1. Common Orthopaedic Conditions Associated with Complex Neurodisability Lindsey Hopkinson and Victoria Healey Heads of Paediatric Physiotherapy Physiocomestoyou Ltd www.physio4thekids.com

2. Contents Complex Neurodisability At risk of developing: Hip displacement Scoliosis (spinal curve) Lower limb contractures -Hamstring Muscles -Adductors Muscles -Hip flexor Muscles -Calf muscle

3. Complex Neurodisability Cerebral Palsy Neuromuscular Disease Stroke Acquired Head Injury Brain Tumour Metabolic Diseases Genetic Syndromes

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Lower Limb Contractures - Hamstrings Hamstrings: -3 muscles are on located at the back of the thigh.

12. Signs of shortening How 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

13. 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

14. 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

15. 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

16. 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 (< 10 ⁰ ) Tight hamstring – popliteal angle < 50 ⁰ degrees

17. When we refer to Orthopaedic Consultants Non walking children: Reduced hip abduction <40 ⁰ Pain Hamstring tightness 60 ⁰ < Unable to extend hips – hip flexion contracture < 20 ⁰ Unable to straighten knees <20 ⁰ If toes pointing down more than 20 ⁰ In line with hip surveillance ANY at risk patients re spine / sign of scoliosis EVEN if flexible

18. 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.

19. QUESTIONS

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