Hip surveillance in children with cerebral palsy

Authors

Min S. Phang, MRCP, FRCPC (biography and no disclosures) and Stacey Miller, PT (biography and disclosures)

Disclosures: Stacy Miller: Involved in the international consensus process to develop the American Academy of Cerebral Palsy and Developmental Medicine Hip Surveillance Care Pathway. Mitigating potential bias: Recommendations are consistent with these published guidelines and current clinical practice. Recommendations are consistent with current practice patterns.

Acknowledgments: Child Health BC, Dr. Kishore Mulpuri, and Dr. Maureen O’Donnell.

What I did before

Ensuring the physical and functional challenges of children with cerebral palsy are met has always been an important part of my practice. However, specific guidelines on how to do the right things haven’t always been available. Cerebral palsy is an umbrella term used to describe “a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behaviour, by epilepsy, and by secondary musculoskeletal problems”. ^{(p7, 1)}  Those secondary musculoskeletal problems include hip displacement, a surprisingly common problem in children with cerebral palsy.

One in three children with cerebral palsy will have hip displacement.^2-4 Population-based studies have shown a linear relationship between a child’s gross motor function, as described by the Gross Motor Function Classification System (GMFCS), and risk of displacement.^2-4 The GMFCS is a five level ordinal scale that describes a child’s self-initiated movement. Children at Level I walk without limitations but have difficulties with balance and coordination while children at Level V require considerable physical assistance and assistive technology.^5,6 Up to 90% of children whose motor function is classified at GMFCS level V will have hip displacement.³

Children with cerebral palsy are born with a normal hip. A lack of, or delay in, weight-bearing and abnormal muscle forces around the hip can contribute to changes in the proximal femur and gradual subluxation. However, it’s a silent problem that often has no signs or symptoms until a hip is dislocated and becomes painful. As such, the problem is often overlooked. Once a hip is fully dislocated, the head of the femur can become damaged with the cartilage being worn away. In such cases, treatment options are often limited to salvage surgeries where the femoral head is removed. Such procedures have variable outcomes with only partial pain relief and a higher number of complications.  Detecting hip displacement early allows for less complex surgery and improved patient outcomes.

Ordering hip x-rays for children with cerebral palsy was something I did but not on a routine basis. If a child complained of pain, a radiograph was ordered or a referral to a pediatric orthopaedic surgeon was initiated. Unfortunately, in some cases, the referral was made too late and the hip was already dislocated. I had a number of patients that required complex orthopaedic hip surgeries. Some children may have received intermittent hip x-rays when followed by a pediatric orthopaedic surgeon but most children with cerebral palsy in the province have not had routine monitoring for hip displacement by a physician. Lack of screening is a common problem in Canada and the world.

What changed my practice

Hip surveillance programs in Australia and Sweden have demonstrated that, together with timely orthopaedic management, the incidence of hip dislocations can be significantly reduced in children with cerebral palsy.^7-9   In 2011, Child Health BC, a network dedicated to improving the health of BC’s children and youth, brought together over 50 key stakeholders from all regions of the province to discuss the need for hip surveillance in British Columbia. This interdisciplinary group included parents, orthopaedic surgeons, developmental pediatricians, pediatricians, general physicians, radiologists, physiotherapists, other health care professionals, and policy makers. There was unanimous agreement among the group that hip surveillance was needed in BC. The group worked collaboratively to reach a consensus on guidelines for hip surveillance (see Quick Guide) based on the current best evidence, international surveillance practices, and the feasibility of surveillance in our province of over 1 million square kilometers. Subsequently, the group developed a provincial implementation plan that was practical for rural and urban settings.

The Child Health BC Hip Surveillance Program for Children with Cerebral Palsy, the first in North America, launched in 2015. All children with cerebral palsy in BC are eligible. The program is coordinated at BC Children’s Hospital and works together with a child’s local healthcare team to complete hip surveillance in the child’s local community (view care provider tools). Children do not need to travel to BC Children’s Hospital for screening. The child’s physiotherapist, in the local child development centre or school, completes a short clinical exam and, if necessary, the child has an x-ray of their hips at their local hospital. The clinical exam and x-ray are ordered by the Program Coordinator based on the frequency recommended by the established consensus guidelines. The results of the exam and x-ray are reviewed by the team at BC Children’s Hospital and recommendations are made back to the family and local healthcare team. If indicated, the child or youth is referred to a pediatric orthopaedic surgeon for a more detailed assessment of the hip.

What I do now

I now refer all children with cerebral palsy, or suspected cerebral palsy, to the Child Health BC Hip Surveillance Program. Information about the program is available at www.childhealthbc.ca/hips, including a referral form for physicians.  Anyone can refer a child to the program, including parents. All children and youth with cerebral palsy in BC are eligible.   It is important to note, that cerebral palsy is a clinical diagnosis with many causes. Altered brain development may be caused by bleeding in the brain in the prenatal, perinatal or post natal period, underlying genetic conditions, chromosomal abnormalities, metabolic conditions, infections of the brain, and traumatic brain injuries.

Once my patient has been referred, I can expect they will have regular hip screening based on their level of risk. I receive communication from the Program Coordinator whenever a clinical exam or x-ray is completed; this includes the test results, recommendations for further hip surveillance, and, if necessary, recommendations for referral to Orthopaedics. For more information, contact the program coordinator at hips@cw.bc.ca.

Resources

From the Hip Surveillance Program For Children With Cerebral Palsy:

1. Care provider resources: http://www.childhealthbc.ca/hips#reports
2. Quick Guide (View)
3. Referral form (View)
4. eLearning module (View)
5. Clinical Exam Instructions (View)

Handouts for patients

Parent Booklet: (View)

References

1. Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M. A report: the definition and classification of cerebral palsy – April 2006. Dev Med Child Neurol. 2007;49:8-14. (Request with CPSBC or view with UBC)
2. Hagglund G, Lauge-Pedersen H, Wagner P, et al. Characteristics of children with hip displacement in cerebral palsy. BMC Musculoskelet Disord. 2007;8:101. (View)
3. Soo B, Howard JJ, Boyd RN, et al. Hip Displacement in Cerebral Palsy. J Bone Joint Surg. 2006;88:121-129. (View with CPSBC or UBC)
4. Conelly A, Flett P, Graham H, Oates J. Hip surveillance in Tasmanian children with cerebral palsy. J Paediatr Child Health. 2009;45:437-443. (Request with CPSBC or view with UBC)
5. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39:214-223. (View)
6. Palisano R, Rosenbaum P, Bartlett D, Livingston M. Content validity and the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol. 2008;50:744-750. (View)
7. Dobson F, Boyd R, Parrott J, Nattrass G, Graham H. Hip surveillance in children with cerebral palsy – Impact on the surgical management of spastic hip disease. J Bone Joint Surg Br. 2002;84B:720-726. (View)
8. Hagglund G, Andersson S, Duppe H, Lauge-Pedersen H, Nordmark E, Westbom L. Prevention of dislocation of the hip in children with cerebral palsy – The first ten years of a population-based prevention programme.  Prevention of dislocation of the hip in children with cerebral palsy. J Bone Joint Surg Br. 2005;87B:95-101. (View)
9. Kentish M, Wynter M, Snape N, Boyd R. Five-year outcome of state-wide hip surveillance of children and adolescents with cerebral palsy. J Pediatr Rehabil Med. 2011;4:205-217. (Request with CPSBC or view with UBC)

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Hip surveillance in children with cerebral palsy

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