Clinical Guidance. Neonatal Manual Chapter 10: Musculoskeletal problems

Transcription

1 Clinical Guidance Neonatal Manual Chapter 10: Musculoskeletal problems Summary This manual contains clinical guidelines developed by the Neonatal Unit multidisciplinary team over recent years. This chapter contains guidelines on musculoskeletal problems. It is linked to and should be used in conjunction with the completed neonatal manual details of which are contained in the introductory chapters. Document Detail Document Type Clinical Guideline Document name Neonatal Manual Chapter 10: Musculoskeletal problems Document location GTi Clinical Guidance Database Version 2.0 Effective from September 2011 Review date September 2013 Owner Clinical Lead, Children s Services Author Timothy Watts, Consultant Neonatologist Approved by, date Neonatal and Paediatric Clinical Governance Group, September 2011 Superseded documents Neonatal Manual Chapter 10: Musculoskeletal problems v1.0 Related documents Neonatal Manual Chapters 1-15 Keywords Neonatal, Neonatology, Neonatal Unit, Newborn, NNU, NICU, SCBU, Erb s palsy, brachial plexus, talipes, CTEV, spina bifida, sacral pit, developmental dysplasia, congenital dislocation of the hip, DDH, CDH, dysraphism Relevant external law, regulation, standards Change History Date Change details, since approval Approved by

2 CONTENTS 10. Page 10.1 Brachial plexus palsies Talipes equinovarus Screening for neonatal hip problems Lower spinal abnormalities sacral dimples, pits and spinal dysraphism Spina bifida / meningomyelocoele Hemivertebrae 9 Page 2 of 9

3 10.1 BRACHIAL PLEXUS PALSIES Risk factors - LGA, IDDM, shoulder dystocia & difficult deliveries Erb s palsy C5-C6 nerve roots "waiter's tip" position - decreased or absent shoulder abduction with elbow extension, forearm internal rotation and wrist flexion Klumpke's palsy (rare) C8-T1 nerve roots claw hand - intrinsic muscles of the hand involved, along with wrist and finger flexors, sympathetic nerves leading to Horner s syndrome and also hyperabduction of shoulder Erb-Duchenne-Klumpke palsy C4-T1 nerve roots entire arm paralysed raised hemidiaphragm may occur if extensive enough lesion to involve C4 Assessment Observe for signs of fracture of humerus or clavicle or cervical spine subluxation; if in doubt do X-ray of limb, shoulder and cervical spine. Assess and record full neurological examination of affected limb Position including flexion / extension of elbow / wrist Extent of spontaneous movement of shoulder, elbow and wrist and degree of reduction of movement (e.g. reduced or absent Moro reflex on affected side) Muscle tone and tendon reflexes Presence or absence of grasp reflex Assess for signs of respiratory distress (implying diaphragm involvement) or unequal pupils (Horner s syndrome) which may indicate a worse prognosis CXR if lesion extensive or if C4 likely to be involved Parents should be spoken to by senior doctor regarding prognosis and recovery. Liaise with consultant, Associate Specialist or registrar. Any discussion should be recorded in the neonatal notes. Management Refer to physiotherapy (Bleep 2247 or 1649), who will see the baby after the prognosis has been discussed with the parents. They will give general advice on positioning and handling, sensory stimulation and passive stretches of the hand, wrist and elbow. They will also refer for outpatient physiotherapy follow-up. Page 3 of 9

4 If the child is seen and discharged at the weekend, record their details and refer to physiotherapy via EPR (see below). The national guidelines from the Association of Paediatric Chartered Physiotherapists state that movements of the shoulder joint should not start for a minimum of 48 hours, with a preference for 5 days. This advice should be given to the parents if discharged from the ward prior to physiotherapy involvement. Arrange follow-up: Neonatology OPD 6 weeks EPR referral to Paediatric Physiotherapy in ECH. Process on EPR is as follows: Enter Orders; Other Requests and Referrals; Therapy Referrals; Physiotherapy OUTPATIENT Referrals (ensure Paediatrics is chosen from the Paediatric Speciality drop-down menu) Prognosis 80-90% chance of full recovery in all but most extensive lesions If no biceps recovery evident at 6 weeks a referral should be made to the Peripheral Nerve Injury Unit Royal Orthopaedic Hospital, Stanmore. Referral should also be made if weakness persists >3 months. Babies over 1 year can be referred to the orthopaedic team at ECH Page 4 of 9

5 10.2 TALIPES EQUINOVARUS Check mother s antenatal notes and u/s scan results. Fully examine baby for any other abnormalities with particular attention to neuromuscular, spinal and hip examination. Referral to physiotherapist is only required for structural talipes. Bleep 2247 or 1649 to confirm whether physiotherapist will be able to see baby before discharge home. If there is uncertainty if the deformity is structural or positional, the physio will be happy to advise. Outpatient physiotherapy referral should be done via EPR. An antenatal diagnosis of talipes may lead to antenatal referral of the mother to the CTEV (Congenital Talipes Equina Varus) clinic. If mother has been seen antenatally she will have been advised to contact the appropriate physiotherapist at discharge (extension 84660). Positional talipes Caused by abnormal pressures compressing the foot while it is developing. This may be a result of its position in-utero or a lack of amniotic fluid. Usually the position of the foot at the ankle and sub-talar joints, are altered. The ankle is inverted and plantarflexed. There maybe associated tightness of the soft tissue If there is active movement at the ankle joint, and it is passively correctable past neutral into eversion, there is no need to refer to physiotherapy Reassure the parents that this should correct itself independently, but if persistent beyond 6 weeks they should inform their GP If the foot is not correctable to neutral and there is limited active movement, a referral to physiotherapy should be made (EPR or bleep 2247 or1649). If the child is seen and discharged at the weekend, refer to physiotherapy via EPR. Structural talipes Does not correct beyond the neutral position. Examine the hips carefully and arrange a hip u/s scan to exclude congenital dislocation of the hips Refer to Paediatric Physiotherapy via EPR Manipulation and application of well-moulded plaster casts (Ponsetti method) may correct even severe deformities, but must be performed by a trained paediatric physiotherapist in a children s orthopaedic setting. This service is available at ECH in the CTEV clinic. Casting starts as soon as the baby is seen in the clinic, which would normally be by 2 weeks of age. Babies who have had talipes diagnosed antenatally should be seen and assessed in the CTEV clinic regardless of apparent severity. Ensure parents have contact details (if seen antenatally) or refer via EPR. Page 5 of 9

