Complex Paediatric Neurodisability

Common Orthopaedic Conditions
Associated with Complex
Lindsey Hopkinson and Victoria Healey
Heads of Paediatric Physiotherapy
Physiocomestoyou Ltd
 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
 Growth of the
musculoskeletal system
 Weight
 Muscle strength
 Altered tone
 Active volitional movement
/ wheelchair bound
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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
 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
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How to monitor your child’s hips as
they Grow
 Hip Surveillance (Active
screening programme)
DISCUSS with your
 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
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• Pain on movement
(rotation / abduction)
• Leg length
• Tightness within thigh
• Change in sitting posture
• Pain / change in walking
pattern of ambulant
• Windswept posture
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
 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
 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
- 3 muscles are on
located at the back of
the thigh.
Signs of shortening
How to monitor for shortening:
- 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
 Crouch / anterior tilted pelvis
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Muscles located between your
child’s inner thigh
Signs of shortening including:
 Scissoring
 Difficulty with dressing and
 Sitting posture
 Windswept posture
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Soleus and gastrocnemius
muscles – back of lower leg
How to monitor for shortening:
 Difficulty tolerating Splints
 Walking on toes
 Heels flat but feet rolling
Non ambulant:
 Feet pointing downwards
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When we refer to Orthopaedic
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
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
 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.

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