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Orthopedic Manifestations of Cerebral Palsy

Orthopedic Manifestations of Cerebral Palsy

by | Jun 22, 2021 | Neurology

Content included below was presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Lane Wimberly, M.D.

Watch the full lecture or download this summary.

At Scottish Rite for Children, we have a multidisciplinary team dedicated to providing excellent care to children with cerebral palsy (CP) through an interdisciplinary approach with evaluation, treatment, and support of the families throughout their childhood. We provide services grounded in evidence-based interventions, employing standardized practices to best demonstrate treatment outcomes for orthopedic and neuro-developmental conditions, including neuromuscular scoliosis, hip subluxation, spasticity, and associated co-morbidities.

With the multidisciplinary approach at Scottish Rite, orthopedic surgery, neurology, pediatric development medicine, movement, orthotics, physical therapy, occupational therapy, science, neurosurgery, psychology, and nutrition experts all work together to determine each patient’s treatment plan.

Cerebral Palsy and Orthopedic Surgery
With this population, it is important to communicate realistic goals and expectations to the patient and family. Surgical recovery may be prolonged—6 to 12 months in some cases – before patients have regained their preoperative strength and functional abilities. Many patients will require new approaches to care and new equipment, like seating systems.

The Scottish Rite utilizes mutual decision making, meaning patients, parents, surgeons, and the rest of the care team work together to make decisions about an appropriate treatment plan for the child, especially when discussing surgery. With these medically complex patients, there are greater risks of surgical complications, which orthopedic surgeons discuss with the patient and the family as part of the decision-making process. Our team helps families cope with the best and less optimal outcomes to ensure the best care for the child.

Gross Motor Function Classification System (GMFCS)
The GMFCS allows physicians to guide treatment and expectations. This standardized tool helps to classify the function of the child on a scale of 1 to 5 depending on their functional level.

  • Level 1 = the child is physically active with a slightly noticeable difference.
  • Level 5 = the child is in a wheelchair and requires assistance with all activities and daily living.

There may be some subtle changes as the child grows and ages, but it is very hard for a child to change one level. Most children achieve their optimum level by age 5 or 6. Children with lesser functional abilities often have a decline in their functional abilities as they age. As the child grows and gets heavier, the inherent weakness with their muscular disorders becomes more apparent, and they may need more assistance.

GMFCS Guide to Surgery
Surgery is optimally offered between 7 and 11 years of age. At this age, recovery is typically easier on the patient and family, and it has shown to be the window to obtain maximum benefit. In addition, contractures at that point are usually becoming less amenable to non-operative treatments.

  • Surgical goals for patients at GMFCS levels 1,2 & 3
    • Maintain function
    • Maintain ambulation
    • Prevent contractures
    • Prevent pain
    • Maybe increase function
      • Not always possible
  • Surgical goals for patients at GMFCS levels 4 & 5
    • Prevent pain
    • Allow ease of care
    • Maintain range of motion
    • Improve sitting tolerance or balance
    • Improve foot positioning
    • Unlikely to improve ambulation
    • May prolong standing tolerance or transfers

Orthopedic and Neuro-developmental Conditions Associated with Cerebral Palsy
Neuromuscular Scoliosis
In periadolescent patients, neuromuscular scoliosis is usually managed with a spinal fusion and implants. The goal of this surgery is to prevent curve progression while improving sitting balance and providing a better seated position.

  • Refer for pediatric orthopedic care if the patient develops:
    • an obvious increase in stiffness of the back.
    • an altered seating posture.
    • a persistent leaning to one side.
    • pelvic asymmetry.

Neuromuscular Hip Dysplasia
Children with cerebral palsy are typically born with normally developed and positioned hips. Over time, excessive linear and rotational muscle forces affect the growth of the femur and pelvis  which may cause the hip to dislocate. The likelihood of neuromuscular hip dysplasia is directly related to the patient’s functional ability – a child with a higher GMFCS level has a higher risk. There is little documented benefit to bracing, Botox injections, or physical therapy for treating neuromuscular hip dysplasia. Surgery is recommended to treat this condition.