6 10.3 SCREENING FOR NEONATAL HIP PROBLEMS Risk factors for congenital dislocation of the hip and developmental dysplasia of the hip include family history, breech presentation (>36 weeks gestation even if baby becomes cephalic after that), oligohydramnios, sterno-mastoid tumour and torticollis, foot deformities and congenital myopathies and neurological disease. If neonatal examination is otherwise normal in this group of patients then arrange OPD hip ultrasound scan at 4-6 weeks of age. The ultrasound department will inform parents of the result and ensure referral to Mr. Norman-Taylor (Consultant Paediatric Orthopaedic Surgeon) if abnormal. There is no need to arrange Neonatology OPD follow-up. For babies with abnormal clinical examination, i.e. Ortolani's test or Barlow's test is positive, clicky hips, asymmetrical creases or limited abduction, ask registrar or consultant for post-natal ward to examine baby. Hips that are in joint but dislocatable or subluxable do not need immediate orthopaedic referral as many resolve spontaneously. These babies should have an ultrasound at 4-6 weeks of age. The ultrasound department will inform parents of the result and ensure referral to Mr. Norman- Taylor if necessary. If dislocated hips are diagnosed (limited abduction, thigh shortening, positive Ortolani test) initiate immediate referral to Mr. Norman-Taylor via his secretary on extension These babies will be followed up in the joint physiotherapy and orthopaedic baby clinic for hips and feet. Page 6 of 9

7 10.4 LOWER SPINAL ABNORMALITIES SACRAL DIMPLES, PITS AND SPINAL DYSRAPHISM Dimples or pits within or just above the natal cleft are common. If skin overlying the defect is intact and there are no other abnormalities on examination then reassure. If you are uncertain whether skin is intact and there is no sinus or discharge, and the neurological examination is normal, ask registrar or consultant to review and then arrange an AP and lateral x-ray of the lumbo-sacral spine and an u/s scan of the lower spinal cord, kidneys and bladder (can be done as an outpatient if early discharge planned) and Neonatology OPD follow-up. Any lesion at any spinal level with a fat pad, significant hairy patch, atretic skin, sinus or swelling or if there is associated lower limb neurological signs or bladder dysfunction, warrants early investigation. Inform registrar or consultant. Arrange an early u/s scan of the lower spinal cord, kidneys and bladder. If this is abnormal then it may be necessary to investigate further with an AP and lateral x-ray of the lumbo-sacral spine and MRI scan. Discuss further follow-up with Paediatric Neurology team. There is a small risk of recurrence and advice is to take high dose folic acid pre-conception and during early pregnancy in subsequent pregnancies. These conditions do not usually warrant a formal Clinical Genetics referral, but they are happy to advise as needed. Page 7 of 9

8 10.5 SPINA BIFIDA / MENINGOMYELOCOELE Closed lesion Look for other congenital anomalies, particularly midline malformations SpR or consultant review Investigations: Lumbo-sacral spine x-ray Cranial u/s scan Spinal u/s scan Renal tract u/s scan Discuss with Neurosurgical team at King s College Hospital within 24 hours of birth Open lesion Resuscitate as necessary Cover the lesion with saline soaked sterile gauze and cover with cling film Refer urgently to Neurosurgical team at King s College Hospital Start antibiotic prophylaxis (IV Penicillin and Gentamicin) Look for other congenital anomalies, particularly midline malformations Full neurological examination by an experienced neonatologist or paediatric neurologist including an assessment of ability to pass urine and stool normally Investigations: Lumbo-sacral spine x-ray Cranial u/s scan Spinal u/s scan Renal tract u/s scan May need cranial and spinal MRI Page 8 of 9

9 10.6 HEMIVERTEBRAE Hemivertebrae may be diagnosed antenatally or postnatally. They may be isolated or part of a more extensive syndrome. They are usually symptom free at birth but compression of the spinal cord sometimes occurs. There is a high risk of later scoliosis Management and investigations Complete examination at birth to exclude other abnormalities Full neurological examination at birth by experienced neonatologist or paediatric neurologist including an assessment of ability to pass urine and stool normally. X-ray of whole spine, A-P and lateral (and other bones if indicated clinically) U/S scan of the spinal cord If abnormal neurological signs and/or u/s scan abnormality of cord - MRI of spinal cord Referral If no neurological or ultrasound scan abnormality refer to the children s spinal team on x51603 or (this mobile held by the on-call SpR or Fellow). If neurological and/or MRI abnormality refer to both the children s spinal team and Paediatric Neurology Page 9 of 9