How an Orthopedic Surgeon Thinks

Bert Knuth, MD June 20 2014

• Is he happy?• Is he in pain?• Am I doing

everything he needs?

• Am I doing everything right?

• What if I do more?• More of what?

• What does the future hold?

• Therapy PT OT Speech Developmental Social work• Orthotics?• Pediatrics• Neurology• ENT• MRI ?• Genetics• Medical

Diagnostics

Hypotonia- Low muscle tone

Contractures

Hip subluxation/ dislocation

Scoliosis

Polydactyly, Syndactyly

Musculoskeletal Involvement

… “for those who have nothing, a little is a lot”… Jacquelin Perry,MD

Priorities◦ Communication◦ Activities of daily living- ADLs

Perineal care, feeding, bathing etc.◦ Mobility

Sitting/ Seating Walking

◦ Pain free

Function, Function, Function

92% CHOP cohort

Role of Physical Therapy◦ Disuse- more is better◦ Developmental vs age appropriate ◦ Function

Role of Bracing◦ Temporary support◦ Prevention of contractures?

Hypotonia

Nonambulatory children with neuromuscular involvement are prone to develop flexion contracture of the hips and knees. Equinus contracture of the ankle can occur.

Physical therapy for gentle range of motion of the joints should be instituted.

The role of surgical release of contractures is controversial as function may not be improved and recurrence is commonplace.

Contractures

Common in nonambulatory patients Proximal muscle weakness predisposes to

structural abnormalities which leads to uncoverage of hips.

Hip Subluxation/ Dislocation

Unilateral dislocation can lead to pelvic obliquity and uneven seating pressure.

Bilateral dislocation can accentuate lumbar lordosis.

Management is controversial as pain is inconsistent and treatment is difficult.

Hip Subluxation/ Dislocation

More common in nonambulatory patients Discovered at an earlier age and progresses

more rapidly in nonambulatory patients. Nonoperative treatment- Bracing

◦ May make sitting easier but usually ineffective in preventing curve progression or altering need for surgery.

◦ A rigid orthosis can further tax a compromised respiratory status

◦ Role of soft TLSO may be tolerated in young children with flexible curves between 20-40 degrees to allow more time prior to surgery.

Scoliosis

Surgical Treatment- spinal fusion◦ Goal is to balance trunk over level pelvis to

facilitate seating.

Scoliosis

• Indications are progressive deformity with curve magnitude greater than 50-70 degrees

• Preoperative traction? for low vital capacity

• Posterior spinal fusion for patients who can tolerate surgery

• Fusion should include entire thoracic and lumbar spine and extend to the pelvis.

Scoliosis

Extra or webbed digits◦ Extra toes are usually not a functional concern

and are only removed for shoe wear difficulties or cosmetic concerns.

◦ Much more aggressive with extra or webbed fingers if function is altered/ decreased

Polydactyly/ Syndactyly

Thank You