  • Early referral and close monitoring can improve surgical outcomes when it becomes necessary. Current guidelines include:
    • Initial assessment at age 2.
    • A supine pelvis X-ray for baseline.
    • Further imaging is based on the patient’s functional level, exam and prior radiographs.
    • Being seen relatively early is most important for non-ambulatory children.

Knee Contractures
Hamstring spasticity can cause knee contractures, which lead to a crouched gait position and challenges with transfers and other care. This can become very taxing as the child moves. Sometimes early muscle releases can prevent or reduce contractures.

  • Refer for pediatric orthopedic care if the patient develops:
    • Asymmetry in knee extension range of motion.
    • Contractures or intolerance to stretching or positioning to prevent knee flexion contractures.
    • Crouched gait or difficulty with ambulation or sitting.

Foot and Ankle Deformities
The foot and ankle are very flexible in children. When they are flexible, braces can be used. Over time, the foot tends to become more stiff, resulting in bony changes that make bracing difficult and less tolerated. Toe walking is the most common orthopedic manifestation of cerebral palsy, due to an Achilles tendon contracture.

When treating foot and ankle deformities, the goal is for the patient to have a flat, braceable, shoable, flexible, and pain-free foot. The goals may differ depending on the age, GMFCS level, and stiffness of the patient.

  • Refer for pediatric orthopedic care if:
    • bracing is not tolerated.
    • contractures develop.
    • foot position is changing.
    • shoe wear difficulties are apparent.

Are you interested in learning more? Visit our on-demand page for more educational opportunities available for medical professionals.

Detecting and Treating Scoliosis

Detecting and Treating Scoliosis

by | Jun 3, 2021 | Scoliosis & Spine

Content included below was previously presented at the 2021 Pediatric Orthopedic Education Symposium by pediatric orthopedic surgeon Megan E. Johnson, M.D.

People hear the term scoliosis often, but they may not know what it means. Pediatric orthopedic surgeon Megan E. Johnson, M.D., walked through each phase of detecting and treating scoliosis in a recent lecture. This summary provides health care professionals with a succinct summary and language to navigate the steps and conversations with patients presenting with suspected scoliosis.

Watch the full lecture or download this summary

Defining scoliosis
Scoliosis is a structural lateral rotated curvature of the spine. For a condition to qualify as scoliosis, the Cobb angle, or the measurement of the degree of side-to-side spinal curvature, must be a minimum of 10 degrees. If the Cobb angle is less than 10 degrees, it is considered a spinal asymmetry, not scoliosis.

What are the types of scoliosis? 

  • Idiopathic scoliosis: The most common type of scoliosis. Idiopathic means that all other causes of scoliosis have been ruled out.
  • Congenital scoliosis: When vertebral malformations cause a curvature of the spine. The vertebrae weren’t formed correctly or haven’t separated from the other surrounding vertebrae correctly.
  • Neuromuscular and syndromic scoliosis: Occurs in patients with underlying neurologic disorders like cerebral palsy, spina bifida and other genetic conditions.

What age is scoliosis diagnosed?
Scoliosis may be diagnosed at any age, but earlier recognition often improves treatment options and outcomes. A patient’s age also helps to define the type of scoliosis that they may have.

  • Infantile idiopathic scoliosis: patient is between 0 and 3 years old at the time of diagnosis.
  • Juvenile idiopathic scoliosis: patient is between 4 and 9 years old at the time of diagnosis.
  • Adolescent idiopathic scoliosis: patient is 10 years or older at the time of diagnosis.

The most common type is adolescent idiopathic scoliosis (AIS). The patient’s curve typically goes to the right and can include either the thoracic or lumbar spine or both.

