There are multitudes of neurological disorders that may present in an orthopaedic clinic. These can vary from polio, which has now almost disappeared from the developed world (but which once dominated orthopaedics), through to rare familial disorders.

Classification

Neurological disorders can be divided into simple groups. There are those which are static, such as polio and cerebral palsy, and there are those which are progressive, such as Huntington’s chorea. Secondly, there are those that affect only the motor or sensory modality (polio only affects motor nerves), or they can be mixed motor and sensory. The diagnosis and management is to a large degree based on this simple classification.

Management

The principles of management revolve around the same principles as in the rest of orthopaedics – the relief of pain, deformity and disability. In these cases disability is usually the main problem and physiotherapists, occupational therapists and social workers have a very major role to play in enabling these patients to live as full a life as possible.

Cerebral palsy

This is a non-progressive condition. The cause is unknown. It used to be thought that it was usually caused by birth trauma. More recently it appears that sometimes the damage may have already occurred in utero. The child is commonly a floppy baby with delayed ‘milestones’, and it is not for some time that the spasm develops that characterises cerebral palsy. These children are frequently of normal intelligence and great care must be taken not to assume that just because they are physically disabled and may have difficulty in communicating, that they are not of normal intelligence. The spasm of muscles reduces the ability of the child to produce powerful, coordinated movements, but also may produce fixed deformities of joints. These need to be avoided wherever possible.

Treatment goals in cerebral palsy

One of the key skills with a patient with a neurological disorder is to set realistic and useful goals. Devoting every waking hour for 5 years to getting a child to walk may be a triumph for everyone. But if this is achieved at a cost to their development in other ways, and if in a few years they go back off their feet, then this was not an appropriate goal. It might have been better devoting time and effort to developing good seating and training in the use of computers to help communication.

This is the specialty of producing braces and splints designed to provide patients with support for limbs and artificial limbs. These can be temporary or permanent and may serve to reduce pain, improve function or even improve cosmesis. The traditional materials of leather and steel have been replaced with lightweight plastics, which conform so well in shape and colour that they can be almost invisible. They can be static (providing simple support) or dynamic (reproducing a movement that the patient is not capable of producing themselves).

When requesting imaging, you would be wise not to tell the radiographer what views you want, just explain the problem. The same rules apply to an orthotist; it is their job to decide what splint is required. It is your job to explain the problem in terms of pain, deformity and disability, so that they can decide on the best way of managing the problem.

Dilemma of limb reconstruction versus early amputation

Severely injured limbs can pose a difficult clinical dilemma. Should a long reconstruction programme be started with an uncertain result, or would a better result be obtained by an early amputation with quick discharge from hospital and return back to normal life? As fast as new techniques are developed for reconstructing severely damaged limbs, new designs of prosthesis are appearing which are strong, cosmetically acceptable and give very good function, especially in the lower limb. Upper limb prostheses are hampered by the fact that no artificial limb can come near to the function of a normal limb that has feeling and which can use that feeling to control grip.

Sensory loss

However, if sensory function is unlikely to return because of permanent damage to sensory nerves, then amputation of a lower limb is strongly indicated. This is because if there is no protective sensation, then sores will develop which will ulcerate, and which may even lead to septicaemia. Amputation may also be the most appropriate route if there is no muscle power to stabilise joints, as this too severely reduces the functionality of a limb.

Modern methods of reconstruction

Bone transport using the Ilizarov fixator has now made it possible to grow bone across large defects in long bones. Similarly, vascularised flaps allow large soft tissue defects of muscle, as well as skin, to be covered. However, all these procedures are time-consuming and difficult to perform. If they fail, the patient is left depressed and will have been in hospital for so long that their chances of return to normal life have effectively been destroyed. In retrospect an early amputation may have been the best option.

Modern orthotics

Below-knee prostheses are now light and strong. They are cosmetically almost indistinguishable from a normal leg and allow the patient to run, dance and take an active part in life. Above-knee amputations are more difficult as the knee hinge is more difficult to manage and the fit that can be obtained onto the thigh may be more difficult than the shin where there is less fat. Even so, a properly fashioned aboveknee prosthesis can prove highly functional.