Common Orthopaedic Conditions Associated with Complex

NeurodisabilityLindsey Hopkinson and Victoria Healey

Heads of Paediatric PhysiotherapyPhysiocomestoyou 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 NeurodisabilityCerebral PalsyNeuromuscular DiseaseStrokeAcquired Head InjuryBrain TumourMetabolic DiseasesGenetic Syndromes

Neurodisability and Orthopaedic ConditionsGrowth of the

musculoskeletal systemWeightMuscle strengthAltered toneActive 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 hipImage from www.hipchicksunite.com

How to monitor your child’s hips as they GrowHip 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

tummyUnable to lie on their back with leg

straightCrouch / 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 hygieneSitting postureWindswept 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 ConsultantsWalking 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

ConclusionEnsure 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.

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