What history and physical exam findings are important with scoliosis?
In order to evaluate patients, it is important to learn if patients have had back pain, headaches, other neurologic symptoms or a family history of scoliosis. For girls, it is also necessary to know their menstrual history to gauge where they are in their growth cycle.

The physical exam is focused on identifying asymmetries in static posture. This includes:

  • Differences in shoulder height.
  • Scapular asymmetry – scapulae are at different heights or one is more retracted.
  • Pelvic obliquity – iliac crests are at different heights.
  • Trunk shift – drawing an imaginary line from the patient’s head to their waist and seeing if the head is centered over their waist.
  • Waist asymmetry – a visible bulge (typically on left) on the convex side of a lumbar curve, and crease on the concave side of the curve.

Special test
A very common test for scoliosis that most people are familiar with is the Adams forward bend test. Patients bend forward at the waist, and the examiner looks for signs of rotational deformities. Curves in the coronal plane cause rotation in the axial plane, which are visible in the Adams test. For example, a left midline lumbar prominence and the prominence of the right ribs are evident with a right thoracic curve.

Neurologic exam
A thorough neurologic exam assesses for asymmetries and changes in sensation, reflexes and motor function in the trunk and lower extremities. The patellar tendon, the Achilles tendon and the abdomen are tested to look for symmetry in reflexes. Being hyper-reflexive is fine when it is present on both sides. If there are reflexes on one side and not the other, it is an abnormal finding. Foot abnormalities, like a cavovarus foot or a significant flat foot on just one side, may indicate an underlying neurologic concern.

What radiologic imaging is used to diagnose scoliosis?
Plain film radiology (X-rays)
X-rays are essential to assess the patient’s scoliosis. Full-length X-rays of the spine, including the pelvis and the top parts of the hips and femurs, will give physicians all the information that they need to determine what the curve looks like, how big the curves are and how much growth the patient has left. Full-length X-rays are necessary for final diagnosis and treatment planning. Scottish Rite for Children uses advanced imaging technology called EOS, which utilizes a very-low-dose radiation for efficient and effective full-length images. To avoid unnecessarily repeating X-rays, images are not required for referrals for suspected scoliosis.

Advanced imaging
An MRI is indicated with these findings:

  • Curve abnormalities like a left-sided curve, a back that is rounder than expected or an abnormal appearing curve.
  • Short and sharp curves and kyphosis are red flags requiring further evaluation with an MRI.
  • Abnormal neurologic exam or other neurologic symptoms, like daily headaches.
  • Significant progression in the patient’s curve between follow-up appointments.

What factors are considered in planning treatment for scoliosis?
The goal of scoliosis treatment is to keep the spinal curve(s) as small as possible and prevent progression to surgery. The following are considered:

  • Age of the patient.
  • How skeletally mature they are.
  • Size of the scoliosis curve(s).

Bracing
Bracing is recommended for patients with curves between 20-25 and 40 degrees if they have at least two years of growth remaining. Thoracic lumbar sacral orthosis (TLSO) braces are worn 18 to 20 hours a day and are typically used for curves in the thoracic spine or both the thoracic and lumbar spine. If the patient only has a lumbar curve that is flexible, nighttime bracing may be recommended.

Surgery
Surgery is recommended when the patient’s curve has a Cobb angle of 50 degrees or more to prevent the curve from progressing into adulthood. Surgery is generally not recommended until the patient is at least 10 years old because if the fusion is done too early, the growth of the patient’s spine can cause some secondary issues.

When should a patient with suspected scoliosis see a pediatric orthopedic specialist?
Patients should be referred to Scottish Rite for Children:

  • If they have a scoliosis curve and are still skeletally immature.
  • If they are fully grown with a significant deformity that is visible in the clinical exam.
  • If they have a scoliosis curve with an abnormal neurological exam, chronic back pain, daily headaches, an asymmetric foot deformity or any other unusual symptoms.

Many patients evaluated at Scottish Rite for Children do not have scoliosis, but our team provides reassurance and recommendations for monitoring over time. Annual or six-month observation visits are indicated for some patients since curves change as the patient grows.

