Module 17, Pediatric Orthopaedic Level

1,2

This boy is seen at age four with the diagnosis of mentally retarded spastic quadriplegic cerebral palsy. He is a non-ambulator. He was delivered by C-section at 31-weeks gestation of a twin pregnancy. Body weight at birth was 1558 gram. Sitting was still unstable. He was first seen at the age of 2 years and 4 months when an x-ray of the hip was obtained(image 1). Thomas test was 30 degrees and abduction was 15 degrees bilaterally. At the age of 4 years another x-ray was obtained(image 2). Popliteal angle was 45 degrees and Thomas was 30 degrees bilaterally.

Question 17A

It will be very difficult to prevent this boy from having a dislocated hip or from developing significant hip dysplasia.

Question 17B

At the initial visit at age two, one treatment option would be to take this boy to the operating room, do an arthrogram. If the hip is shown to reduce following a percutaneous adductor tenotomy, place him in a hip spica cast for 3 to 6 months.

Question 17C

By the x-ray at age four, the only option which will give a reliable long term positive result will be a varus osteotomy.

Question 17D

A break in Shenton's line is an important x-ray sign to monitor in spastic hip disease.

Question 17E

At age two injection of the adductors with botulinum toxin to decrease the spasticity is another option in the treatment of this child.