It is with a great deal of happiness that we bring you the first issue of POSITIVE. We would welcome your critical comments about the format and the material included in this issue. The primary aim of this publication will be to promote a wider understanding of the developments in the field of Paediatric Orthopaedics in different parts of the world. In addition to this, we would try to use this publication to promote a very active scientific dialogue between the members of POSI.
To begin with, POSITIVE will have four parts; the first section would contain edited abstracts of recent articles published in various international journals to which many of our members may not have access; the second section would be an invited contribution briefly reviewing the current concepts on a topic of popular interest; the third section would be in the form of a debate on controversies in the field of Paediatric Orthopaedics and the last section would be devoted to news and notes.
In due course we may widen the scope of the publication as the Society feels appropriate.
The current issue includes selected abstracts from the Journal of Pediatric Orthopaedics of 1994, the Journal of Bone & Joint Surgery of 1994 and Developmental Medicine and Child Neurology of 1994. An attempt has been made to select articles which are likely to be of maximum interest to our readers in India.
1.Sensory deficit in the hands of children with cerebral palsy. A new look at assessment and prevalence.
Yekutiel M,Jariwala M,Stretch P. National Centre for Cerebral Palsy,The Spastics Society of India,Bombay, India. Developmental Medicine & Child Neurology, 1994;36:619-24.
Three sensory functions of the hand viz. stereognosis, two point discrimination (TPD) and location of touch were tested in 55 children with cerebral palsy and 15 controls. It was assumed that a 10% error in responses is compatible with normal sensation based on the frequency of erroneous responses noted in the control group. 51 % of children with cerebral palsy had abnormal scores (> 10% error) for either stereognosis, TPD or for both these tests. Among children with cerebral palsy, TPD was more frequently impaired (64%) as compared to stereognosis (27%). Sensory deficits appeared to be less common in athetoid children than in spastics. Hemiplegic children had far greater impairment than diplegics, with only the plegic hand showing the abnormalities in sensory perception.Editorial Comment
The authors have re-confirmed the findings of Tizard & Crothers who for the first time in 1952 drew attention to the fact that sensory abnormalities do occur in cerebral palsy. This aspect of cerebral palsy has often been ignored. However, it is now recognised that functional recovery following surgery on the upper limb may be influenced by the status of the sensory function.
2.The role of selective dorsal rhizotomy in cerebral palsy. Critical evaluation of a prospective clinical series.
McLauglin JF, Bjornson, Astley SJ et al. Children's Hospital & Medical Center, Seattle, USA. Developmental Medicine & Child Neurology. 1994;36:755-69.
This was a prospective observational study of a consecutive series of 34 children with cerebral palsy who underwent selective dorsal rhizotomy (SDR) and were followed up for a minimum period of one year. The variables measured were the Ashworth Scale for spasticity, the deep tendon reflex response, the range of motion and the Gross Motor Function Measure . The results show that there is often a decrease in spasticity of the lower limbs and functional improvement, but there was considerable variability in outcome. Randomised prospective clinical trials with masked objective outcome measures are needed to determine the efficacy of SDR.Editorial Comment
Selective dorsal rhizotomy (SDR) has caught the attention of the media in India with some centres adopting this treatment modality for cerebral palsy. Paediatric Orthopaedic Surgeons are often asked by anxious parents if SDR is a cure for cerebral palsy. This article places in perspective the variability of outcome following this procedure, suggesting thereby that results following SDR like any modality of treatment in cerebral palsy is often unpredictable. The authors very rightly emphasise the need for randomised controlled clinical trials.
3.The use of therapeutic electrical stimulation in the treatment of hemiplegic cerebral palsy
Hazelwood ME, Brown JK, Rowe PJ, Salter PM.Royal Hospital for Sick Children, Edinburgh, UK. Developmental Medicine & Child Neurology 1994; 36: 661-73.
