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Children’s Orthopaedics. Dr Rob Alcock, Consultant Anaesthetist Mr Nigel Kiely, Consultant Orthopaedic Surgeon Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry. Children’s Orthopaedics (The Long and Short of it). Outline. Children’s Orthopaedics Gentle Musings Case Presentations.

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children s orthopaedics
Children’s Orthopaedics
  • Dr Rob Alcock, Consultant Anaesthetist
  • Mr Nigel Kiely, Consultant Orthopaedic Surgeon
  • Robert Jones & Agnes Hunt Orthopaedic Hospital, Oswestry
outline
Outline
  • Children’s Orthopaedics
  • Gentle Musings
  • Case Presentations
children s orthopaedics5
Children’s Orthopaedics
  • Wide range of conditions
  • Multidisciplinary care
  • Generally well children
  • Associated conditions
    • Syndromes
    • Dysplasias
    • Neurological
    • Metabolic
children s orthopaedics6
Children’s Orthopaedics
  • Hub and spoke care model
  • Dedicated ward staff
  • Consultant level of care
  • Paediatricians
gentle musings
Gentle Musings
  • Getting the Ward on your Side
  • Singing from the Same Hymn Sheet
  • Painful But Not Ill
  • Blocks work Really Well
slide10
DDH
  • 2 yr old child, limping
  • Fit and well, normal milestones
  • 12kg
  • Surgery
    • Anterior open reduction
    • Femoral & pelvic osteotomy
    • Spica
slide11
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
slide12
DDH
  • Well Child
  • Prolonged Surgery
  • Blood loss
  • Caudal or Epidural?
  • Spica
slide14
DDH
  • Well Child
  • Prolonged Surgery
  • Blood loss
  • Caudal or Epidural?
  • Spica
  • Pain not usually a problem
caudal
Caudal
  • 1ml/kg 0.2 % Bupivicaine + Ketamine 0.5mg/kg
  • OR
  • 8ml 0.25% Bupivicaine + 2ml Saline + Preservative Free Ketamine 5mg
cerebral palsy cp
Cerebral Palsy (CP)
  • Variety of Causes
  • Non progressive neurological lesion, immature brain
  • prematurity
  • 70 % Spastic
  • 30% Dyskinetic, Ataxic or Mixed
cp non walker
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
cp non walker19
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
anaesthetic considerations
Anaesthetic Considerations
  • Epilepsy
  • Bulbar Involvement?
  • Spasm
  • Airway
cp walker
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
cp walker22
CP Walker
  • Post op pain and spasm control
  • Long, multiple procedures
  • Early mobility
anaesthetic considerations23
Anaesthetic Considerations
  • Understanding and Affect
  • Multilevel / staged
  • Older child
epidural infusions
Epidural Infusions
  • 0.125% Bupivicaine
  • 0.1 – 0.4 ml/kg/hour
  • Typically 0.2 ml/kg/hour
spina bifida
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
spina bifida27
Spina bifida
  • Multiple Procedures
  • VP shunts
  • Pain control
  • Latex Allergy
  • Bladder- mitroffanof
  • Bowel- ACE
  • Pressure areas
  • infection
femoral fracture
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
femoral fracture29
Femoral fracture
  • Caudal
  • NCA / Oral Analgesia
clubfoot
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?
clubfoot31
Clubfoot
  • Small Infants
  • Well
  • Small procedure
  • Simple Analgesia
foot deformity and frame
Foot deformity and frame
  • Fixed foot deformity
  • Frame and osteotomy
  • gradual distraction of deformity
  • Frame on for several months
foot frame
Foot frame
  • Pain
  • Compartment syndrome
  • Dressing changes
  • Psychology
  • compliance
slide34
SUFE
  • 12 yr old
  • Obese child
  • Fit and well
  • Pain and limping
  • Treatment- bilateral pinning in situ
  • Percutaneous
  • Traction table
slide35
SUFE
  • Co-morbidites – uncommon
  • Post op- pain usually resolves quickly
  • Early mobility
thank you for your attention
Thank you for your attention!
  • Final tip- always open cefuroxime boxes from the bottom!
  • Avoids the annoying patient information leaflet.