This April I’d be starting my #Clubfoot clinic as part of the Pediatric Orthopedic Clinic at Sri Ramakrishna Ashrama Charitable Hospital, #Thiruvananthapuram, Kerala.
This hospital caters to poor patients in the city and a cost effective Clubfoot Clinic will add to the existing services run here.
Last month I had started my Paediatric Orthopaedic Clinic there officially and we plan to step up the services for Cerebral Palsy, Pediatric Sports Injuries and Pediatric Limb Deformities in coming months as more ancillary services are commissioned here.
Clubfoot Clinic at Thiruvanathapuram,KeralaPediatric Orthopedic & Cerebral Palsy Clinic at Thiruvanathapuram,Kerala
Do pass the news around to people who may benefit. Our main focus would be to keep it state of the art and cost effective.
Overtime we will add features to the clinic and ancillary services . Watch this space !!
After many years of work we finally have a #PediatricNeurologist ( Dr.Velmurugan, Hope Neuro Centre , Coimbatore ) (geared towards #DevelopmentalNeurology), Occupational Therapists, #Pediatrician (Dr. Lakshmi, Coimbatore), #Psychiatrist(Dr. Sajal), #Psychologist joining our team to treat Developmental Neurological issues in Children and Cerebral Palsy.
This is the first day of two day free medical camp. First day is dedicated to the neurological issues in children like #Autism, #Seizure disorders and second day for #PediatricOrthopedic Diseases, Limb Deformities like #ClubFoot and #CerebralPalsy.
This was in organised in association with #Sevabharathi who has been most kind in donating money, arranging volunteers etc.. The premises itself is a Lifecare Physiotherapy clinic of Biju Bhasker at #Palakkad, #Kerala.
Most kind have been Sevabharathi, it’s volunteers and Dr. Sreeram Sankar without whom this wouldn’t be possible. When me and Mr.Biju approached them with the idea 2 years ago they had a kind heart to go ahead and help us with much needed sponsorship and man power.
Watch this space. The next event would be bigger and better !!
Recently gave an interview to a popular news channel in #Kerala in #Malayalam.
The topic was “Common Children’s Orthopedic Disorders and Cerebral Palsy”.
It’s is in an interview format with patients who are interested phoning in the channel to discuss some of their doubts about these disease conditions.
The idea was to take up and discuss the most common children’s bone diseases that parents would need guidance on like Bow Legs, Knock Knees, Club Foot, TB infection of Bones, Perthes Disease of hip, Cerebral Palsy and interact with patients who may phone in.
I have great pleasure to announce that along with the launch of a Cerebral Palsy Clinic at Sri Ramakrishna Ashrama Charitable Hospital , Thiruvananthapuram, Kerala I am also starting an exclusive Pediatric Orthopedic Clinic.
This will cater to children suffering with bone and joint disorders, congenital deformities like Club Foot, Flat foot, Knock Knees and Bow legs among many others. Treatment advise for Spine problems in children like spina bifida, congenital and idiopathic scoliosis are also offered.
I am hereby attaching a video clip showing the many clinical conditions for which services are being offered here.
This hospital being a charitable one caters to the poor and these services would be of benefit to many.
Kindly share among your friends so that people are aware of the new service.
Dr. Easwar TR Pediatric Orthopedic & Spine Surgeon
Dr. Easwar T R addressing the parents on care giving in Cerebral Palsy and treatment options
It was a wonderful experience to be part of the team that organised #WorldCerebralPalsyDay event to bring parents, children, caregivers, NGOs, Doctors, Therapists, Counsellors together for a day and have fun and enrich themselves.
The event was organised by Lifecare #Physiotherapy Centre, #Palakkad, Kerala along with #Sevabharathi, #Kerala at Thrupthi Hall in the centre of town.
The choice of centre was superb as it was right in centre of town allowing easy transit for children coming in from rural areas and those with limited mobility.