The study was undertaken to evaluate the effect of electrical stimulation of the anterior tibial muscles of hemiplegic children in increasing the range of dorsiflexion of the ankle. Ten children received electrical stimulation to the anterior tibial muscles for one hour a day for 35 days while ten matched hemiplegic control children continued the regular physiotherapy programme. The results showed a significant increase in the passive range of dorsiflexion in children who received electrical stimulation.Editorial Comment
The results of this well designed study suggest that electrical stimulation may well be yet another therapeutic option in reducing the risk of contractures developing in cerebral palsied children. However, it has been shown in the past that the effects of electrical stimulation are temporary and it is also known to produce some significant changes in the muscles some of which may be deleterious. Thus, this form of treatment may be most appropriate as an adjunct to regular physiotherapy particularly when there is evidence of contractures beginning to develop. The need for such intervention may be more in India where community based physiotherapeutic services are in short supply and in children whose parents are not able to keep up with the regular regimen of physiotherapy at home.
4.Factors associated with the inability of children with cerebral palsy to walk at six years: A retrospective study.
Trahan J, Marcoux S. Centre Cardinal-Villeneuve, Quebec, Canada. Developmental Medicine & Child Neurology. 1994;36:787-95.
264 quadriplegic and diplegic children were reviewed at the age of six years.Using multivariate analysis, five factors affecting locomotor potential were identified. These factors were; the topography of the involvement, the presence of a Moro reflex or the asymmetric tonic neck reflex, a history of epilepsy and the inability to retain the sitting position independently.
5. Walking prognosis in cerebral palsy: A 22 year retrospective analysis.
Campos da Paz. Jr. A, Burnett SM, Braga LW. SARAH / Institutio Nacional de Medicina Aparelho Locomotor, SMHS 501 CEP: 70330-150, Brasila - DF, Brazil. Developmental Medicine & Child Neurology 1994; 36:130-4.
272 children with cerebral palsy were reviewed to determine the ages at which important gross motor milestones were achieved. These variables were correlated to the prognosis for ambulation. It was observed that achievement of head balance before 9 months, sitting by 24 months and crawling by 30 months were all good prognostic factors for walking. On the other hand, delay in achieving head control till 20 months, sitting till 36 months and crawling till 60 months were all associated with a poor prognosis for walking.Editorial Comment
The preceding two papers address a very important issue viz. the prognostic indicators for ambulation in cerebral palsy. The knowledge of these factors will go a long way in defining realistic goals in treatment planning in cerebral palsy.
6. Closed reduction for congenital dysplasia of the hip. Functional and radiographic results after an average of thirty years.
Malvitz TA, Weinstein SL. Department of Orthopaedic Surgery, University of Iowa Hospitals, Iowa City, USA.Journal of Bone & Joint Surgery 1994;76A: 1777.
The functional & radiographic results of 152 congenitally dislocated hips treated by closed reduction were evaluated after a mean follow-up period of 31 years (range: 16 to 56 years). The average age at the time of reduction was 21 months (range: 1 to 96 months). At the last follow-up the mean Iowa hip rating was 91 points
(range 38 to 100 points) and the mean Harris hip score was 90 points (range: 33 to 100 points). The Severin classification was as follows : Class I, 35 hips; Class II, 35 hips; Class III, 28 hips; Class IV, 53 hips; Class V, 1 hip.
Disturbance of growth of the proximal femur was evident in 60% of the affected hips. Physeal arrest was often not evident for 10 to 12 years after the reduction had been achieved. The hip function tended to deteriorate with time even in the absence of subluxation or growth disturbances in the proximal femur.Editorial Comment
The long term follow up of a large group of dysplastic hips treated by closed means show that despite adequate reduction in early childhood there is the distinct possibility that many , if not all, the hips will develop some degree of degenerative arthritis in due course.The question however remains - would the frequency of degenerative changes be less if the hips had been reduced earlier than at 21 months or are all hips with DDH destined to develop degenerative arthritis ?
7. Opening-wedge osteotomy for angular deformities of long bones in children.
Scheffer M M, Peterson HA. Department of Orthopedics, Mayo Clinic, Rochester, Minnesota 55905 USA. Journal of Bone & Joint Surgery 1994: 76A:325
The authors report a technique of performing an open wedge osteotomy with insertion of an autogenous iliac graft with minimal or no internal fixation.They advocate this technique in situations where the angular deformity is less than 25o and where the limb length discrepancy at skeletal maturity is likely to be less than 25mm.Editorial Comment
As the authors rightly state, there is a recent trend towards the use of external fixators to correct angular deformities gradually. Such techniques though very effective, are time consuming and very labour intensive. The authors offer a simple and elegant alternative for dealing with mild degrees of angular deformities. The need to adopt the simplest possible option in any given surgical situation can never be overemphasised.
