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How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014.

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Presentation on theme: "How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014."— Presentation transcript:

1 How an Orthopedic Surgeon Thinks Bert Knuth, MD June 20 2014

2 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

3  Hypotonia- Low muscle tone  Contractures  Hip subluxation/ dislocation  Scoliosis  Polydactyly, Syndactyly

4 … “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

5  92% CHOP cohort  Role of Physical Therapy ◦ Disuse- more is better ◦ Developmental vs age appropriate ◦ Function  Role of Bracing ◦ Temporary support ◦ Prevention of contractures?

6  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.

7  Common in nonambulatory patients  Proximal muscle weakness predisposes to structural abnormalities which leads to uncoverage of hips.

8  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.

9  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.

10  Surgical Treatment- spinal fusion ◦ Goal is to balance trunk over level pelvis to facilitate seating.

11 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.

12  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


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