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
Hip Dislocation in children with CP according
to GMFCS
60%
50%
40%
5 yrs
10 yrs
15 yrs
30%
20%
10%
0%
GMFCS 2
GMFCS 3
GMFCS 4
GMFCS 5
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]
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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:
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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
Child diagnosed
with CP and notified
to pathway co-ordinator
Who
Paediatrician or
Physiotherapist
Date
date of diagnosis
Classification
completed (Appendix 1);
copy to co-ordinator, main
record and physiotherapy
record
Paediatrician with
Physiotherapist
date completed
Examination of hips at each
assessment; hip x-ray if
Cause for concern
(Appendix 2)
Paediatrician or
Physiotherapist
(table)
Manchester Hip Surveillance Pathway
for Children with Cerebral Palsy
Standard
Who
Date
Routine hip x-ray
according to severity
level (appendix 3) and
X-ray protocol (appendix 4)
Paediatrician or
Physiotherapist
(table)
MP > or = 30 degrees
refer to orthopaedic
surgeon
Paediatrician
(table)
Manchester Hip Surveillance Pathway
for Children with Cerebral Palsy
Standard
Who
24 hour postural
management to be implemented
within 3 months of referral –
(i) Sleep support for GMFCS
Level III – V (can be used from
birth)
(ii) Home seat for GMFCS
Level III – V (can be used from
age 3 months)
(iii) Standing frame for all bilateral
CP (can be used from age 12 months)
Physiotherapist
Date
Date provided
Date provided
Date provided
Manchester Hip Surveillance Pathway
for Children with Cerebral Palsy
Date
What
(examination,
hip x-ray etc)
Result
Appendix 1 – CP classification
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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
X
age 18/12
age 30/12
X
•
•
age 30/12
annual hip x-ray until skeletal maturity
I + II
X
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 protocol
correct positioning
Appendix 4 – x-ray protocol
migration percentage
Migration percentage = (AC x 100)/AB