Replies - severe plagio with shunt

Replies - severe plagio with shunt

Clinical Orthotic Consultants

6/25/2009

Below is the original post, followed by replies.still looking for more input
if you have any.just to add, no torticollis, has no active head control.

 

 

I was just sent a 10 week old boy. He was a twin, 3 weeks premature. Cleft
palate, banding issues, and hydrocephaly. He has had a shunt inserted
already by a Neurosurgeon (4 hours away). The Neurosurgeon would like me to
apply a plagio helmet already. He claims there will be no issues with
swelling as long as I don't impinge on the shunt! Shunt arises just over
the left ear, runs down behind the ear and into abdomen. Severe flattening
posterior/right.

This child obviously has several health issues, and at 10 weeks is not
actively rolling at all.



Any thoughts on design and treatment? Parents are ready to go, but I would
like to get some input from the experienced Orthotists that use this forum.
This will obviously be the most challenging plagio case I have ever treated
(if I treat it).

 

 

I have treated a number of kids with hydrocephalus. The helmets are good on
these kiddos for a number of reasons. The shunt reduces the fluid and the
skull tends to collapse in stange and asymmetrical ways. The helmet helps
to manage the shape of the head and keep things from getting too far out of
alignment. We do a bivalve helmet and and create an oval build up over the
shunt. (the flat spot is ususlly on the other side as parents try not to
lay the child on the shunt) This buildup is cut out and enlarged at the
fitting to be sure nothing touches the shunt area and the parent can see it.
We have found that even for these kids, we see some improvement dependent on
the severity and the amount of hydrocephalus. Parents are advised to
contact us with any concerns at all

 

 

When you model, consider running a small piece of thin adhesive-backed foam
right along the top of the shunt so that you further minimize the chance of
direct pressure on the shunt.

 

Hope all goes well. You always seem to ask very intelligent questions and
I'm sure that you will do well on this case as you demonstrate careful
consideration to the issues at hand. Good luck!

 

 

---------------------

just recently provided cranial band management for an 8 month old with a
shunt that had multiple medical issues. I rectify the positive models and
forward to Orthomerica for fabrication. Initially they indicated that it is
contraindicated to treat plagiocephaly when a shunt is inserted.

 

However, it is more for using caution, than being an unacceptable treatment.
It is important to have the parents, Pediatrician and neurologist sign off
from the potential risks associated with using the cranial band verses the
benefits.

 

When rectifying the model, I prefer to build out for the shunt to avoid
compromising. When I spoke with the neurologist, he indicated that the
shunt was quite solid and wouldn't be compromised easily.

 

You must monitor growth closely, educate parents and make sure everyone is
on the same page. Follows everyone to two weeks initially.

 

10 weeks is a bit soon. Adjusted age is 7 weeks, even younger. Does the
baby have independent head control to support the helmet? Is there any
torticollis and PT intervention for it? The shunt should not really play a
part in this if accurately located. How do you modify the sub occipital
region? That could be an area of impingement for the shunt.

 

If you are going to attempt a plagio helmet or band for this child, I would

suggest using a custom Starband type of orthosis with relief channels for

the shunt and surrounding area to its entrance and exit. The helmet should

be well padded with enough leeway for adjustments. The padding should be

layered for easy removal of a layer as the child grows. In the past I've

used a combination of 2 to 3 peltie inner removable liners to extend the

life of the cranial orthosis as well as ease of adjustment. Each pelite

layer is molded over the cast and the succeeding layer. At 10 weeks the use

of the cranial remolding orthosis is a bit much but if the surgeon is saying


its a necessity for stability and healing then you must be sure that the

caretakers of this child understand that the orthosis has to be fitted

properly and the child has to be watched closely so that the child does not

get smothered pillows, blankets etc. If the child is swaddled, they have to

be sure that he does not roll over. These issues become more of a problem

as the baby gets older and develops. Another option for head stability is to


setup an out rigging so that the baby's head stays in position. Now that

I've laid out the method, I can honestly say that remolding at this point

may not be the best option and that you may want to use a simple soft band

type control until the child matures some. Since the child is so young you

may suggest to the surgeon to use a soft custom helmet or band until the

child is a little older like 3 months of age.

Best of luck with your approach.

 

 

 

Derek Kozar M.Sc., C.O.(c)

Certified Orthotist

Clinical Orthotic Consultants of Windsor, Inc.

316-3200 Deziel Dr.

Windsor, ON

N8W 5K8

519-944-8340 p

519-944-8360 f