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.

QUESTIONS

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