Neuro-orthopaedics

Children with neurological impairment (eg cerebral palsy) are at risk of developing fixed shortness of their muscles or changes in the alignment of their bones. The orthopaedic team overseeing these problems at Chelsea and Westminster Hospital consists of two Paediatric Orthopaedic Surgeons and three Advanced practice physiotherapists (APPs) in paediatric orthopaedics who provide orthopaedic management for children with neurodisability from 0–19 years of age.

The team provides screening for the development of fixed or dynamic deformities that may require orthopaedic intervention such as soft tissue release, bony surgery or botulinum toxin injection. Children with neurodisability are subject to changes in their musculoskeletal problems with growth and for this reason they may be monitored by the team over long periods depending on the level of need.

Referrals are accepted from GPs, paediatricians, neurologists, often in conjunction with the local physiotherapists.

All new referrals are triaged by the APP team and assessed initially in APP-led clinics, where initial advice on management of the condition is given and some conservative treatment may be advised or planned.

Where surgical intervention may be necessary children are followed up in joint consultant/practitioner clinics for the purpose of treatment planning.  We work in liaison with the gait laboratory at Queen Mary’s Hospital and the one small step gait laboratory at Evelina Children's Hospital where we are able to hold review clinics to examine the complex data from 3D gait analysis for ambulant children where surgical intervention is required. This allows for refinement of the surgical prescription and audit of surgical outcomes.

Assessment may include:

• Clinical examination
• Manual muscle strength testing
• X-ray, particularly for hip surveillance
• Video assessment
• 3D gait analysis
• Outcome measurement questionnaires

Interventions may include:

• Postural management recommendations
• Advice on exercise programmes
• Advice on and referral for orthotics
• Serial casting
• Botulinum toxin injections
• Soft tissue surgery
• Bony surgery

The team liaises closely with local paediatric physiotherapists and provides outreach clinics in a number of special schools and a health centre.

When orthopaedic intervention is indicated, the APPs coordinate preoperative planning, liaising closely with local services to ensure continuity of care. Pre-admission appointments are arranged one month prior to admission to ensure pre and post operative plans are in place and appropriate. The practitioners follow up all children postoperatively and will remove and replace casts, provide serial casting and arrange appropriate and timely orthotic provision, and ongoing monitoring, as indicated.