8. The role of fibular osteotomy in rotational osteotomy of the distal tibia.
Manouel M, Johnson LO. Shriners Hospital for Crippled Children, Twin Cities Unit, Minneapolis, Minnesota,USA. Journal of Pediatric Orthopaedics 1994; 14:611-4.
In a prospective study, 35 patients who underwent derotational osteotomy of the distal tibia were randomised into two groups, one in which the fibula was osteotomised and another in which it was not. The results failed to show any advantage of osteotomising the fibula.
9. Rotational osteotomies of the leg: Tibia alone versus both tibia and fibula.
Rattey T, Hyndman J. Division of Orthopaedic Surgery, Izaak Walton Killam Children's Hospital, Halifax, Nova Scotia, Canada. Journal of Pediatric Orthopaedics 1994; 14:615-8.
A retrospective study of 45 consecutive cases of children who underwent derotational osteotomies of the tibia showed that the operating time,and complications were less when the fibula was left intact.Editorial Comment
Both these articles emphasise a useful surgical point that in children it is unnecessary to osteotomise the fibula when a tibial derotation is being performed.
Congenital Dislocation of the Radial Head
Congenital dislocation of the radial head, the commonest congenital anomaly of the elbow, may occur as an isolated entity or as part of a more generalised skeletal abnormality. As associated skeletal abnormalities are seen in as many as 60% of cases, the presence of a radial head dislocation should alert the clinician to look for other skeletal anomalies.
Familial aggregations of this entity have been reported. Autosomal dominant and recessive patterns of inheritance have been implicated.
The radial head can dislocate anteriorly (47%), posteriorly (43%) or laterally (10%).Isolated radial head dislocations tend to be anterior dislocations while radial head dislocations associated with other skeletal anomalies are more commonly posterior
In the vast majority of instances, the dislocation does not cause a significant disability or symptoms in childhood. Often the dislocation is diagnosed by chance. In adolescence and adult life pain may develop. Some degree of limitation of movement may be present with anterior dislocations restricting terminal flexion of the elbow and posterior dislocations restricting terminal extension. There may also be some degree of restriction of pronation and supination. Lateral dislocations cause very little restriction of movement but may cause a valgus deformity at the elbow.
The radiological features of a long standing case of congenital dislocation of the radial head include characteristic changes in the distal humerus, the proximal radius and ulna. Hypoplasia of the capitellum is the most common feature seen in the distal humerus. This led several authors to suggest that this is the cause of the dislocation. However, it is now well known that the same changes in the distal humerus can be seen in paralytic and traumatic dislocations of the radial head. The ulna is often shorter than normal and the radial head is dome shaped with loss of the normal central cupping.Treatment
Though seldom successful, a closed reduction may be attempted when the diagnosis is made in the new born infant. The dislocated radial head may reduce on supination of the forearm. In general, however, on account of the paucity of symptoms treatment is seldom indicated. While this view is accepted by several authors, others have advocated, surgical repositioning of the dislocated radial head. It must be borne in mind that surgical reduction may not always be feasible on account of the radius being relatively longer than the ulna and that when reduction is achieved it may not always be associated with an impro-vement in the range of motion.Open reduction
Open reduction must be combined with reconstruction of the annular ligament and transcapitular K-wire fixation. Reconstruction of the annular ligament is best done by the Bell-Tawse technique using a strip of the triceps tendon. The palmaris longus may also be used for reconstructing the ligament. The K-wire should be retained for 6 weeks. If during surgery, difficulty in reduction of the radial head is encountered the radius may need to be shortened. If this is needed, it is recommended that the radius be shortened at the level of the insertion of the pronator teres. Osteotomy of the radius at a more proximal level runs the risk of producing a radio-ulnar synostosis. If the biceps brachii is found to be contracted, it should be lengthened through the substance of the tendon or at the musculo-tendinous junction.Osteotomy
Futami et al recommend a rotational osteotomy of the radius just distal to the insertion of the pronator teres. The proximal fragment is externally rotated by 40 degrees and fixed with a plate. The osteotomy is combined with shortening of the radius if there is disparity in the lengths of the radius and ulna. The rationale of the osteotomy is that the reduction achieved following external rotation of the proximal fragment would be maintained by relaxing the biceps brachii muscle and by increasing the tension of the pronator teres.Radial head excision
In general, it is recommended that this mode of treatment be deferred till skeletal maturity. Pain and significant restriction of movement are the primary indications for excising the radial head. Some authors suggest that though the procedure may improve the appearance and reduce the pain it does not produce an increase in the range of movement, but others have demonstrated a moderate increase in the range of movement post-operatively. Excision of the radial head is best avoided in the growing child as it may lead to a valgus deformity and instability at the elbow and secondary subluxation of the inferior radio-ulnar joint.References:
- 1. Mital MA. Congenital radioulnar synostosis and congenital dislocation of the radial head. Orthop Clin North Am 1976;7:375-83.
