Poliomyelitis and its management

POLIOMYELITIS
AND ITS
MANAGEMENT
Dr. Arojuraye S. A
(MBBS, FWACS, FMCOrtho)
Consultant Orthopaedic & Trauma Surgeon
National Orthopaedic Hospital, Dala - Kano
Refresher Course in Orthopaedic Nursing, June 2019.
doctoraroju@yahoo.com

Outline
 Introduction
 Aetiopathogenesis
 Clinical Spectrum
 Differential diagnosis
 Orthopaedic complications
 Management
 Prevention
 Treatment
 West African Peculiarities
 Conclusion

Introduction
 Poliomyelitis: Acute infectious viral disease
spread by the oropharyngeal route.
 Major cause of morbidity & mortality until
1960s
 Large epidemics in 1940s & 1950s in
developed world

Introduction…
 Only 10% of patients exhibit any symptoms
 CNS involvement occurs in < 1%
 “Silent circulation”
 Many may be infected prior to the development of
a single case of paralysis
 WHO:
 a single confirmed case of polio in an area of low
occurrence is an epidemic

Introduction…
 Effects:
 Anterior horn cells of the spinal cord & brainstem
 Flaccid paralysis of the affected muscle groups
 Rare disease (1988):
 Due to vaccination
 Effects of previous dx are still with us
Refresher Course in Orthopaedic Nursing, June
2019. doctoraroju@yahoo.com

Introduction…
 Affects any age & Sex
 Most common in children (<5yrs)
 M:F = 3:1
 Immunity
 Maternal immunity disappear during the first six
month of the life.
 Immunity after the infection is life long but
reinjection
 No cross immunity: types I, II & III

Introduction…
 3 countries are endemic (2014):
 Pakistan
 Nigeria
 Afghanistan
 WHO (25/09/2015):
 Nigeria out of polio - endemic list
 Sporadic cases occur in many others

Introduction…
 Patients with polio sequelae:
 Still abundant
 They are not infectious
 They are crippled & outcast in modern society
The role of Orthopedic surgeon & nurses is not
during acute phase, but to effectively treat its
sequelae to help these people lead a more
normal life

Aetiopathogenesis
 Infection is caused by poliomyelitis virus:
 Group: Enterovirus
 Family: Picornavirus
 Single-stranded RNA
 3 different strains of virus: type I, II, III
 No cross immunity
 Polio virus can survive for long periods in the
external environment
 4 months in water & 6 months in faeces

Aetiopathogenesis…
 Polio is more likely:
 During rainy season
 Overcrowding
 Poor sanitation
 Source of infection are contaminated:
 Water
 Food
 Flies

 Route:
 Oral route
 Multiplies in intestine (may manifest as diarrhea)
 Reaches the nervous system via bloodstream
 Incubation period: 7 – 14 days
 Affinity:
 Some brainstem nuclei
 Anterior horn cells of the spinal cord
(lumbar & cervical enlargements of the cord)

 Effects:
 Flaccid paralysis
The proportion of motor
units destroyed is
variable & the resultant
weakness depends on
the % of motor units that
have been destroyed

Clinical Spectrum
 Polio passes through several clinical phases:
 Acute illness
 Paralysis
 Convalescence
 Residual paralysis

Clinical Spectrum (Acute illness)
 Prodromal symptoms (1/3):
 Sore throat
 Mild headache
 Slight pyrexia
 Diarrhea
 With increase in severity:
 Neck stiffness (like in meningitis)
 Joints flexed; the muscles are painful & tender
 Passive stretching provokes painful spasms

Clinical Spectrum
(Paralysis)
 Muscle weakness appears:
 It reaches a peak in 2–3 days
 May give rise to dyspnea & dysphagia
 May die or survive
 If the patient does not succumb:
 Pain and pyrexia subside after 7–10
 Patient is infective for at least 4 weeks

Clinical spectrum…

Clinical Spectrum
(Recovery & Convalescence)
 Return of muscle power:
 Most noticeable within the first 6 months
 There may be continuing improvement:
 For up to 2 years.