We assembled at the centre around 10 am and crowd had already trickled in at that time. In another hour about 40 children, parents, caregivers and health care professionals had assembled. The inauguration was a minimal affair with Dr. Sreeram Shankar starting the welcome address with respects paid to the almighty and the parents who had taken time to get here. This was followed by a medical camp by me, a painting competition and a singing competition for the children. There was a talk after that by Dr. Deepa, Psychaitrist, District Hospital, Palakkad which was followed by my parental awareness on treating #CerebralPalsy children.
Cerebral Palsy Event inaugural address by Mr. Kalyanaraman, Palakkad, Sevabharathi
It was a red-alert day in many places for #Kerala because of fear of inclement weather. However, rain stayed away largely apart from slight drizzle. That was a relief.
Parental counselling on treatment options in cerebral palsy
Painting Competition for Children
Dr. Easwar T R addressing the parents on care giving in Cerebral Palsy and treatment options
Adult Cerebral Palsy is becoming a major issue. I was surprised that patients had pertinent questions on that topic.
Dr. Sreeram Shankar Inaugural address
Dr. Sreeram Shankar Inaugural address
Adult Cerebral Palsy is becoming a major issue. I was surprised that patients had pertinent questions on that topic.
Dr. Easwar T R addressing the parents on care giving in Cerebral Palsy and treatment options
Painting Competition for Children
Parental counselling on treatment options in cerebral palsy
About 40 children took part in the celebrations, competitions, talks and counselling sessions. It was well appreciated by all, many who are experiencing this for the first time.
Positive vibes which would rub off into the child’s care was the key. Parents took strength from one another and participated in the awareness session. Many misconceptions about Cerebral Palsy, Seizure Disorder, Autism, Global Developmental Delay were cleared.
We are planning sessions throughout this month and hopefully improve the quality and participation of these events in the next iteration.
World Cerebral Palsy Day - at Palakkad and Shoranur, 2018
#WorldCerebralPalsyDay is afoot. Like last year, I am planning to conduct month long events across Palakkad and Shoranur to raise parental awareness on treatment of #CerebralPalsy.
Most of the parents who come for care of their children come late, unfortunately with joint contractures, hip subluxations, alteration in knee mechanics and foot deformities. Aside from these the problems these children have with upper limbs, hands and doing activities.
Many of these children have uncontrolled seizures, terrible difficulties communicating, speaking out their issues apart from ambulation. Ambulation may in fact be least of their issues. This sad fact goes to show how important early referral is and how important it is to enroll the child under a care of a Pediatric Neurologist, Pediatric Physiotherapist who can then co-ordinate care with their colleagues in Pediatric Orthopedics, Pediatric Medicine, Occupational Therapy, Speech Pathology, Audiology etc ..
Cerebral Palsy care is a great team effort. No part of the team is greater than other, but the role of the General Practitioner / Pediatric Medicine Doctor, Pediatric Physiotherapist is central, at least in India. They determine the sole referral entity, a person with whom the parents spend their maximum time and trust with. They are the ones in whom they confide most of their issues with.
World Cerebral Palsy Day is a wonderful concept to reinforce these simple care giving principles. Parent education and empowerment being central to the cause of care of these children. Like 2017, we are organising activities across the district of Palakkad – in Palakkad town and neaby rural areas and Shoranur town to educate parents and also conduct early detection and intervention camps to identify children who need care.
