Western Health Orthopaedic Registrar presenation – Poliomyelitis by Dr Todd Mason
Definition
Viral infection of the anterior horn cells of the spinal cord & brainstem (lower motor neuron cell bodies)
Incidence
Can affect any age
Probably > 10 million with residual deformities
Seen far less since the introduction of vaccination
Pathology
Virus gains entry to the body via the gut
Usually flu-like illness
If it attacks the anterior horn cells it causes varying° of paralysis
in isolated muscles or in muscle groups
Some of the neurons survive & the muscle regains power
after 6 months there will be no further return of power
Clinical
Following a trivial illness (diarrhoea or a sore throat) a small proportion develop meningitis
Muscle aches & tenderness are seen, passive stretching is painful
Paralysis follows within 2-3 days
muscles with short column of anterior horn cells more affected (eg tib ant)
hamstrings less affected because long column of horn cells at multiple levels
Can die from respiratory involvement
Starts to resolve after 7-10 days
Infective for 4 weeks from the onset of symptoms
Treatment
Acute
Symptomatic
Isolation
Respiratory support
Pain relief
Gentle passive physiotherapy
Recovery
Aggressive physiotherapy
Splinting
Muscle charting
Residual
5 problems that require treatment
Isolated muscle weakness (quadriceps)
Deformity (due to unbalanced paralysis – may be correctable or fixed)
Flail Joint (due to balanced paralysis)
Shortening (due to lack of muscle activity ± contractures)
Vascular dysfunction (cold, blue limbs)(? sympathectomy)
By Region
Upper Limb
Shoulder
Arthrodesis at 50 o abduction & 25 o flexion
will restore good function provided scapulothoracic muscles are OK
Contracted adductors will need division
Elbow
To restore flexion pect. major transfer to biceps tendon
Wrist
Arthrodesis will resolve instability & weakness problems & active muscles can be used for finger movement
Thumb
Weakness of opposition can be improve by transfer of FDS(to the ring finger) after winding it around FCU which acts as a pulley
Spine
Scoliosis
Long thoracolumbar curve is common + may extend to involve pelvis
Surgical correction may be indicated
Lower Limb
Hip
Balanced paralysis causes instability
Unbalanced paralysis often leads to flexion deformity that can be treated with flexor muscle slide or psoas transfer (as for SB)
Occasionally there will be fixed abduction secondary to pelvic obliquity & this can be treated with ITB & FL division
Knee
Weakness leads to instabilty, often requiring a caliper to keep the knee in extension for walking
Fixed flexion is common & the options are:
Hamstrings division
Hamstrings to Quads transfer
Supracondylar femoral extension osteotomy
Foot
Multiple deformities can occur & bony & soft-tissue procedures are often combined to restore shape & achieve muscle balance for varus or valgus deformity
Grice inlay fusion
Slot bone graft into vertical grooves on each side of the sinus tarsi, resulting in subtalar fusion
Triple Arthrodesis
Lambrinudi’s operation (for varus or valgus + foot drop)
Triple arthrodesis but the fully plantarflexed talus is slotted into the navicular with the forefoot in only slight plantaris (this corrects the footdrop as the talus can no longer plantarflex, whilst the slight equinus helps to stabilise the knee in extension in the stance phase of walking) for calcaneocavus deformity
Elmslie’s operation
2 stages
triple arthrodesis with the foot in calcaneus, then corrected later by a posterior wedge excision & tenodesis using half of the tendo achilles for claw toes
flexor to extensor transfers if correctable
IPJ arthrodesis & transfer of extensors to the proximal phalanx if it is fixed
