How an Orthopedic Surgeon Thinks
Bert Knuth, MD
June 20 2014
• 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

Hypotonia- Low muscle tone

Contractures

Hip subluxation/ dislocation

Scoliosis

Polydactyly, Syndactyly
… “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

92%

Role of Physical Therapy
CHOP cohort
◦ Disuse- more is better
◦ Developmental vs age appropriate
◦ Function

Role of Bracing
◦ Temporary support
◦ Prevention of contractures?



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.


Common in nonambulatory patients
Proximal muscle weakness predisposes to
structural abnormalities which leads to
uncoverage of hips.



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.


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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.

Surgical Treatment- spinal fusion
◦ Goal is to balance trunk over level pelvis to facilitate
seating.
• 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.

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