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