- 2. Almquist EE, Gordan LH, Blue AI. Congenital dislocation of the head of the radius. J Bone Joint Surgery (Am) 1969; 51A:1118-27.
- 3. Mardam-Bey T, Ger.E. Congenital radial head dislocation. J Hand Surg 1979; 4: 316-20.
- 4. Agnew DK, Davis RJ.Congenital unilateral dislocation of the radial head. J Pediatr Orthop 1993;13:526-8.
- 5. Kelly DW.Congenital dislocation of the radial head: Spectrum and natural history. J Pediatr Orthop 1981; 1:295-8.
- 6. Bell SN, Morrey BF, Bianco AJ. Chronic posterior subluxation and dislocation of the radial head. J Bone Joint Surg (Am)1991; 73A:392-6.
- 7. Futami T, Tsukamoto Y, Fujita T. Rotation osteotomy for dislocation of the radial head. Acta Orthop Scand 1992;63:455-6.
Is there a need to internally fix forearm fractures in children ?
The approach to the management of fractures in children has been heavily biased towards a conservative non-operative outlook. Blount (1955) in the very first book in English devoted to fractures in children emphasised that the majority of paediatric fractures can and should be treated by closed methods. Many surgeons still adhere to this view which was expressed 40 years ago. The proponents of a non-operative approach have in their favour a pliable immature skeleton, which has a remarkable propensity for remodelling, and for invoking adaptive changes in the growth plate and the adjacent joints which may make some degree of malunion seem inconsequential. Furthermore, the healing potential in childhood is so good that non-union is rare except in very few clinical situations. Reports of excellent results of carefully performed closed reduction and cast application continue to appear in the literature (Chess et al 1994).
On the other hand, Green (1994) in a recent editorial suggests that there is a need for reappraisal of such long held beliefs and justifies a more aggressive approach to dealing with paediatric fractures. Newer modalities of treatment are constantly being reported and the results of surgical management of paediatric fractures are often impressive (Cramer et al 1992). Those in favour of operative management of paediatric trauma have demonstrated that anatomical restoration of the skeleton with a short hospital stay and less external immobilisation is possible (Green 1994). Internal fixation with bio-degradable implants have even obviated the need for implant removal after fracture union, but these methods are not without complications (Bostman et al 1993, Svensson et al 1994).
In the light of the differing opinions expressed above, the novice in the field of Paediatric Orthopaedics is in a quandary as to which path to follow. To help make the choice, information gleaned from literature published in the last five years is presented here.In Support of Non - Operative Treatment of Forearm Fractures in Children
Voto et al (1990a) in an analysis of 1346 forearm fractures noted that virtually all forearm fractures in children could be reduced by closed methods, though about 7% of these fractures tend to reangulate or displace despite acceptable primary reduction.The redisplacement usually occurred within the first two weeks, though a few displaced as late as 4 weeks after the primary reduction. Voto et al went on to suggest that forearm fractures must be monitored by sequential weekly radiographs over the first four weeks, as this would enable the surgeon to detect virtually all redisplacements. They also analysed the outcome of 90 redisplaced fractures which were remanipulated and found that a more accurate reduction was obtained at the time of remanipulation than that obtained at the primary reduction and this re-reduction position was maintained till healing. The swelling of the limb had decreased by the time of remanipulation and thus a more snugly fitting cast could be applied. An awareness that there is a propensity for redisplacement of forearm fractures, a prompt recognition of this complication and a closed remanipulation ensured excellent results.
