Knee valgus and patellofemoral instability after pediatric anterior cruciate ligament reconstruction: a case report and review of the literature

BACKGROUND

Pediatric athletes who undergo anterior cruciate ligament reconstruction are at risk for a growth deformity if the surgery violates the physes.

CASE

A 12-year-old African American boy underwent anterior cruciate ligament reconstruction using a hamstring autograft. The procedure violated the distal femoral growth plate and the perichondrial ring of LaCroix, resulting in a distal femoral lateral physeal growth arrest. Three years later, he had developed a 15° valgus deformity, an increased quadriceps angle and patellofemoral instability. He was able to return to sports after undergoing a distal femoral osteotomy to correct the valgus and medial patellofemoral ligament reconstruction to stabilize the patella.

CONCLUSION

Anterior cruciate ligament reconstruction in athletes with open physes has the potential to cause distal femoral valgus deformity, an increased quadriceps angle, and subsequent patellofemoral instability.

Dostoevsky, The Brothers Karamazov, and Epilepsy

Fyodor Mikhailovich Dostoevsky was a brilliant nineteenth-century Russian novelist who had a seizure disorder that influenced his life and his creativity. His novels explore issues of love, faith, doubt, morality and reflect his personal experience with epilepsy. He was a keen observer of familial psychodynamics. The Brothers Karamazov (1880)was Dostoyevsky's longest and last novel, completed just a few months before his death from a pulmonary hemorrhage, most likely related to his life-long habit of cigarette smoking. In this novel, he explores the subtility of interpersonal relationships and the psychopathology within the Karamazov family and how one of the three brothers, Smerdyakov, uses psychogenic non-epileptic seizures as an alibi to get away with the perfect crime of patricide.

Late Presentation of a Retained Wood Foreign Body as an Expanding Soft-Tissue Mass in an Adolescent's Foot: A Case Report

CASE

A 12-year-5-month-old boy presented with a 3-month history of a 2 × 3-cm enlarging painful mass on the medial plantar aspect of his left foot. The radiograph was normal, but the magnetic resonance (MR) images clearly disclosed a foreign body in the shape of a toothpick that had been quiescent for 31 months. Thirty-three months after surgical removal, the patient was asymptomatic and had returned to full activity.

CONCLUSION

A retained wood foreign body can present as an expanding mass, and MR is the modality of choice to image wood foreign bodies.

Indications for and Risks Associated With Implant Removal After Pediatric Trauma

A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.

Radial Width of the Lateral Meniscus at the Popliteal Hiatus: Relevance to Saucerization of Discoid Lateral Menisci

BACKGROUND

A discoid lateral meniscus (DLM) is a congenital anomaly of the knee in which the lateral meniscus has an "O" shape and contains irregular, abnormal collagenous tissue. A DLM can cause mechanical symptoms and pain. Treatment of a symptomatic DLM is arthroscopic saucerization to reshape the meniscus to a more normal contour. Enough tissue must be removed to eliminate mechanical symptoms but not too much to create instability. The residual width of the meniscus is crucial at the popliteus hiatus because here the peripheral rim is unattached at the capsule. Reports in the literature recommend a residual width of 6 to 8 mm.

PURPOSE/HYPOTHESIS

The purpose of this research was to determine the width of the lateral meniscus at the popliteal hiatus in normal specimens. Our null hypothesis was that a residual width of 6 to 8 mm will be sufficient to approximate normal anatomy.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We made direct measurements of the radial width of the lateral meniscus from the outer rim at the popliteal hiatus to the inner edge in 19 specimens (age, 2-120 months.) We measured one 4-year-old specimen with a bilateral complete DLM. We also measured 39 digital images of specimens (age, 1-132 months) using ImageJ. Finally, we made direct arthroscopic measurements of 8 skeletally mature specimens.

RESULTS

The average width of specimens <3 years old was 5.5 mm. The average width of the 10-year-old specimens was 12 mm. The average width of the skeletally mature specimens was 16 mm. A 4-year-old DLM specimen measured 19 mm.

CONCLUSION

We rejected our null hypothesis. Direct measurements suggest that a residual width of 6 to 8 mm is insufficient for children ≥8 years old. A width of at least a full centimeter approximates the normal for 8-year-olds and at least 15 mm for adolescents.