Clinical spectrum
(Residual paralysis)
 Incomplete recovery:
 Asymmetric flaccid (LMN) paralysis
 Unbalanced muscle weakness
 Joint deformities and growth defects
 Although sensation is intact

Clinical spectrum
(Residual paralysis)

Clinical Spectrum
(Post-polio Syndrome)
 Reactivation of the virus (50% of cases):
 Progressive muscle weakness
 Unaccustomed fatigue
 Diagnosis:
 Patients with a confirmed history of poliomyelitis
 Period of neurological stability of at least 15 years
 Diagnosis of exclusion

Differential diagnosis
 Diagnosis of polio must be considered in
endemic areas whenever a child presents
with acute flaccid paralysis
 Differentials:
 Guillain-Barré syndrome
 Acute transverse myelitis
 Traumatic paraplegia
 Myopathy, Neuropathy
 Spinal dysraphism

Differential diagnosis
Guillain-Barre
syndrome
Ascending symmetrical myelopathy that occurs later in life.
Facial nerve palsy can be seen. Most cases have complete
recovery
Acute transverse
myelitis
Acute sensory & motor paralysis below a particular level at
which the vascular supply to cord has been interrupted
Traumatic
paraplegia
History of trauma & radiograph may show the fracture.
Neuropathy Both motor & sensory loss. Generally bilateral. Treating the
cause may lead to improvement.
Myopathy LMN paralysis with no sensory loss. Mostly genetic. The pattern
is predictable & generally symmetrical. Paralysis tends to
worsen over time. Muscle biopsy may provide the diagnosis
Spinal dysraphism Tuft of hair or swelling at the back. There may be both motor &
sensory loss & the paralysis may deteriorate with growth

Orthopaedic complications
 Distribution
 Lower limb: 92 %
 Trunk + LL: 4 %
 LL + UL: 1.33 %
 Bilateral UL: 0.67 %
 Trunk + UL + LL: 2 %
 Reasons :
 Some muscles have short columns of cells in the
spinal cord while some have long columns
 Short column muscles develop complete paralysis

Orthopaedic Complications
 In the lower limb:
 Most common partially paralyzed muscle is
quadriceps femoris
 Most common completely paralyzed muscle is
tibialis anterior
 In the upper limb:
 Most commonly involved muscle is deltoid
 Hand muscles are rarely involved
 Most common: opponens pollicis

Orthopaedic Complications…
 Deformities in LL
(ITB contracture)
 Hip flexion, abduction
& external rotation
 Knee flexion & valgus
 Knee triple deformity:
 Flexion
 Posterior subluxation
 External rotation

 Deformities in LL
(ITB contracture)
 Equinovarus
 Lumbar scoliosis
 Pelvic obliquity

 Causes of progressive deformities
 Muscle Imbalance
 Unrelieved Muscle Spasm
 Growth
 Gravity And Posture
 Bony Deformities

Management (Prevention)
 Prevention:
 Oral polio vaccine (OPV)
 Inactivated polio vaccine (IPV)
 Even if a patient has had an attack of polio;
 he should be immunized as there are 3 strains of
the virus and no cross immunity

Management (Prevention)…

Management (Treatment)
Depends on the phase of the dx.
 Acute phase:
 Symptomatic as the disease run its course
 Bed rest & splintage of paralyzed limbs
 Active movements are avoided
 Ventilatory support for resp. paralysis

Management (Treatment)…
 Convalescent phase:
 Joints are splinted to reduce pain
 Joint mobilization exercises are begun
 Paralysis:
 Limit the resultant deformities

 PPRP
 Correct the deformities
 To provide maximum attainable function
 Nonoperative: splints and traction

PPRP
 Operative treatment:
 Soft-tissue release (ITB contracture)
 Tendon transfers
 Osteotomies
 Arthrodesis
 Arthroplasty

Prognosis
 Depends on 2 factors:
 Severity of initial paralysis
 Diffuseness of its regional distribution.

Prognosis…
Generally:
 If total paralysis persists beyond the 2nd month,
significant recovery is unlikely.
 If the initial paralysis is partial, prognosis is better
 The more extensive the paralysis in the first 10
days of illness the more severe the ultimate
disability

References
 WHO Fact sheet on Poliomyelitis, March 1 2019.
https://www.who.int/news-room/fact-sheets/detail/poliomyelitis.
 Deborah E. Poliomyelitis In: Apleys GA, Solomon L. Apleys System
of Orthopaedics & Trauma; Neuromuscular disorders. CRC Press,
2018; Chp 10: 261 – 265.
 Mukul M, Jitesh JK. Poliomyelitis In: Fundamentals of
Orthopaedics; Neuromuscular disorders. Jaypee Brothers Medical
Publishers, 2016; Chp 8: 311 – 314.

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