PROYECTO DE CONVENIO DE ADHESION PARA SUSCRIBIRSE CON ENTIDADES FEDERATIVAS

Epidural catheter provides adequate analgesia and al- lows early mobilization.

rehabilitation..Assess.the.severity.of.the.problem.to.determine. the. expected. functional. result. of. surgery.. The. Gross. Motor. Classification.System.is.a.way.to.assess.severity.of.involvement.. Try.to.get.treatment.for.co-morbidities.such.as.seizures,.gastro- esophageal. reflux. and. infections. preoperatively.. Evaluate. the. severity. of. mental. retardation,. behavioural. disturbances. and. social. problems.. Consider. gastrostomies. for. children. with. oromotor.dysfunction.and.growth.retardation..Plan.preoperative. physiotherapy,.exercises.and.instructions.in.walker.or.crutch.use.. Postoperative care

Analgesia

Pain. accompanies. all. operations.. Focus. on. pain. and. anxiety. relief,.muscle.relaxation.in.the.immediate.postoperative.period. [A]..Usually.a.combination.of.a.narcotic.analgesic.and.diazepam. helps.to.control.the.immediate.pain..Elevation.of.the.extremity.is. essential.for.both.pain.relief.and.oedema.prevention..

Pain. is. very. common. in. the. postoperative. period,. though. it.is.difficult.to.predict.who.will.have.mobilisation.problems. because.of.pain..Postoperative.pain.management.is.important.for. early.rehabilitation..Parenteral.analgesics.and.patient.controlled. epidural. analgesia. are. options. to. control. pain. [B].. Consider. epidural.anesthesia.for.all.operations.of.the.lower.extremities. in.the.older.child..Insert.a.urinary.catheter.before.the.epidural.. Continue. the. epidural. catheter. for. postoperative. analgesia. at. least.24.hours.for.muscle.and.72.hours.for.bone.operations..Turn. the.epidural.off.afterwards.and.switch.to.oral.medications.like. diazepam.or.oxycodone..Remove.the.epidural.catheter.if.oral. medications.control.the.pain..Routinely.use.antiinflammatory. medication. for. pain. relief.. Do. not. use. ketodolac. after. bony. surgery.because.it.delays.bone.healing..Reassure.the.child.and. family.that.the.pain.will.subside.within.few.days. Ice.application.after.all.operations.relieves.pain.and.keeps. the.swelling.down..Apply.the.ice.for.2-3.days.through.the.cast.. Try.to.distinguish.spasticity.pain.from.inflammatory.muscle/ joint.pain.and.make.an.effort.to.relieve.it..After.surgery.spasticity. may. be. reduced. because. the. muscle. length. has. changed. but. it. frequently.returns.3.-.6.months.later..Choose.diazepam.or.baclofen. for. muscle. relaxation. and. analgesia.. Baclofen. has. analgesic. effects.in.pain.due.to.spasticity..The.administration.of.diazepam. as.a.central.muscle.relaxant.and.sedative.agent.is.helpful.. Mobilization

Minimize. recumbency. and. immobilization.. Encourage. early. mobilization.and.early.weight.bearing.as.well.as.strengthening. of. the. trunk. and. upper. extremities.. Following. surgery. use. casts.[C],.splints,.plastic.AFO’s.or.KAFO’s.depending.on.the. age.and.cooperation.of.the.child.as.well.as.surgical.stability.. Choose.prefabricated.knee.immobilizers.in.older.children.after. hamstring.lengthening..Allow.to.bear.weight.on.the.second.to. fourth.days.after.soft.tissue.surgery..Time.for.weight.bearing. is. guided. by. the. quality. of. internal. fixation. of. the. bones. in. combined. soft. tissue. and. bony. surgeries..Adequate. nutrition. and.skin.care.are.necessary.to.prevent.complications.such.as. pressure. sores.. Use. a. synthetic. cast. if. the. child. has. bladder. control.. Prefer. a. plaster. of. Paris. cast. and. overwrap. with. synthetic. material. to. avoid. making. the. cast. too. heavy. if. the. child. is. incontinent..A. thin. layer. of. plaster. of. Paris. absorbs. urine.and.prevents.skin.irritation.

Immobilize the patient in a cast or brace for a few days after surgery. Osteotomies take longer to heal. Keep the child in cast longer after osteotomies. Elevate the legs with pillows under the shins. Use abductor wedges in the early postoperative period after hip adductor lengthenings.