Late Stabilization of Developmental Dysplasia of the Hip Without Treatment: A Case Report

CASE

Approximately three-quarters of neonates with unstable hips will spontaneously stabilize without treatment in the first few weeks of life. This report presents the long-term follow-up of an infant with developmental dysplasia of the hips that stabilized at an older age and without any orthopaedic treatment.

CONCLUSIONS

Factors contributing to the spontaneous stabilization in this case included the patient's self-selected lower extremity position of comfort with hips flexed, abducted, and externally rotated; her delayed walking; and her light body weight.

Bilateral Medial Patella Sleeve Fractures in a Child: A Case Report

CASE

An 8-year-old girl presented with a displaced right medial patella sleeve fracture. She underwent open reduction and suture fixation. Three years later, she presented with a left medial patella sleeve fracture that was less displaced than on the right. This was treated with immobilization and structured rehabilitation. She was able to return to full activity with normal radiographs at the final follow-up.

CONCLUSION

Patella sleeve fractures are rare. We report a unique case of bilateral medial patella sleeve fractures in an otherwise healthy child in which one side was treated operatively and the other was treated nonoperatively.

Fracture of the Supracondylar Process in a Child: A Case Report and Review of the Literature

CASE

A 5-year-9-month-old boy sustained a fracture of the supracondylar process of the distal humerus. The fracture healed with cast immobilization and with no neurovascular complications. Magnetic resonance imaging showed the medial nerve and the brachial artery to be located under the ligament of Struthers that extended from the supracondylar process to the medial epicondyle.

CONCLUSIONS

Fracture of the supracondylar process of the humerus in children is rare and easy to misdiagnose, but once discovered, the fracture can be treated successfully with cast immobilization and without compromise to the neurovascular structures passing under the ligament of Struthers.

Clinical motion analyses over eight consecutive years in a child with crouch gait: a case report

BACKGROUND

This case report provides a unique look at the progression of crouch gait in a child with cerebral palsy over an 8-year time period, through annual physical examinations, three-dimensional gait analyses, and evaluation of postural balance. Our patient received regular botulinum toxin-A injections, casting, and physical therapy but no surgical interventions.

CASE PRESENTATION

A white American boy with spastic diplegic cerebral palsy was evaluated annually by clinical motion analyses, including physical examination, joint kinematics, electromyography, energy expenditure, and standing postural balance tests, from 6 to 13 years of age. These analyses revealed that the biomechanical factors contributing to our patient's crouch gait were weak plantar flexors, short and spastic hamstrings, moderately short hip flexors, and external rotation of the tibiae. Despite annual recommendations for surgical lengthening of the hamstrings, the family opted for non-surgical treatment through botulinum toxin-A injections, casting, and exercise. Our patient's crouch gait improved between ages 6 and 9, then worsened at age 10, concurrent with his greatest body mass index, increased plantar flexor weakness, increased standing postural sway, slowest normalized walking speed, and greatest walking energy expenditure. Although our patient's maximum knee extension in stance improved by 14 degrees at 13 years of age compared to 6 years of age, peak knee flexion in swing declined, his ankles became more dorsiflexed, his hips became more internally rotated, and his tibiae became more externally rotated. From 6 to 9 years of age, our patient's minimum stance-phase knee flexion varied in an inverse relationship with his body mass index; from 10 to 13 years of age, changes in his minimum stance-phase knee flexion paralleled changes in his body mass index.

CONCLUSIONS

The motor deficits of weakness, spasticity, shortened muscle-tendon lengths, and impaired selective motor control were highlighted by our patient's clinical motion analyses. Overall, our patient's crouch gait improved mildly with aggressive non-operative management and a supportive family dedicated to regular home exercise. The annual clinical motion analyses identified changes in motor deficits that were associated with changes in the child's walking pattern, suggesting that these analyses can serve to track the progression of children with spastic cerebral palsy.

Primary Psoas Pyomyositis Presenting as Subluxation of the Hip: A Case Report

CASE

An eight-year-old girl presented with a septic subluxation of the right hip secondary to spontaneous drainage of a psoas pyomyositis. The course of the infection was protracted, and the symptoms were mild relative to the magnitude of the psoas abscess and the volume of purulence in the hip that caused subluxation of the femoral head. At the time of surgical drainage, the hip capsule directly communicated with the psoas abscess along the course of the iliopsoas tendon sheath. Methicillin-sensitive Staphylococcus aureus (MSSA) was the microorganism that was isolated from the abscess and from the hip joint.

