Module 56, Pediatric Orthopaedist Level

A nine year old male with a diagnosis of spastic quadriplegic, cerebral palsy presented for a follow-up exam. This patient was non-ambulatory and non-verbal. Patient had good head control and was capable of sitting if propped up. The patient had bilateral release of iliopsoas, gracilis, adductor longus, distal hamstrings and right tensor facia lata release 4 weeks prior to this examination. Now, the patient still required valium and analgesics due to pain and muscle spasms. At this time a firm mass was palpated in the left groin. The whole groin was warm to touch and the child was reported to have intermittent temperature elevation to 38.5 degrees. He appetite was also diminished. Two months post op the patient was still having pain. Four months post op the patient was more comfortable but still having pain with motion at (the end of his range) 90 degrees flexion, -30 degrees extension, 20 degrees of abduction and no rotation.

Question 56A

Manipulation under anesthesia should now be considered to improve range of motion (ROM).

Question 56B

This child should have been placed on indomethicin at the first suggestion that a heterotopic ossification (HO) was forming.

Question 56C

Although alkaline phosphatase is initially elevated, 2 to 3 months after surgery this child's alkaline phosphatase should be back to near normal.

Question 56D

Heterotopic ossification which forms after hip surgery in children with Cerebral Palsy usually requires surgical excision followed by radiation treatment.

Question 56E

Heterotopic ossification occurs more commonly in children with CP in the area of the iliopsoas or when hip surgery is done in close temporal proximity to spinal surgery.