World Cerebral Palsy Day – at Palakkad and Shoranur, 2018
Activities planned :
Free medical camps for underpriviliged children
Special clinics with Gait Analysis
Funded Orthotic programme for poor children
Pediatric Physiotherapy advice
Custom made Wheel Chair fitting
Parent awareness of Cerebral Palsy – lectures and symposias in rural areas
Notices and public handouts to improve general awareness
Involvement of other NGOs , social service organisations to improve public outreach
These activities would be done throughout Ocotober 2018 under aegis of the Cerebral Palsy Clinic at Rajiv Gandhi Cooperative Hospital & Research Centre and ICCONS, Shoranur
Contact Numbers for Clinic bookings and more information:
#IFSBHCON2018
#SPINABIFIDA
#hydrocephalus
#spinabifidafoundation
Lovely conference and lovely to see the so many families and patients viewing life with such a positive attitude https://t.co/eXqZWmuhoa
Dr. Santhosh Karmakar and Spina Bifida Foundation deserve credit for bringing together different professionals -doctors, physiotherapists and families, together for this event
Had a wonderful #CerebralPalsy and #PediatricOrtho #medical #camp at #Palakkad #Kerala organised by wonderful people at #SevaBharathi . It was well attended with parents and children braving the heavy rain.
@sevakeralam
@sevabharathitn https://t.co/Z3FT9C6RVO
I’m conducting a free medical camp for #Childrens #Orthopedic #Disorders and #BoneDiseases , #LimbDeformities and #CerebralPalsy at #Palakkad ,#Kerala . Event is organised by #SevaBharathi .
The event will be held in the premises of Life Care Cerebral Palsy Clinic which is in centre of Palakkad town enabling easy transport to the venue.
Patients and relatives are advised to bring all old records while seeking opinion. All old x-ray, other scans and will also be needed for evaluation.
Phone number for Booking :+91-80759-21075
Contact the phone on last line of notice for appointment.
(Notice is in #Malayalam, local language of Kerala )
Developmental Dysplasia of Hip - Left hip is dislocated
DDH otherwise called Developmental Dysplasia of Hip is a condition where the ‘ball-and-socket-joint’ of the hip is not formed well at birth. It used to be called Congenital Dislocation of Hip.
The child is born with a slightly misfitting hip joint where the ball is slightly shifted out of cup or a hip joint where the ball is completely outside the cup and cup is also very shallow. This can occur on one side or both sides.
Developmental Dysplasia of Hip – Left hip is dislocated
Why does it happen ?
Most times its ‘Idiopathic’ , a medical term which means – cause is not known. In many other patients, the child will be having one of the syndromes (a group of clinical features and disorders in other organs systems and external appearance) or neurological issues in the spine (like meningomyelocele) that also causes this. This second group is sometimes medically referred to as Teratogenic DDH and is much more difficult to treat.
We will discuss below the aspects as related to Idiopathic DDH. They don’t apply to Teratogenic or Neurological DDH.
How do we know the child has DDH ?
Most newborn screening procedures at the hospitals have doctors checking to see if the new born child has clinical signs of DDH. It is easiest to detect and treat it at that early stage.
Once a clinical suspicion of DDH is there the Neonatologist usually refers the child to a Pediatric Orthopedic Surgeon. In addition to establishing the clinical diagnosis by physical examination, the doctor will order an x-ray and an Ultrasound Scan of the Hips to check the dislocated hips. Several measurements need to be taken and ease of dislocation need to be established under Ultrasound scan by a procedure called Dynamic -Ultrasound. The treatment starts after these are done.
In many children, the initial diagnosis may not be made in the immediate post-delivery period. Children may be brought to the OPD by parents with complaints that the thigh skin fold dont look symmetrical and the hips don’t open out fully for parents to change diapers.
In older children parents may notice a limp when the child walks or a limb length difference may also be noted with the dislocated side being shorter.
Limb Lengths may be noted to be different in DDH when child is older and walking. The limb with the dislocated hip will appear shorter.
How soon should the treatment start ?
As described in previous section, treatment should ideally start in neonatal period once the problem has been detected. After clinical examination and Ultrasound examination, your doctor will suggest usually a belt type device called Pavlik Harness to be applied on the child to keep the hip reduced inside the cup. This harness is to be worn full time. Parents are counselled on how this is applied and how the straps are tightened.