CONCLUSION

Drainage of the psoas abscess and septic arthritis coupled with antibiotic treatment eliminated the infection, and the child returned to normal activities. At the five-year follow-up, she was asymptomatic, but the subtle changes in the sphericity of the femoral head as well as the slight joint-space narrowing may be associated with problems in the future.

Painful Ununited Fracture of the Posterior Process of the Talus in an Adolescent Dancer: A Case Report

CASE

Fractures of the talus in children and adolescents are uncommon and generally involve the body or neck of the talus. We present a thirteen-year-old dancer with an ununited fracture of the posterior process of the talus that was initially thought to be a painful os trigonum.

CONCLUSION

This injury was confused with a painful os trigonum. We found that the size of the fragment, the extent to which the fracture line undercut the tibial plafond, and the findings on magnetic resonance imaging were helpful in clarifying the diagnosis of the fracture.

Hip adductor injury in competitive swimmers

METHODS

The authors conducted a survey of 296 competitive swimmers to assess the incidence and importance of interfering groin pain in breaststroke swimmers.

RESULTS

Breaststroke swimmers were more likely to have current groin pain (6.92%) than individual medley swimmers who did not compete in pure breaststroke events (0, P = 0.015). Breaststroke swimmers (42.7%) were also more likely than individual medley swimmers (21.5%, P = 0.000622) or nonbreaststroke, nonindividual medley swimmers (5.8%, P = 0.00000311) to have been unable to train breaststroke in practice during the past year due to groin injury.

CONCLUSION

Results indicate that breaststroke swimmers are at significant risk of groin injury, groin injury is positively correlated with increased magnitude of breaststroke training, and groin injury may prevent participation in practices and competitions.

Postural balance in children with cerebral palsy

Postural control deficits have been suggested to be a major component of gait disorders in cerebral palsy (CP). Standing balance was investigated in 23 ambulatory children and adolescents with spastic diplegic CP, ages 5 to 18 years, and compared with values of 92 children without disability, ages 5 to 18 years, while they stood on a force plate with eyes open or eyes closed. The measurements included center of pressure calculations of path length per second, average radial displacement, mean frequency of sway, and Brownian random motion measures of the short-term diffusion coefficient, and the long-term scaling exponent. In the majority of children with CP (14 of 23) all standing balance values were normal. However, approximately one-third of the children with CP (eight of 23) had abnormal values in at least two of the six center of pressure measures. Thus, mean values for path length, average radial displacement, and diffusion coefficient were higher for participants with CP compared with control individuals with eyes open and closed (p<0.05). Mean values for frequency of sway and the long-term scaling exponent were lower for participants with CP compared with control participants (p<0.05). Increased average radial displacement was the most common (nine of 23) postural control deficit. There was no increase in abnormal values with eyes closed compared with eyes open for participants with CP, indicating that most participants with CP had normal dependence on visual feedback to maintain balance. Identification of those children with impaired standing balance can delineate factors that contribute to the patient's gait disorder and help to guide treatment.

Electromyographic differentiation of diplegic cerebral palsy from idiopathic toe walking: involuntary coactivation of the quadriceps and gastrocnemius

Clinical differentiation of patients with mild diplegic cerebral palsy (CP) and idiopathic toe walking (ITW) can be difficult. However, an involuntary extensor pattern may be a distinguishing sign. The purpose of this study was to determine if selected gait parameters or patterns of electromyogram (EMG) timing of quadriceps, gastrocnemius, and tibialis anterior during knee extension while sitting can distinguish between these patients. The hypothesis was that EMG testing for selective control of the quadriceps and gastrocnemius could differentiate patients with diplegic CP from normal controls and from patients with ITW. We evaluated 10 control, eight CP, and eight ITW subjects. Measurements included walking speed, energy expenditure index (EEI), ankle position during stance, and EMG of the quadriceps, gastrocnemius, and tibialis anterior during gait and during knee extension while sitting. Dynamic EMG timing during gait showed significant differences in the mean onset of the gastrocnemius between subjects with CP and ITW, but there was considerable overlap. More consistent differences were found during active and active-resisted knee extension while sitting. Mean values for gastrocnemius EMG timing recorded as a percentage of duration of quadriceps EMG while sitting were 0 and 0.4% for controls, 0 and 3.9% for ITW subjects, and 84.3% and 93.4% for CP subjects. Patterns of EMG timing of the quadriceps and gastrocnemius during knee extension while sitting can help to differentiate patients with mild diplegic CP from those with ITW.

