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A 15-year-old, non-ambulatory patient with cerebral palsy who is unable to maintain an upright head position against gravity, has pain while sitting in his wheelchair. An AP pelvis radiograph is shown in Figure A and attempted frogleg lateral view in Figure B. A preoperative CT scan (Figure C) demonstrates significant femoral head flattening. What is the most accurate Gross Motor Function Classification System level, and what is the most appropriate surgical intervention?
GMFCS V: Open reduction with varus derotational osteotomy, femoral shortening, psoas release, and pelvic osteotomy
GMFCS I: Hip adductor and psoas release plus abduction bracing
GMFCS V: Open reduction with varus derotational osteotomy
GMFCS V: Proximal femoral resection
GMFCS I: Open reduction with femoral varus derotational and pelvic osteotomy
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This patient would classify as a Gross Motor Function Classification System Level (GMFCS) V. Proximal femoral resection is indicated in a nonambulatory patient with cerebral palsy that has pain while sitting in his wheelchair.
The Gross Motor Function Classification System Level (GMFCS) is commonly used for cerebral palsy. Level V is characterized by physical impairment which restricts voluntary control of movement and the ability to maintain antigravity head and trunk postures. Children have no means of independent mobility and are transported. Hip instability is uncommon in the ambulatory CP patient, but it is very common in the nonambulatory CP patient. 50% to 75% of dislocated hips will become painful in CP patients.
Muthusamy et al. performed a Level 4 review of 27 CP patients that were followed for nearly 8 years following a proximal femoral resection. They found that hip pain, range of motion, activities of daily living, and quality of life after surgery were all improved.
Leet et al. also conducted a Level 4 review of patients that underwent femoral head resection with traction or a McHale procedure (femoral head resection and valgus osteotomy). They found that the McHale group had a shorter length of stay in the hospital, less postoperative superior migration, and lower surgical and medical complications. However, both groups had increased sitting tolerance and decreased pain, and overall satisfaction with the surgical outcome.
Figure A demonstrates a dislocated left hip. Illustration A shows the Gross motor function classification system (GMFCS) for patients aged 6-12 years with cerebral palsy. Illustration B demonstrates the Mchale procedure consisting of femoral head resection and valgus osteotomy.
Answer 1, 3, and 5: Open reduction is relatively contraindicated in the setting of a flattened head. Reducing a degenerative femoral head may cause hip pain.
Answer 2: Soft tissue releases and bracing would be unlikely to obtain a sustainable reduction.
Muthusamy K, Chu HY, Friesen RM, Chou PC, Eilert RE, Chang FM
J Pediatr Orthop. 2008 Dec;28(8):884-9. PMID: 19034183 (Link to Abstract)
Leet AI, Chhor K, Launay F, Kier-York J, Sponseller PD
J Pediatr Orthop. 2005 Jan-Feb;25(1):70-3. PMID: 15614063 (Link to Abstract)
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The parents of a wheelchair-bound 8-year-old boy with cerebral palsy present with difficulty during diaper changes and with hygiene care. His physical exam demonstrates 5° of hip abduction on the left hip and 15° on the right. An AP pelvis radiograph is shown in figure A. What is the most appropriate treatment?
Bilateral botox injections and physical therapy
Nighttime Pavlik harness
Bilateral abductor release and valgus femoral osteotomies
Bilateral adductor release, varus femoral osteotomies and acetabuloplasties
Observation with repeat radiograph in 6 months
Children with spastic cerebral palsy develop hip subluxation as the result of long term muscle imbalance. Subluxation can progress to hip dislocation with resulting difficulties in seating, hygiene or personal care, and/or hip pain. The patient has bilateral dislocated/near dislocated hips with acetabular dysplasia.
Flynn and Miller provide a thorough review of hip disorders in patients with cerebral palsy including etiology, physical exam and treatment guidelines. Recommendations included hip reconstruction for children over 4 years of age with severe subluxation or dislocation if severe degenerative changes are absent. Hip reconstruction consists of a one-stage soft-tissue lengthening with varus derotational femoral osteotomy and possible acetabuloplasty.
Spiegel and Flynn also have provided a comprehensive review of hip dysplasia in patients with cerebral palsy. The article discusses early intervention to prevent complications associated with subsequent hip dislocations. Surgical intervention in patients older than 4 years with hip dislocations was once again hip reconstruction with soft-tissue lengthening, femoral osteotomies and acetabuloplasties in patients in patients with marked acetabular abnormalities.
Flynn JM, Miller F.
J Am Acad Orthop Surg. 2002 May-Jun;10(3):198-209. PMID: 12041941 (Link to Abstract)
Spiegel DA, Flynn JM.
Orthop Clin North Am. 2006 Apr;37(2):185-96, vi. PMID: 16638449 (Link to Abstract)
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HPI - 17yoM with quadriplegic CP GMFCS level 5, with chronic right hip dislocation suffered a mildly displaced R hip intertrochanteric fracture while being positioned. He is very high surgical risk due to seizure d/o, recurrant pneumonia, and Crohn's disease.
How would you treat this?
Yeul-Bum Park, MD1;Seong-Ho Kim, MD1;Sang-Woo Kim, MD1;Chul-Hoon Chang, MD1;Soo-Ho Cho, MD1; and Sung-Ho Jang, MD2; 1;Departments of Neurosurgery, 2;Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Korea