150
Journal of the Royal Society of Medicine Volume 85 March 1992
Management of hip posture in cerebral palsy
J F Redden FRCS2 'United Sheffield and District Hospitals and 2Department of A M Clarke FRCS' Orthopaedic Surgery, Doncaster Royal Infirmary, Armthorpe Road, Doncaster DN2 5LT Keywords: cerebral palsy; seating
Summary Seating arrangements for cerebral palsy children with total body involvement are often unsatisfactory and can pose considerable problems for the multi-disciplinary team. Hip joints at risk of dislocation must be kept in an abducted position in order to minimize pain. A new wheelchair with a barrel-shaped cylindrical seat has been developed which improves the femoral head location and alleviates pain.
Introduction The maintenance of hip location is a well established goal in the management of cerebral palsy. The principal methods in the control of hip displacement are surgery and the control of posture1. Although soft tissue surgery can be very helpful, its results are not always longlasting2'3 and continued observation and judicious intervention are required if the best possible results are to be obtained. In the totally involved spastic patient, between 2.6% and 34% of patients may have unilateral or bilateral hip dislocations4. Ambulation in these cases is often impossible and unrealistic5 and therefore pain free sitting is crucial. Dislocated hips may give rise to pain5'6 and make comfortable seating arrangements difficult. Indeed over halfof non-walking children may have pain from a dislocated hip37. Splintage ofthe lower limbs in the abducted position is sometimes required to maintain the hip reduction, but these splints are frequently poorly tolerated2. Moreover, because many children spend a large part of the day in a wheelchair, the hips, so held in this flexed and adducted position, may lead to hip pain and may also have a greater tendency to dislocate. It should be possible to improve the hip position by keeping the joints in a more abducted position
Figure 1. Supinepelvic radiograph showing a subluxated right hip joint. Migration percentage: 86%o, right hip; 13%, left hip Correspondence to: Dr A Clarke, Department of Orthopaedic Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU
Figure 2. Pelvic radiograph taken in a conventional wheelchair showing a poorly covered right femoral head. Migration percentage: 83%, right hip; 29%, left hip. Same patient as Figure 1
Figure 3. Radiograph taken with the subject seated in the Sandall Wood wheelchair. Migration percentage 60%, right hip; 10%, left hip. Same patient as Figure 1
throughout the day. Conventional wheelchairs, however, do not allow for this position. At the Sandall Wood School, Doncaster, a wheelchair has been developed in accordance with Department of Health guidelines. This wheelchair allows the hip abduction required to improve femoral head location compared with that obtained with more conventional models (Figures 1-3). With better hip location throughout the day, the child is free from pain and is therefore able to interact better with his or her surroundings. Methods and results The Sandall Wood wheelchair (Figure 4) has been used in selected patients suffering from cerebral palsy with total body involvement in Doncaster who are under the age of 12 years. Other exclusion criteria include the presence of athetosis, children with such poor hip abduction that this prevents them from sitting astride the chair and those patients who co-operate poorly. Despite the 30 degrees of hip
0141-0768/92/
030150-02/$02.00/0 © 1992 The Royal Society of Medicine
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Journal of the Royal Society of Medicine Volume 85 March 1992
Pain is a significant problem for those children affected by hip subluxation/dislocation and therefore every attempt should be made in its prophylaxis. If the hips can be held in abduction with the use of a cylindrically seated wheelchair, it would seem that this may be an easy and acceptable method of achieving this aim in a number of patients. Furthermore the posture of the patient in a conventional wheelchair may be deleterious to the maintenance of hip location (Figure 2).
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Acknowledgments: The authors would like to thank-Mrs P Crome, Senior Physiotherapist and Mr R Spooner, technical advisor. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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Figure 4. The Sandall Wood wheelchair
abduction required for this seat, we have had no children with sacral or ischial sores and all patients to date have tolerated the chair well.
Discussion In many children suffering from cerebral palsy it is possible to achieve an acceptable walking ability, but this goal is unrealistic in a number of children with total body involvement.
References 1 Rang M, Douglas G, Bennet GC, Koreska J. Seating for children with cerebral palsy. J Pediatr Orthop 1981; 1:279-87 2 Samilson RL, Tsou P, Aamoth G, Green WM. Dislocation and subluxation ofthe hip in cerebral palsy. JBone Joint Surg [Am] 1972;54-A:863-73 3 Hoffer M. Management of the hip in cerebral palsy. J Bone Joint Surg [Am] 1986;68-A:629-31 4 Kalen V, Bleck EE. Prevention of spastic paralytic dislocation of the hip. Dev Med Child Neurol 1985; 27:17-24 5 Hoffer M, Stein GA, Koffman M, Prieto M. Femoral varusderotation osteotomy in spastic cerebral palsy. J Bone Joint Surg [Am] 1985;67-A:1229-35 6 Sharrard WJW, Allen JMH, Heaney SH, Prendiville GRG. Surgical prophylaxis of subluxation and dislocation of the hip in cerebral palsy. J Bone Joint Surg [Br] 1975;57-B:160-6 7 Cooperman DR, Bartucci E, Dietrick E, Millar EA. Hip dislocation in spastic cerebral palsy: long term consequences. J Pediatr Orthop 1987;7:268-76
(Accepted 11 September 1991)
151
Journal of the Royal Society of Medicine Volume 85 March 1992
Management of hip posture in cerebral palsy
J F Redden FRCS2 'United Sheffield and District Hospitals and 2Department of A M Clarke FRCS' Orthopaedic Surgery, Doncaster Royal Infirmary, Armthorpe Road, Doncaster DN2 5LT Keywords: cerebral palsy; seating
Summary Seating arrangements for cerebral palsy children with total body involvement are often unsatisfactory and can pose considerable problems for the multi-disciplinary team. Hip joints at risk of dislocation must be kept in an abducted position in order to minimize pain. A new wheelchair with a barrel-shaped cylindrical seat has been developed which improves the femoral head location and alleviates pain.