Ultrasound exam for a child with Hip and Knee dislocation
Once this harness has been applied, the hips are scanned with Ultrasound every 2 weeks to check for improvements. Ideally this has to be kept for about 3 months and taken off after the hip stabilizes inside the socket. A slow weaning period is there before the child can be fully taken off the Pavlik Harness. This is to ensure that the Ball ( head of femur ) stabilizes inside the socket (Acetabulum of Pelvis) and the hip is stable. The tissues around the hip also has to shrink and adapt to the new location of Head of Femur. Otherwise re-dislocation or partial slip (medically called subluxation) is a possibility.
In many cases the parents may not be willing for a device to be applied on the child full time post-delivery or the DDH itself may go undetected. This child eventually may be brought later in life by the parents with complaints necessitating surgical procedures.
What is the treatment options for DDH?
As previously described if the newborn is detected to have DDH the treatment is to apply Pavlik harness on the child after Ultrasound exam proves hip is reducible and stable in what is called a safe zone. Safe Zone is a zone where the position in which the harness has to be applied to the child does not compromise the blood supply the head of femur. This is very important decision to make.
Pavlik Harness for DDH hip needs to be fitted properlyHip Spica Plaster in child with DDH
Application of Hip Spica under anesthesia in DDH
If the child is brought later in life, before 1 year, the hip has to be checked for reducibility as the tissues around the hip would have become contracted and sometimes it is difficult to reduce the hip back into the socket. Usually anaesthesia would be required and the hip once reduced back into the socket is held there by application of the plaster of paris or POP called Hip Spica. This is kept for approximately 3 months until the hip has stabilised inside. A CT scan to verify whether the hip is reduced should be done while child is in POP as slippage of the hip socket is also seen when POP cast becomes loose with time.
Surgery is the only option in older children with DDH. These range from relatively simple procedures to complex hip reconstruction procedures depending on age of the child, slope of cup, angle of rotation of the neck of the thigh bone and shape of the head. These are best evaluated as per the needs of the child.
Arthrogram for DDH
Generally these surgical procedures can be grouped into a few types :
Open Reduction of Hip and Capsulorraphy (medical term meaning stitching up of capsuleor the covering around the joint)
This is basic necessity. Here the hip is reduced back into the socket and the covering, the capsule, which is loose is tightened with several sutures
Femur Derotation Osteotomy with shortening
This would involve a slight shortening of the hip bone and turning it around. The bone would then be stabilied with a metal plate and screws
The need for your child to have this done depends on the age of the child and the angle of the ‘neck of the femur’, something medically known as Anteversion. This procedure essentially de-rotates the femur neck and allows the head of femur (the Ball) to deeply sit inside the Acetabulum (the socket). A slight shortening of the thigh bone may be needed as the child , if old enough, would have developed tightness of the tissues and hip should be sitting inside the socket slightly loose than in tension.
Acetabular Osteotomy
In many children, when they present to the clinic their Acetabulum would be shallow and not deep enough to receive the Head of Femur. In such children deepening of the Acetabulum by a surgical procedure called Osteotomy (a type called Salter Osteotomy being the most popular) may be done.
The above procedures may be combined along with Open Reduction as the surgeon sees fit after evaulating the child. These options and its pros-and-cons would be discussed with the parents before the surgery.
What happens if we don’t treat DDH promptly ?
Best time to treat the child is in the newborn period. With time the tissues around the hip gets tighter and the bone structure of thigh bone and pelvis alters since the normal growth with moulding of the ball being inside the cup doesn’t happen.
This lack of moulding results in a shallow cup. Additionally the thigh bone’s upper end would be twisted out of shape and the ball also would be misshapen since it has not been moulded by the acetabulum.
All these result in a much more complex procedure to try and restore the hip.
Left untreated DDH causes osteoarthritis or the Hip joint and Hip pain in early adulthood often requiring complex reconstructive procedures.
It is best if the treatment is not postponed and done at the earliest.
Hip Dysplasia Awareness Month – June !!
