Childrens Orthopaedics

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Childrens Orthopaedics

• Dr Rob Alcock, Consultant Anaesthetist
• Mr Nigel Kiely, Consultant Orthopaedic Surgeon
• Robert Jones Agnes Hunt Orthopaedic Hospital,
  Oswestry

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Childrens Orthopaedics(The Long and Short of
it)
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Outline

• Childrens Orthopaedics
• Gentle Musings
• Case Presentations

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Robert Jones Agnes Hunt Orthopaedic Hospital
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Childrens Orthopaedics

• Wide range of conditions
• Multidisciplinary care
• Generally well children
• Associated conditions
• Syndromes
• Dysplasias
• Neurological
• Metabolic

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Childrens Orthopaedics

• Hub and spoke care model
• Dedicated ward staff
• Consultant level of care
• Paediatricians

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Gentle Musings

• Getting the Ward on your Side
• Singing from the Same Hymn Sheet
• Painful But Not Ill
• Blocks work Really Well

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Case Presentations
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DDH

• 2 yr old child, limping
• Fit and well, normal milestones
• 12kg
• Surgery
• Anterior open reduction
• Femoral pelvic osteotomy
• Spica

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DDH

• 3 1/2 hour operation
• 250mls blood loss
• Drip out 48 hrs post op
• Vomited, settled with oral fluids
• Home day 4 post op

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DDH

• Well Child
• Prolonged Surgery
• Blood loss
• Caudal or Epidural?
• Spica

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JRH Table
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DDH

• Well Child
• Prolonged Surgery
• Blood loss
• Caudal or Epidural?
• Spica
• Pain not usually a problem

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RECIPE ALERT!
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Caudal

• 1ml/kg 0.2 Bupivicaine Ketamine 0.5mg/kg
• OR
• 8ml 0.25 Bupivicaine 2ml Saline Preservative
  Free Ketamine 5mg

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Cerebral Palsy (CP)

• Variety of Causes
• Non progressive neurological lesion, immature
  brain
• prematurity
• 70 Spastic
• 30 Dyskinetic, Ataxic or Mixed

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CP non walker

• 5 yr old girl
• CP spastic diplegia
• standing frame, non- walker
• Intellectually good, talker
• Epilepsy, increasing in frequency, Valproate
• Pre-op optimisation of medical conditions
• Subluxed right hip
• Previous soft tissue surgery

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CP Non Walker

• Surgery delayed due to increasing fits
• Stabilised
• Had a fit night before surgery!
• Surgery- bilat femoral osteotomies and pelvic
  osteotomy
• Spica
• Blood loss 150mls
• Post op- uneventful

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Anaesthetic Considerations

• Epilepsy
• Bulbar Involvement?
• Spasm
• Airway

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CP Walker

• Spastic Diplegia
• 11 years old
• High intelligence
• No medical problems
• Staged Multiple level surgery
• Bilat fem derotation
• Foot stabilisation
• Iliac crest bone graft

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CP Walker

• Post op pain and spasm control
• Long, multiple procedures
• Early mobility

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Anaesthetic Considerations

• Understanding and Affect
• Multilevel / staged
• Older child

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RECIPE ALERT!
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Epidural Infusions

• 0.125 Bupivicaine
• 0.1 0.4 ml/kg/hour
• Typically 0.2 ml/kg/hour

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Spina bifida

• 12 yrs old
• Ambulant, mixed level
• Bladder and bowel control
• Lower limb deformity
• Partially sensate legs
• Iliac crest graft
• foot surgery,
• Tibial osteotomy
• Tendon transfer

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Spina bifida

• Multiple Procedures
• VP shunts
• Pain control
• Latex Allergy
• Bladder- mitroffanof
• Bowel- ACE
• Pressure areas
• infection

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Femoral fracture

• 7 yr old boy
• Isolated injury
• Put on Thomas splint in local hospital
• Admitted for flexible nailing
• Traction table
• Distal femoral incisions
• Early mobility

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Femoral fracture

• Caudal
• NCA / Oral Analgesia

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Clubfoot

• Ponseti treatment
• Hub and spoke model of care
• 6 week old child
• Minimum weight 4kg
• Percutaneous tenotomy and plaster
• Can be done under LA?

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Clubfoot

• Small Infants
• Well
• Small procedure
• Simple Analgesia

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Foot deformity and frame

• Fixed foot deformity
• Frame and osteotomy
• gradual distraction of deformity
• Frame on for several months

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Foot frame

• Pain
• Compartment syndrome
• Dressing changes
• Psychology
• compliance

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SUFE

• 12 yr old
• Obese child
• Fit and well
• Pain and limping
• Treatment- bilateral pinning in situ
• Percutaneous
• Traction table

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SUFE

• Co-morbidites uncommon
• Post op- pain usually resolves quickly
• Early mobility

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Thank you for your attention!

• Final tip- always open cefuroxime boxes from the
  bottom!
• Avoids the annoying patient information leaflet.