Are you interested in learning more? Visit our on-demand page for more educational opportunities including scoliosis and orthopedic topics.

Non-Pharmacological Pain Management in Pediatric Orthopedics

Non-Pharmacological Pain Management in Pediatric Orthopedics

by | May 7, 2021 | Spotlight

In caring for the whole child, our team uses a multidisciplinary and multimodal approach to pain management. This means we go beyond prescribing analgesics (medicine for pain), in fact, we are actively working to eliminate the use of addictive opiods in our care.

A variety of approaches are used to prevent pain associated with a procedure. In addition to general anesthesia, nerve (hematoma) blocks are offered for some surgical procedures and fracture reductions. These have analgesic effects that can last up to 36 hours. Topical anesthetics are offered for invasive procedures including medication infusions and joint injections and aspirations.

Ambulatory nurse manager at the Frisco campus, Tabetha Rowe, R.N., says, “Not all patients have a procedure, but many of our patients present with musculoskeletal pain. Therefore, our guidance applies to most patients we see.” The ambulatory clinic, radiology and surgery staff provide education and resources to patients. Anyone can recommend or request that the provider make a referral to Child Life and/or Psychology for Scottish Rite patients that may benefit from additional assistance.

Non-Pharmacological Approaches to Pain Management at Scottish Rite
Patient and Family Education
With a new diagnosis and before and after procedures, relevant education is provided to ensure families understand the methods of pain control most appropriate to the situation.

  • Protection, Rest, Ice, Compression and Elevate (PRICE) continues to be the gold standard to quickly offer an array of tools to address swelling and pain associated with an acute, and sometimes, chronic condition.
  • Distinguishing between discomfort and pain is another point to address with patients and families. Some discomfort with an injury or after surgery should be anticipated, pain-free may not be a realistic goal to set for patients.
  • Movement greatly reduces stiffness and muscle tension. This is the most important instruction for each patient. Moving as much and as often as is recommended based on the condition or procedure addresses comfort and risks of complications associated with inactivity, including stiffness and venous thromboembolism (blood clots).
  • Getting enough quality sleep improves mental function and this can decrease sharpness of pain. Encourage eight or more hours/night.
  • Optimal environmental factors can contribute to improved mood and may decrease the perception of pain. Open the shades and encourage interaction with others.

Child Life Specialists
Certified child life specialists are clinically trained to work with patients to reduce stress and anxiety during visits at Scottish Rite for Children. Child life specialist Laurie Hamilton, CCLS, explains, “Fear and anxiety can often be misinterpreted as feelings of pain. With preparation and support during procedures, patients can utilize appropriate coping plans to help with pain management..” Patients and families often tell us the child life specialist greatly helps to make the experience positive. 

Here are some interventions child life specialists offer during a clinic, peri-operative or imaging visit.

  • Age-appropriate explanation of the procedure or treatment can improve pain-like behaviors caused by fear and anxiety. This can also help the child focus on a coping plan that can help modulate pain.
  • Providing pictures or an opportunity to see or touch equipment in advance may help a child understand the experience more accurately and be more confident with the plan of care.
  • Advocating for the patient during a procedure helps the patient express feelings and find appropriate outlets for those feelings.
  • Providing distraction techniques during the procedure encourages mental and physical relaxation which can help divert the child’s focus from the pain.

Pediatric Psychologists
Scottish Rite for Children recognizes the value of a psychological assessment and care in the treatment of children and adolescents. A consultation may be offered for several reasons, but may include discussing treatment decisions, a patient’s expressed need for psychological support or a formal mental health screening. Pediatric psychologists also help prepare patients and families for surgery. 