Analysis of radiographic measurements as prognostic indicators of treatment success in patients with developmental dysplasia of the hip

Measurements were taken and statistically analyzed from the initial radiographs, the 1-year follow-up radiographs, and the most recent radiographs of 81 patients (103 hips) to determine which measurements could predict the success of treatment. The average follow-up was 49 months (range, 12-139 months), and the average age of the patients at the last follow-up was 65 months (range, 15-190 months). Analysis of the data showed that the measurement with statistically significant predictive value was the Tonnis grade of dislocation determined from the initial radiograph. A single unit increase in the Tonnis grade was associated with a doubling of the odds of failure in patients treated with a Pavlik harness (P < 0.04, odds ratio = 2.2) or a closed reduction (odds ratio = 2.0).

Postural balance measurements for children and adolescents

Measurements of standing balance were determined for 92 children and adolescents, 5-18 years old, while they stood on a force plate with eyes open or eyes closed. The measurements included center-of-pressure calculations for path length per second, average radial displacement, anterior-posterior and mediolateral amplitudes, area per second, mean frequency of sway, Brownian random motion measure of short-term diffusion coefficient, and long-term scaling exponent. All balance parameters improved from youngest to oldest subjects, and the parameters improved when measured with the subjects' eyes open compared with closed. The mean values for data from three trials varied by only 5% when compared with the mean values from 10 trials. Data from this study suggest that force-plate center-of-pressure data can be used to determine differences in standing balance between children and adolescents of different ages and those with movement and balance abnormalities.

Effectiveness of ice packs in reducing skin temperature under casts

Skin temperature lowering effects were measured after application of crushed ice packs to the surface of synthetic and plaster casts. The skin temperature of legs in synthetic casts decreased an average of 10.4 degrees C (range, 8.3 degrees-12.6 degrees) to a minimum temperature of 19.7 degrees C (range, 16.2 degrees-21.8 degrees), and the temperature of legs in plaster casts decreased an average of 11 degrees C to a minimum of 18.7 degrees C (range, 13 degrees-22.8 degrees). It took an average of 56 minutes (range, 40-80 minutes) for the legs in synthetic casts and 63.8 minutes (range, 26-116 minutes) for the legs in plaster casts to reach the minimum temperature. Cryotherapy is used clinically with the intention of lowering skin temperature and presumably decreasing the pain and swelling of a patient's injured extremity. The presence of a synthetic or a plaster cast does not eliminate the lowering effects of skin temperature when crushed ice packs are applied to the surface of the casts.

Loss of elbow and wrist motion in hemophilia

The longitudinal changes in elbow and wrist motion for 48 patients with hemophilia were reviewed to determine the effect of recurrent hemarthroses. The average age of the patients at the time of followup was 23 years 9 months. The average duration of followup was 10.8 years. The patients were divided into 3 age groups: younger than age 15 years (14 patients), age 15 to 25 years (11 patients), and older than age 25 years (23 patients). For patients older than age 25 years, pronation, supination, elbow flexion and extension, wrist flexion and extension, and ulnar deviation were significantly decreased relative to patients younger than age 15 years. Pronation was the first motion to show a significant change, decreasing by 19% in patients age 15 to 25 years and by 31% in patients older than age 25 years. Loss of elbow extension showed the greatest change. In cases of severe hemophilic arthropathy of the elbow, synovectomy and radial head excision decreased elbow pain and bleeding episodes and improved supination and pronation.

Gastrointestinal problems in patients who have type-III osteogenesis imperfecta

We performed a study of forty-three patients who had type-III osteogenesis imperfecta. Our purpose was to determine the frequency and severity of abdominal problems and the relationship between these problems and pelvic deformity. Twelve patients had had recurrent episodes of abdominal pain. Eleven of them had a history of chronic constipation, and five had been treated for fecal impaction. Radiographs had been made for ten of these patients, and eight of them had radiographic evidence of pelvic deformity with severe acetabular protrusion. Chronic constipation and recurrent abdominal pain are more frequent in patients who have osteogenesis imperfecta and acetabular protrusion than in those who do not have protrusion. These patients may benefit from early attention to a bowel program and referral to a gastrointestinal specialist.