The Hip Dysplasia Awareness Month of June is to educate parents on Hip Dysplasia and its treatment methods. We hope that parents would bring children to care centers at the earliest if suspicion of hip dysplasia is there.
Once clubfoot is corrected with Ponseti plaster application and tendoachilles tenotomy, it’s time to maintain the correction of foot till child is grown more and started walking well. There is risk of clubfoot recurring without proper bracing.
Recurrent clubfoot without bracing
Types of braces
Steinbeck device, Iowa Brace and Dobbs Brace are commonly used clubfoot Foot Abduction Orthosis.
Dobbs brace in particular has the added advantage of providing extra mobility to the child potentially improving compliance. Comparatively it’s more expensive.
Compliance
In rural India it’s especially difficult to ensure compliance to orthosis for parents as many feel clubfoot treatment finishes with Ponseti casting. Social issues and sensitivity of going out of home with brace fitted is one of the issues that makes parent fall out. Some of them don’t spend enough time learning to put it on and take it off and give up once child starts crying. It’s an easy procedure that we teach aling with nurses and orthotists to help parents during initial days.
Osteogenesis Imperfecta is a congenital disorder of bones that has varied types and presentations. Severity varies based on the type of the genetic mutation that causes this disorder.
Regardless of the type the genetic modification cause malformed and weak bones and in some cases malformed teeth. Bone bend and deform or break easily and heals in deformed position. This results in cosmetic deformity along with issues with walking , standing for the child.
The bend of the bone if significant can cause repeated fractures either due to poor handling by caretakers or when child tries to bear weight and stand up.
Fortunately for the milder variants there’s are medications to make bones stronger and surgery to straighten bent bones. This allows child with help of walking aids and/or splints to ambulate.
For the very severe variants unfortunately clinical breakthrough is still awaited.
A free medical camp for underpriviliged children suffering from Cerebral Palsy and Pediatric Orthopaedic disorders was organised by Dr. Easwar T.R and the administrative team at ICCONS, Shoranur, Kerala on 24th, May,2018.
A gamut of problems commonly seen in children with Cerebral Palsy was observed in OPD. While some parents had the good fortune of seeking medical care and intervention early in course of disease and others were not so fortunate. Lack of parental knowledge, distance / accessible care, financial cruch, normal siblings to care for and single parent challenges were the most important issues observed on casual data collection.
The medical camp was followed by an awareness class for parents, therapists and other care givers by Dr. Easwar T.R on the various aspects of Cerebral Palsy.
Custom wheel chair and mobility solutions for needy patients was discussed with Physiotherapists and low cost solutions for the same identified. Mobility solutions continue to be a major challenge for children in rural areas with poor roads, small homes with narrow doors and steps inside homes especially with outdoor toilets.
Flat foot in Cerebral Palsy
Cerebral Palsy child with widestance and flat foot
I have created a Facebook Community to foster awareness about Paediatric Orthopaedic Limb & Spine Deformities, Bone Dysplasias, Growth Disturbances and Rare Orthopaedic Disorders in Children.
Paediatric Orthopaedic Problems cover a varied spectrum of disorders that require extensive training to handle well.These include congenital (birth defects) of limbs, scoliosis, hip and foot deformities, metabolic disroders like rickets, dysplasias, bone and joint infections and trauma (fractures).
May be you would have seen a child known to you with a bone problem, or may be one of your dear ones has a problem and didnt know whom to ask. Many parents delay the treatment either because of financial constraints or delay seeking treatment thinking that nothing can be done. Awareness is very important. With a specialised Paediatric Orthopaedic and Limb Deformity Surgeons advise these children can get better results it treatment is started early.
This Community will help parents discuss matters pertaining to treatment of these conditions. I will also be posting awareness articles, images periodically.
Please visit my Facebook Page to join, like and share the group. Please help raise awareness among general public that these children can get specialised treatment and can improve their quality of life.
Dr. Easwar T.R 