Mental and emotional factors have been shown to influence outcomes of medical treatments, therefore, it is in the patient’s best interest to address those early in the treatment. Allowing the child to express feelings of fear, anxiety or other emotions can reduce stress associated with treatment or upcoming surgery. Pediatric psychologist Emily Gale, Ph.D., L.P., ABPP, says, “Untreated anxiety or depression can prevent engagement in the necessary steps for rehabilitation and recovery to return efficiently to their favorite activities.” Many times, the intervention is brief and aligns with phases of treatment and recovery. Gale says, “Managed early, the outcomes from a mental health perspective are good, and the physical recovery is frequently positively enhanced.”

The Psychology department offers clinic consultations, outpatient visits and referrals to resources in the community. 

Pediatric Psychologist’s Perspective: Five Tips Managing Acute Pain in Children

  1. When introducing new medical terminology, always include an age-appropriate description.
  2. Help the child find words to describe their feelings of pain. This might include:
    • Bruised feeling
    • Tightness
    • Soreness
    • Aching
    • Sharp pain
    • Burning
    • Stinging
    • Numbness
  3. Pain and anxiety can become cyclical and can cascade into other feelings of fatigue and depression. Managing pain and discomfort before it starts is important. Use the techniques offered by the medical team proactively.
  4. Recognizing pain that is out of alignment with the condition or treatment can be a difficult process. Acknowledge the patient’s perceived pain while assessing for other risk factors of mental health conditions.
  5. Parents should model positive coping strategies, not only for pain, but for stress and uncertainty. Coping skills may include regular exercise, relaxation skills, breathing exercises, seeking social support, psychotherapy for mental health concerns and positive thinking.

Pain and discomfort cannot always be avoided. Proactive coping techniques to prevent prompt response, to escalating pain and using a multi-dimensional approach to will help to reduce the need for pharmacological analgesics, in particular opiods. As society continues to cope with opiod addiction, chronic pain and physical inactivity, our team is focused on getting kids back to childhood quickly, safely and without pain.

Find more resources for Medical Professionals. 

Hip Injuries in Young Athletes

Hip Injuries in Young Athletes

by | Mar 31, 2021 | Sports Medicine

Pediatric orthopedic surgeon and associate director of clinical research, Henry B. Ellis, M.D., presented this as part of Coffee, Kids and Sports Medicine education series.

Watch the full lecture
Print the PDF

Ellis provided a detailed discussion of the history and physical exam of young athletes with hip complaints to distinguish between common and less common hip conditions. Young athletes require a different approach than an adult athlete. Numerous conditions present more often, or only, in a younger patient compared to an adult. These include slipped capital femoral epiphysis (SCFE), adolescent hip dysplasia, epiphyseal dysplasia, apophysitis, stress fractures and more.

The ball and socket joint allows motion in all planes. For some young athletes, the soft tissue is particularly flexible which can increase the risk for injuries. A review of the anterior-posterior (AP) pelvis X-ray in a growing child provides an excellent overview of the pertinent anatomy in the growing pelvis and hips. There are physes, growth centers, that are present early and active through adolescence. Pelvis and hip growth centers include:

  • Acetabular physis (triradiate cartilage)
  • Proximal femoral physis
  • Greater trochanter apophysis
  • Ischial tuberosity
  • Anterior superior iliac spine

Five Key Tips for Evaluating the Youth Athlete’s Hip

  • History can help focus the exam.
  • Always examine both sides.
  • Adequately expose the area of interest while maintaining modesty.
  • Look beyond the hip.
  • Consider chaperone or an assistant in the room with hip exam.

Ellis says his detailed hip exam will last about 15-20 minutes. To provide an overview, he demonstrated a “three-minute hip exam” before he provided a detailed explanation of each step discussing associated conditions with each step.

Tests for recognizing signs of concerning conditions: 

  • Passive hip flexion that causes obligate (automatic) external rotation is indicative of SCFE and requires a prompt referral to minimize sequelae.
  • Dial test/passive circumduction with the hip joint relaxed. The provocation of pain indicates intra-articular problems such as synovitis or infection.
  • Hip flexion (90+ degrees) with adduction and internal rotation that causes pain is a sensitive screening tool for labral pathology.
  • Hip apprehension sign is positive when hip abduction and external rotation in side-lying causes apprehension and indicates a need for additional assessment for hip dysplasia.

