Manchester Hip Surveillance Pathway for Children with Cerebral Palsy 13 th June 2011 Greater...

Manchester Hip Surveillance Pathway for Children with Cerebral

Palsy

13th June 2011

Greater Manchester Cerebral Palsy Network Meeting

Dr Wendy Rankin, Consultant Paediatrician

Hip displacement (MP >30%) by GMFCS level Soo et al 2006

H ip D i s lo c a t io n in c h i ld r e n w i th C P a c c o r d in g to G M F C S

0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

G M F C S 2 G M F C S 3 G M F C S 4 G M F C S 5

5 y r s1 0 y r s1 5 y r s

Does hip surveillance work?

• Haggalund [2005] showed results of first 10 years of a hip surveillance programme with early intervention surgery.

– From 1992, only 2 children had dislocated hips out of 251 children with CP.. This compared to 8 in previous control group of 103 children

• Dobson et al [ 2002] reported on first 3 years of Orthopaedic clinic based on early detection and surgery [total 133 children]

– They showed elimination of hip dislocation and salvage surgery, at expense of rise in preventive surgery.

Liverpool - Current recommendations for hip screening

• Should start at 18 months [Dobson,2002, Hagglund,2005, Thomason,2002 ]

• Should be repeated every 6 months in severely affected children and yearly in others children [Dobson,2002, Haggalund, 2005]

How can this be rationalised ?• All children age 18 months with bilateral spastic CP with high tone who are

estimated to be in GMFCS 1V or V should have a hip radiograph in the standard position to measure migration percentage. [These children will have poor trunk and head control at this age]. This should be repeated 6 monthly.

• Others in GMFCS 111 with these features should have a hip radiograph at 30 months and then at yearly intervals until 8 years of age.

Hip Surveillance Clinical Indicators:• All children with Cerebral Palsy* to have a standardised clinical hip

assessment at every examination following diagnosis. Results to be recorded in patient’s notes.

• A hip x-ray is required for:• Children with CP* not walking independently by 30 months of age or not able to sit

without support at 18 months.• Children with CP* under 30 months of age presenting with:

» Significant tonal abnormality» Reduction of abduction range < 30 degrees» Asymmetry of range of movement especially abduction» Leg length discrepancy/ scoliosis» Asymmetrical posterior skin crease» Hip pain/ persistent disturbed sleep» Parents report problem with cares» DDH

• Children with CP* over 30 months showing clinical signs as above and not having had a hip x-ray previously, or last x- ray older than 6 months

Manchester Hip Surveillance Pathway for Children with Cerebral Palsy

Standard Who DateChild diagnosed Paediatrician or date of diagnosiswith CP and notified Physiotherapistto pathway co-ordinator

Classification Paediatrician with date completedcompleted (Appendix 1); Physiotherapistcopy to co-ordinator, mainrecord and physiotherapyrecord

Examination of hips at each Paediatrician or (table)assessment; hip x-ray if PhysiotherapistCause for concern(Appendix 2)

Manchester Hip Surveillance Pathway for Children with Cerebral Palsy

Standard Who DateRoutine hip x-ray Paediatrician or (table)

according to severity Physiotherapist

level (appendix 3) and

X-ray protocol (appendix 4)

MP > or = 30 degrees Paediatrician (table)

refer to orthopaedic

surgeon

Manchester Hip Surveillance Pathway for Children with Cerebral Palsy

Standard Who Date24 hour postural Physiotherapist

management to be implemented

within 3 months of referral –

(i) Sleep support for GMFCS Date provided

Level III – V (can be used from

birth)

(ii) Home seat for GMFCS Date provided

Level III – V (can be used from

age 3 months)

(iii) Standing frame for all bilateral Date provided

CP (can be used from age 12 months)

Manchester Hip Surveillance Pathway for Children with Cerebral Palsy

Date What (examination, hip x-ray etc)

Result

Appendix 1 – CP classification• CP Classification form• Name of child Dob M/F NHS No• Classification of cerebral palsy• CP sub-type (see classification tree from SCPE)•• Function• Motor GMFCS• MACs• Cognitive• Vision• Hearing• Epilepsy• Neuroimaging• • Cause / timing• Classification under previous terminology• Date completed by• References• 1. Revised classification. Dev Med Child Neurol 49 (2007) Supplement109 • 2. Surveillance of Cerebral Palsy in Europe (SCPE). Dev Med Child Neurol 42 (2000) 816-824

Appendix 2 – cause for concern suggesting need for hip x-ray

• Significant tonal abnormality• Reduction of abduction range < 30 degrees• Asymmetry of range of movement especially

abduction• Leg length discrepancy/ scoliosis• Asymmetrical posterior skin crease• Hip pain/ persistent disturbed sleep• Parents report problem with cares• DDH

Appendix 3 –routine hip x-rays

Unilateral Bilateral

Others Severe* IV + V III I + II

X age 30/12 age 18/12 age 30/12 X

X annual hip x-ray until skeletal maturity X

• extensive plantar flexion of the ankle with limited ROM at the knee and hip during swing and stance phase

• X = only x-ray if cause for concern

Appendix 4 – x-ray protocolcorrect positioning

Appendix 4 – x-ray protocolmigration percentage

Migration percentage = (AC x 100)/AB