Voto et al (1990b) encountered the need for additional intervention apart from closed reduction only in 1.5% of 1346 forearm fractures. They opted to treat these children with pins and plaster in order to avoid interfering with the fracture healing process and to obviate the risk of infection at the fracture site.They reported excellent results in twenty patients treated in this manner.
Chess et al (1994), similarly reported excellent results in a group of 761 children with distal radial fractures treated by closed reduction and below elbow casts. They demonstrated the efficacy of well moulded short arm casts in dealing with these fractures.In Support of Operative Treatment of Forearm Fractures in Children
Lascombes et al (1990) reported their experience with elastic stable intramedullary nailing (ESIN) of 85 forearm fractures in 80 children at the Nancy Hospital in France. These 85 fractures represented 32% of forearm fractures seen during the period of study. The age of the children who underwent this form of treatment ranged from as low as four years to 16 years (mean 11 years). The nails which are curved, blunt ended and made of steel or titanium with diameters between 1.5 and 2.5 mm are inserted with the help of image intensification. The curvature of the nail ensures a stable three point fixation even though the nail is narrower than the medullary cavity. The authors reported 92% excellent results, with 12 instances of malunion,six of which did not remodel. Only 4 patients had restriction of pronation and supination of over 20 degrees.The authors, however, themselves state that the technique is not very simple and in inexperienced hands may entail unacceptably high operating and fluorscopic times.
For the individual surgeon to decide whether or not to internally fix a forearm fracture in a child, the following issues need to be considered:
- 1. the potential for remodelling
- 2. the possible outcome of surgical and non-surgical treatment
- 3. the cost involved
- 4.the possible complications of surgical and non-surgical treatment.
Taking these four issues into consideration and based on the literature reviewed here, would you concur with the suggestion that : "in the Indian context, forearm fractures in children should be treated non-operatively" ?References:
- 1.Blount WP. Fractures in children. Baltimore.Williams & Wilkins, 1955.
- 2.Green NE.The evolution of pediatric orthopaedic trauma care. J Pediatr Orthop 1994; 14: 421-2.
- 3.Voto SJ, Weiner DS, Leighley B. Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop 1990; 10: 79-84.
- 4.Voto SJ, Weiner DS, Leighley B. Use of pins and plaster in the treatment of unstable pediatric forearm fractures. J Pediatr Orthop 1990; 10: 85-9.
- 5.Chess DG , Hyndman JC, Leahey JL, Brown DCS, Sinclair AM. Short arm plaster cast for distal pediatric forearm fractures. J Pediatric Orthop 1994; 14: 211-3.
- 6.Bostman O, Makela EA, Sodergard J, Hirvensalo E, Tormala P, Rokkanen P. Absorbable Polyglycolide pins in internal fixation of fractures in children. J Pediatr Orthop 1993; 13: 242-5.
- 7.Lascombes P, Prevot J, Ligier JN, et al. Elastic stable intramedullary nailing in forearm shaft fractures in children. J Pediatr Orthop 1990; 10: 167-71.
15 Meeting of the European Paediatric Orthopaedic Society (EPOS)
Prof. Pavel Dungl Orthopaedic Clinic
PRAGUE Bulovka Budinova
2180 81 PRAGUE
Paediatric Orthopaedic Society of North America POSNA
6300 N.River Rd. , PHOENIX, AZ, USA
Suite 727 Rosemont IL 60018, USA
Published for and on behalf of the Paediatric Orthopaedic Society of India by
Dr.Benjamin Joseph, Dr. K.Sriram Kasturba , Dr.Benjamin Joseph
Department of Orthopaedics, Medical College & Hospital , MANIPAL 576 119 , Karnataka State