In conclusion, Ellis provided some take-home messages for the audience.

  • A good clinical exam will often lead you to the diagnosis.
  • AP and frog pelvis X-ray is appropriate to evaluate for hip problems.
  • 80% of hip injuries are soft tissue strains that can be treated with rest, early range of motion and gradual return to sports when pain improves.
  • Some hip conditions require a MR arthrogram, so avoid an MRI of the hip until evaluated by a specialist, unless a stress fracture or other concerning diagnosis is suspected.

Ellis never disappoints an audience. As the first event after a break from our livestream events, we received these wonderful comments from attendees:

  • “So great to be here again!”
  • “Thank you for a well put together and thorough presentation. Also, I appreciate the handouts.”

Check out our latest on-demand lectures available for medical professionals.

Recognizing Athletes With Disordered Eating

Recognizing Athletes With Disordered Eating

by | Mar 29, 2021 | Sports Medicine

A pediatric sports medicine physician and member of the Female and Male Athlete Triad Coalition, Jane S. Chung, M.D., shares the latest in energy availability and the consequences of under fueling for young athletes.

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Sports can place high demands on growing bodies and athletes need their medical team to identify signs of unintentional or intentional disordered eating.

The traditional model of female athlete triad has evolved in recent years and now acknowledges that males also experience the triad. Osteoporosis, amenorrhea and eating disorders are pathologies that can occur at the extreme end, but the triad is now thought to be in a spectrum of optimal health to disease. In this model, the three components of bone density, menstrual function and energy availability are connected to each other. With this new approach, signs and symptoms are being identified earlier and even prevented.

The triad was known to be caused by the interrelationship of eating, hormone balance and bone health. Sadly, the condition was associated with “eating disorders” and assumptions were made that athletes may be intentionally causing these problems. Though this is still the case in some sports where figure and appearance are highly valued, the newer model of the triad is designed to address all types of “disordered eating.” This can include restrictive eating by “picky eaters” or simply those athletes who are too busy to consume adequate calories.

Energy availability is a more relevant term that accounts for the needs of the individual athlete, the sport and the training schedule. An athlete must fuel, or eat, according to these aspects. When the intake meets the demand, the energy balance is neutral. With a neutral energy balance, the young athlete can stay healthy and build strength, grow taller, compete at his or her optimal performance and minimize unwanted weight gain or loss. With a more sport and performance- centric conversation, athletes may be more willing to discuss their eating habits.

Here are some questions to ask your patients and some thoughts on how to respond to their answers:

ASK YES NO
Do you eat three meals a day plus snacks? Great, be sure to include three food groups in each meal and two food groups in each snack. Eating throughout the day and prior to activity is the best way to ensure your body gets the energy it needs and uses all of the nutrients the right way. Fueling with protein post work-out, practices/games is important to help with muscle healing and recovery.
Do you adjust your eating quality and quantity based on your training schedule? Good. Do you have someone to talk to about how you make those choices? Your body has different energy needs based on the activity you are doing. Begin to pay attention to feeling full or tired during activity to know if you need to adjust your plan.
Do you eat a rainbow of foods on every plate? Great. Eating a variety of foods ensures you get the nutrients you need for your bones to grow, and for your body to become faster and stronger with your training. Without variety in your foods, you may be missing important nutrients that strengthen and help your bones grow.
Do you have a daily goal of water intake? Is your daily goal close to ?? oz.? [calculate ½ body weight in kg] Be sure to choose water and start working toward a daily goal.

Chung participates in national study groups on the subject and has other clinical and research interests including:

  • Stress fractures and other consequences of under fueling for sports
  • Sleep in young athletes
  • Concussion recovery

Check out our latest resources for medical professionals.