Postoperative medication Pain control

Epidural catheter

Antiinflammatory medication (No ketodolac after bone surgery) Reassurance & support

Ice over the cast Spasticity control

Baclofen (oral)

66 Orthopaedic Surgery

Use either a prefabricated elastic knee immobilizer or a simple posterior shell after hamstring lengthenings without gastrocnemius surgery. The child will cooperate much better if his feet are free.

The hip Encourage.prone.sleeping.early.on.after.flexor.releases.

or.osteotomies.of.the.hip..Have.the.child.sleep.in.knee.extension. splints.for.6-8.weeks.after.surgery.to.maintain.hip.extension..

Use.an.abduction.wedge.or.pillow.after.adductor.releases.to. keep.the.hips.in.30o.abduction.at.night..Continue.postoperative. abduction.pillows.for.6.weeks..Limit.the.time.the.child.spends. in. a. wheelchair. after. hip. adductor. and. flexor. releases. or. osteotomies..Do.not.allow.sitting.for.more.than.an.hour.after. bone. surgery.. Start. active. exercises. on. the. 3rd. postoperative. day..Stretching.exercises.are.essential..

Apply. a. hip. spica. cast. for. 4. weeks. in. young. children. after. pelvic. osteotomies,. 3. weeks. after. femoral. varus. derotation. osteotomies.. There. is. no. need. for. hip. spica. casts. after. intertrochanteric.osteotomies.with.stable.internal.fixation.above. age.8..Bed.rest.is.sufficient..Begin.ambulation.with.crutches.in. the.early.postoperative.period..

The knee Use. cylindrical. casts. or. splints. in. knee. extension.

for.3.weeks.after.hamstring.lengthening..Have.the.child.wear. the.splints.[A].or.knee.immobilizers.[B].at.night.for.6.weeks. after.surgery..Limit.elevation.of.the.leg.in.bed.to.one.pillow.in. order.to.prevent.stretch.of.the.sciatic.nerve..Mobilize.the.patient. within.2.or.4.days.with.the.cast.or.splint.on..

Immobilize. the. knee. in. an. extension. brace. or. knee. immobilizer. after. rectus. femoris. transfers.. Begin. knee. flexion.exercises.and.weight.bearing.on.the.second.to.fourth. postoperative.days.to.prevent.adhesions.and.knee.stiffness.[C]..

The foot The.most.common.surgery.in.the.foot.is.heel.cord.

lengthening..In.a.very.young.child.use.a.Vulpius.type.procedure.. An.AFO.is.usually.sufficient.after.surgery..For.tendon.surgery. i.e..split.tendon,.total.tendon.or.anterior.tibial.tendon.transfers,. recommend.6.weeks.in.a.walking.cast..For.bone.operations.such. as.calcaneal.lengthenings,.subtalar.arthrodesis.and.osteotomies. of. the. cuneiform. bones,. recommend. 6. weeks. in. a. cast;. non- weight. bearing. for. the. first. 3. weeks,. weight. bearing. for. the. second.3.weeks..

The spine Following.spine.fusion.for.scoliosis spinal.braces.

are. not. necessary. if. the. fixation. is. stable.. Use. body. casts. or. braces.for.6.months.in.children.with.poor.bone.quality.

Night splints A.period.of.splint.use.to.prevent.the.recurrence.

of.contractures.after.cast.removal.is.helpful..However,.splints. disturb.sleep.by.constantly.keeping.the.muscles.in.the.stretched. position..Night.splints.should.be.used.very.carefully.because. not. all. children. will. tolerate. them.. It. is. important. that. the. child.sleeps.well..Splints.are.not.necessary.in.children.whose. muscle.tone.decreases.during.sleep..The.correction.obtained.by. splints.should.not.be.painful.for.the.child..A.way.to.improve. compliance. is. to. use. night. splints. on. one. extremity. the. first. night.and.on.the.other.the.next.night.

Children.who. tend.to.have.recurrence.of. equinus.or. who. have. had. a. second. heel. cord. lengthening. should. sleep. in. a. dorsiflexion.splint.at.night..The.severe.quadriplegic.child.who. has.dystonia.and.tends.to.contract.severely.can.be.placed.in.an. A.frame.at.night..Do.not.use.night.time.knee.extension.splints. for.more.than.3.months.post.operatively...

Early mobilization is crucial for the success of surgery. Allow ambulation in plastic solid KAFOs in the 2nd day in patients who have had both hamstring and gastrocnemius lengthenings. Proceed to AFOs during the day after 3 weeks. Use night KAFOs for at least 6 weeks.

The knee immobilizer is lighter and easier to use than the plastic KAFO; however it is not suitable in severe flexion contractures.

67