Introduction The maintenance of hip location is a well established goal in the management of cerebral palsy. The principal methods in the control of hip displacement are surgery and the control of posture1. Although soft tissue surgery can be very helpful, its results are not always longlasting2'3 and continued observation and judicious intervention are required if the best possible results are to be obtained. In the totally involved spastic patient, between 2.6% and 34% of patients may have unilateral or bilateral hip dislocations4. Ambulation in these cases is often impossible and unrealistic5 and therefore pain free sitting is crucial. Dislocated hips may give rise to pain5'6 and make comfortable seating arrangements difficult. Indeed over halfof non-walking children may have pain from a dislocated hip37. Splintage ofthe lower limbs in the abducted position is sometimes required to maintain the hip reduction, but these splints are frequently poorly tolerated2. Moreover, because many children spend a large part of the day in a wheelchair, the hips, so held in this flexed and adducted position, may lead to hip pain and may also have a greater tendency to dislocate. It should be possible to improve the hip position by keeping the joints in a more abducted position
Figure 1. Supinepelvic radiograph showing a subluxated right hip joint. Migration percentage: 86%o, right hip; 13%, left hip Correspondence to: Dr A Clarke, Department of Orthopaedic Surgery, Northern General Hospital, Herries Road, Sheffield S5 7AU
Figure 2. Pelvic radiograph taken in a conventional wheelchair showing a poorly covered right femoral head. Migration percentage: 83%, right hip; 29%, left hip. Same patient as Figure 1
Figure 3. Radiograph taken with the subject seated in the Sandall Wood wheelchair. Migration percentage 60%, right hip; 10%, left hip. Same patient as Figure 1
throughout the day. Conventional wheelchairs, however, do not allow for this position. At the Sandall Wood School, Doncaster, a wheelchair has been developed in accordance with Department of Health guidelines. This wheelchair allows the hip abduction required to improve femoral head location compared with that obtained with more conventional models (Figures 1-3). With better hip location throughout the day, the child is free from pain and is therefore able to interact better with his or her surroundings. Methods and results The Sandall Wood wheelchair (Figure 4) has been used in selected patients suffering from cerebral palsy with total body involvement in Doncaster who are under the age of 12 years. Other exclusion criteria include the presence of athetosis, children with such poor hip abduction that this prevents them from sitting astride the chair and those patients who co-operate poorly. Despite the 30 degrees of hip
0141-0768/92/
030150-02/$02.00/0 © 1992 The Royal Society of Medicine
.~ ;. -~~ ~ ~ ~ ~ ~ ~ ~. . . . .:
__ ~ ~ ~ ~ ~
~
~
~
~
~ ~ ~~~..
Journal of the Royal Society of Medicine Volume 85 March 1992
Pain is a significant problem for those children affected by hip subluxation/dislocation and therefore every attempt should be made in its prophylaxis. If the hips can be held in abduction with the use of a cylindrically seated wheelchair, it would seem that this may be an easy and acceptable method of achieving this aim in a number of patients. Furthermore the posture of the patient in a conventional wheelchair may be deleterious to the maintenance of hip location (Figure 2).
...!.:
::
Acknowledgments: The authors would like to thank-Mrs P Crome, Senior Physiotherapist and Mr R Spooner, technical advisor. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
...
~~~~~~~~~~~~~~~~~~~~~.
: ..
Figure 4. The Sandall Wood wheelchair
abduction required for this seat, we have had no children with sacral or ischial sores and all patients to date have tolerated the chair well.
Discussion In many children suffering from cerebral palsy it is possible to achieve an acceptable walking ability, but this goal is unrealistic in a number of children with total body involvement.
References 1 Rang M, Douglas G, Bennet GC, Koreska J. Seating for children with cerebral palsy. J Pediatr Orthop 1981; 1:279-87 2 Samilson RL, Tsou P, Aamoth G, Green WM. Dislocation and subluxation ofthe hip in cerebral palsy. JBone Joint Surg [Am] 1972;54-A:863-73 3 Hoffer M. Management of the hip in cerebral palsy. J Bone Joint Surg [Am] 1986;68-A:629-31 4 Kalen V, Bleck EE. Prevention of spastic paralytic dislocation of the hip. Dev Med Child Neurol 1985; 27:17-24 5 Hoffer M, Stein GA, Koffman M, Prieto M. Femoral varusderotation osteotomy in spastic cerebral palsy. J Bone Joint Surg [Am] 1985;67-A:1229-35 6 Sharrard WJW, Allen JMH, Heaney SH, Prendiville GRG. Surgical prophylaxis of subluxation and dislocation of the hip in cerebral palsy. J Bone Joint Surg [Br] 1975;57-B:160-6 7 Cooperman DR, Bartucci E, Dietrick E, Millar EA. Hip dislocation in spastic cerebral palsy: long term consequences. J Pediatr Orthop 1987;7:268-76
(Accepted 11 September 1991)
151