Muscle pathology and clinical measures of disability in children with cerebral palsy

We performed a histologic and morphometric study of spastic muscle from 10 children with diplegic cerebral palsy, comparing muscle structure with the gait parameters of energy expenditure index and dynamic electromyography. Variations in fiber area within and between fiber types were increased significantly in children with cerebral palsy. In each of the control subjects, the combined coefficient of variation for type-1 and type-2 fiber area was less than 25% and the average was 17%; in the subjects with cerebral palsy, the combined coefficient of variation was more than 25% and the average was 36% (p < or = 0.004). The average difference between the mean area of type-1 and type-2 fibers was 26.7 +/- 18.9% for subjects with cerebral palsy and 4.2 +/- 2.4% for control subjects (p < or = 0.004). There was a 67% predominance of one fiber type in the subjects with cerebral palsy compared with a 55% predominance in the control subjects (p < or = 0.03). The difference between the total area of type-1 and type-2 fibers was 57% in the subjects with cerebral palsy and 17% in the control subjects (p < or = 0.002). There was a significant correlation between the combined coefficient of variation of fiber area and the energy expenditure index (r = 0.77, p < or = 0.03). The difference between the mean area of type-1 and type-2 fibers correlated with prolongation of electromyographic activity (r = 0.69, p < or = 0.05). No abnormalities in fiber ultrastructure were found in the subjects with cerebral palsy. Children with cerebral palsy had abnormal variation in the size of muscle fibers and altered distribution of fiber types. The values for variation in fiber area correlated with the energy expenditure index and with prolongation of electromyographic activity during walking.

A comparison of oxygen pulse and respiratory exchange ratio in cerebral palsied and nondisabled children

Energy expended while walking is increased for children with cerebral palsy compared to nondisabled children. This study compared oxygen uptake, oxygen pulse, and the respiratory exchange ratio (RER) in children with cerebral palsy and nondisabled children walking on a treadmill. Resting oxygen uptake and oxygen pulse values were not different in the two groups. At a given walking speed, oxygen uptake, oxygen pulse, and RER were higher for subjects with cerebral palsy. At a given level of submaximal oxygen uptake, oxygen pulse and RER values were not different in subjects with cerebral palsy compared to nondisabled children. It was concluded that the cardiorespiratory response to walking at submaximal level of work is not significantly different for children with cerebral palsy.

Transverse cervicopertrochanteric hip fracture

A 3-year-old boy sustained a previously undescribed transverse hip fracture that involved the cervical, cervicotrochanteric, and intertrochanteric regions. The fracture was successfully treated with skeletal traction for 4 weeks using a Steinmann pin placed through the distal femoral metaphysis followed by spica cast immobilization. The 3-year follow-up examination demonstrated satisfactory growth and remodeling of the proximal femur with no evidence of osteonecrosis, premature physeal closure, or coxa vara.

Simple method of documenting metatarsus adductus

A simple, accurate, and inexpensive method of documenting metatarsus adductus involves taking photocopies of the foot in the weightbearing position. Subsequently, treatment progress can be assessed objectively by reviewing serial photocopies. Some caution is urged because the strength of the glass copying surface of photocopying machines is unknown.

Arthropathy of the ankle in hemophilia

Seventy-five patients who had hemophilia were followed clinically and roentgenographically to assess the prevalence of hemarthrosis and the prevalence and severity of arthropathy of the ankle. The mean age of the patients at the time of follow-up was twenty-two years and seven months. The patients were divided into four age-groups: less than ten years (eleven patients), ten to nineteen years (twenty-one patients), twenty to thirty years (twenty-four patients), and more than thirty years (nineteen patients). Intra-articular bleeding occurred more frequently in the joints of the lower extremities than in the joints of the upper extremities. During the second decade of life, hemarthroses occurred more often in the ankle than in the knee. A history of recurrent bleeding into the ankle joint, chronic synovitis, and overgrowth of the medial portion of the distal tibial epiphysis was associated with an early onset of arthropathy. In older patients, compression arthrodesis of the ankle joint was helpful in eliminating pain, recurrent bleeding, and equinus deformity.

