eachPaediatrician or(table) assessment; hip x-ray ifPhysiotherapist Cause for concern (Appendix 2)

11. Manchester Hip Surveillance Pathway for Children with Cerebral Palsy StandardWho Date Routine hip x-rayPaediatrician or(table) according to severityPhysiotherapist level (appendix 3) and X-ray protocol (appendix 4) MP > or = 30 degreesPaediatrician(table) refer to orthopaedic surgeon

12. Manchester Hip Surveillance Pathway for Children with Cerebral Palsy StandardWhoDate 24 hour posturalPhysiotherapist management to be implemented within 3 months of referral – (i) Sleep support for GMFCSDate provided Level III – V (can be used from birth) (ii) Home seat for GMFCSDate provided Level III – V (can be used from age 3 months) (iii) Standing frame for all bilateralDate provided CP (can be used from age 12 months)

13. Manchester Hip Surveillance Pathway for Children with Cerebral Palsy DateWhat (examination, hip x-ray etc) Result

14. Appendix 1 – CP classification CP Classification form Name of child DobM/FNHS 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 completedby 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

15. 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

16. Appendix 3 –routine hip x-rays UnilateralBilateral Others Severe*IV + VIIII + II X age 30/12age 18/12age 30/12 X Xannual 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

17. Appendix 4 – x-ray protocol correct positioning

18. Appendix 4 – x-ray protocol migration percentage Migration percentage = (AC x 100)/AB