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
H ip D i s lo c a t io n in c h i ld r e n w i th C P a c c o r d in g to G M F C S
0 %
1 0 %
2 0 %
3 0 %
4 0 %
5 0 %
6 0 %
G M F C S 2 G M F C S 3 G M F C S 4 G M F C S 5
5 y r s1 0 y r s1 5 y r s
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]
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:
» 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 Who DateChild diagnosed Paediatrician or date of diagnosiswith CP and notified Physiotherapistto pathway co-ordinator
Classification Paediatrician with date completedcompleted (Appendix 1); Physiotherapistcopy to co-ordinator, mainrecord and physiotherapyrecord
Examination of hips at each Paediatrician or (table)assessment; hip x-ray if PhysiotherapistCause for concern(Appendix 2)
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy
Standard Who DateRoutine hip x-ray Paediatrician or (table)
according to severity Physiotherapist
level (appendix 3) and
X-ray protocol (appendix 4)
MP > or = 30 degrees Paediatrician (table)
refer to orthopaedic
surgeon
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy
Standard Who Date24 hour postural Physiotherapist
management to be implemented
within 3 months of referral –
(i) Sleep support for GMFCS Date provided
Level III – V (can be used from
birth)
(ii) Home seat for GMFCS Date provided
Level III – V (can be used from
age 3 months)
(iii) Standing frame for all bilateral Date provided
CP (can be used from age 12 months)
Manchester Hip Surveillance Pathway for Children with Cerebral Palsy
Date What (examination, hip x-ray etc)
Result
Appendix 1 – CP classification• 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 I + II
X age 30/12 age 18/12 age 30/12 X
X annual hip x-ray until skeletal maturity 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 protocolcorrect positioning
Appendix 4 – x-ray protocolmigration percentage
Migration percentage = (AC x 100)/AB