Osteomyelitis of the patella in children

The early diagnosis of osteomyelitis of the patella in children can be difficult due to the rarity of this infection and to the vagaries of presentation which may be either acute with systemic signs or insidious with mild local signs. We present four cases of patellar osteomyelitis to illustrate the spectrum of this disorder. There should be a high index of suspicion with persistent pain and swelling above the knee, septic prepatellar bursitis, and septic knees that do not respond to conventional management. Management parallels treatment of osteomyelitis of other bones.

Simultaneous correction of pelvic obliquity, frontal plane, and sagittal plane deformities in neuromuscular scoliosis using a unit rod with segmental sublaminar wires: a preliminary report

Ten patients with neuromuscular scoliosis and pelvic obliquity had segmental spinal instrumentation using a unit Luque rod with sublaminar wires and fixation into the pelvis. Nine of the 10 patients also had anterior spinal fusion without instrumentation before the posterior procedure. Average preoperative pelvic obliquity was 42 degrees which was corrected to 6 degrees (82% correction). Average preoperative scoliosis was 92 degrees, which was corrected to 16 degrees (81% correction). Complications included a wound hematoma in one patient and a superficial wound dehiscence in another. There have been no pseudarthroses or hardware failures to date. Excellent correction of the pelvic obliquity and the spinal curve in neuromuscular scoliosis can be obtained with use of a unit rod and without use of anterior instrumentation.

Glucosaminidase, galactosaminidase, and glucuronidase in the growth plate

The activities of glucosaminidase, galactosaminidase, and glucuronidase were determined in fractions of bovine growth plate cartilage. Glucosaminidase and galactosaminidase activities were lowest in the area corresponding to the reserve cartilage and increased from the upper to the lower portions of the hypertrophic zones of the growth plate, reaching a maximum in the calcifying cartilage. Glucuronidase activity showed a distinct spike of activity in the calcifying cartilage. The spatial distribution of these activities suggests a role in calcification and in the dissolution of the extracellular matrix at the chondro-osseous junction of the growth plate.

Established hip dislocations in children with cerebral palsy

Hip dislocation in children with cerebral palsy is caused by a combination of factors, including spastic muscle imbalance, persistent fetal femoral geometry, acetabular dysplasia, and flexion-adduction contracture. The incidence of dislocation correlates with the severity of the spasticity, and the prevalence is close to 50% in neurologically immature, spastic quadriplegic children. Successful hip reductions improve muscular balance, provide satisfactory reduction of the femoral head, and establish good pelvic coverage. In 31 occurrences of established hip dislocation in 24 patients, the most successful operations used a combined procedure consisting of soft-tissue release, open reduction, femoral varus derotation and shortening osteotomy, and pelvic osteotomy.

Energy expenditure index of walking for normal children and for children with cerebral palsy

Energy expenditure indices (EEI) based on oxygen uptake and heart rate were used to compare the economy of walking at various speeds by normal and cerebral-palsied children. At low walking speeds, EEI values were high, indicating poor economy. At higher speeds the EEI values decreased until a range of maximum economy was reached. For normal children who were capable of walking beyond this range at higher speeds, the EEI increased again. This pattern was noted for both oxygen-uptake and heart-rate indices. Mean EEI values based on oxygen uptake and heart rate for normal children were significantly lower and occurred at faster walking speeds than values for children with cerebral palsy. EEI based on either oxygen uptake or heart rate can be used clinically to provide objective information to help evaluate the influence on gait function of surgical intervention, ambulatory aids or orthotics.

Energy cost of walking in normal children and in those with cerebral palsy: comparison of heart rate and oxygen uptake

The rate of oxygen uptake can be used to assess energy expenditure during walking, but the necessary instrumentation is cumbersome, expensive, and usually unavailable in the clinical setting. Heart rate is an easily measured parameter, but its use as an index of energy expenditure in children has not been validated previously. We found that the relationship between oxygen uptake and heart rate was linear throughout a wide range of walking speeds for both children with cerebral palsy and normal children. There was no significant difference between the slope or the gamma-intercept of the lines for the two groups. These findings validate the use of heart rate as an index of energy expenditure for normal children and for children with cerebral palsy.

Trapeziometacarpal abnormalities in Ehlers-Danlos syndrome

We studied 24 patients with Ehlers-Danlos syndrome with particular attention to the thumb and the trapeziometacarpal joint. The 11 males and 13 females had a mean age of 15.9 years. Symptomatic complaints included pinch, grip and twisting weakness; measurements showed dominant hand strength deficits of 71% for tip pinch, 55% for palmar pinch, 46% for key pinch, and 70% for grip. All finger joint ranges of motion were increased. Sixty-six percent of all the patients had trapeziometacarpal subluxation; 29% had dislocation. Sixteen percent had radiographic evidence of arthritis. Early occupational therapy evaluation and education can help these patients better understand and adapt to their limitations.

Complications of intramedullary rods in osteogenesis imperfecta: Bailey-Dubow rods versus nonelongating rods

Twenty-nine patients with osteogenesis imperfecta underwent 108 intramedullary roddings with 42 Bailey-Dubow rods and 66 nonelongating rods. The average age at insertion of the first rod was 5 years; average follow-up was 3.1 years (range 1-9 years). The overall complication rate was 60%-69% for Bailey-Dubow rods and 55% for nonelongating rods. Forty-seven percent of bones receiving rods required reoperation. Nonelongating rods had a 29% reoperation rate and a 24% replacement rate; Bailey-Dubow rods had a 19% reoperation rate and a 12% replacement rate.

Orthopaedic aspects of central core disease

We studied the cases of fifteen patients who had central core disease, a non-progressive congenital myopathy that is usually inherited as an autosomal dominant trait. As infants, the patients had poor muscle tone and developmental delay, and as adolescents and adults, they had varying degrees of proximal muscle weakness and tended to use the Gower maneuver. The most common musculoskeletal problems were dislocation or subluxation of the hip, pes planus, and hypermobility of the joints. The most serious orthopaedic problems were in the hips: ten patients had a total of nine dislocations and six subluxations, nine being present at birth and six developing later. Only nine hips were stable after the initial treatment, and there was a propensity for hip-joint contractures. Scoliosis and patellar instability were also seen. Although patients who have central core disease have been reported to be at increased risk for malignant hyperthermia, this did not occur in our patients.

Kingella kingae infection in healthy children

Kingella kingae is a gram-negative occasional, but normal, inhabitant of the nasopharynx. We present two new cases of this infection that occurred in previously healthy children, and compare and contrast them to other cases reported in the literature. K. kingae osteomyelitis generally has an insidious, subacute onset, whereas septic arthritis has an acute presentation. To date, all strains of K. kingae have been sensitive to penicillin, and no residual damage has been reported following osteomyelitis or septic arthritis, except that residual disk space narrowing did occur after K. kingae discitis.

Non-union of fractures in children who have osteogenesis imperfecta

Although a fracture rarely fails to unite in a healthy child, non-union is not a rare occurrence in a child who has osteogenesis imperfecta. We identified twelve non-unions in ten patients from a population of fifty-two patients who had osteogenesis imperfecta. The average age of these patients when the diagnosis of non-union was made nine years, and the average age at the time of treatment was 12.5 years. All of the patients had had a decrease in functional ability as a result of the non-union. There were five femoral, four humeral, one radial, one ulnar, and one pubic non-union. Five of the non-unions were hypertrophic, and seven were atrophic. Eight of the nine ununited fractures that were operated on healed after excision of the non-union, intramedullary nailing, and bone-grafting. Three of the non-unions (in two patients) were not operated on, and the one patient in whom surgery failed had an amputation. Non-union was frequently associated with repeated fractures at a progressively deforming site.

Adolescent idiopathic scoliosis

Adolescent idiopathic scoliosis is the single most common form of spinal deformity seen in orthopedic practice. Our knowledge about the epidemiology, etiology, natural history, and treatment has recently increased dramatically. The incidence of small curves is rather high (2% of the population), whereas severe curves are much less common (<0.1%), but we cannot always predict which curve will progress. Abnormalities of the neuromuscular system and of calcium metabolism, and certain growth, genetic, and mechanical factors may all play roles in the pathogenesis of the disorder. The physiologic secondary effects of severe scoliosis relate to restrictive lung disease, but most patients do not have a deformity great enough to affect their cardiorespiratory function. The psychological and social effects of scoliosis are significant for patients but difficult to quantitate. For most patients with moderate scoliosis-that is, more than 25 to 30 degrees-treatment with an underarm brace or electrical stimulation is adequate to "control" progression of the curve. Surgical fusion allows actual correction of the curve but is indicated in only a small percentage of patients-usually those with more than 50 degrees of deformity.