Clifford L. Craig

A reassessment of spinal stabilization in severe cerebral palsy

A homogenous population of 37 institutionalized patients with scoliosis and severe cerebral palsy was evaluated to assess the impact of spinal stabilization on comfort, function, health, and ease of nursing care. Through a prospective care-burden study, a 34-month retrospective analysis, and a healthcare worker questionnaire, 17 fused patients with a mean current scoliosis of 35 degrees were compared with 20 nonfused patients with a mean scoliosis of 76 degrees. No clinically significant differences were noted in pain or pulmonary medication utilization or therapy, decubiti, function, or time for daily care. Nevertheless, the majority of healthcare workers believed that the fused patients were more comfortable.

Subtalar arthrodesis for stabilization of valgus hindfoot in patients with cerebral palsy

All patients with spastic cerebral palsy who underwent correction of valgus hindfoot by Grice extraarticular subtalar arthrodesis between 1971 and 1986 performed by two surgeons using an identical technique were reviewed. Twenty-nine patients (53 feet) were followed at an average of 8.9 years after operation. Traditional radiographic criteria for measurement of hindfoot alignment in skeletally mature individuals have poor reliability. Talar head uncovering is a useful and reproducible method for evaluation of hindfoot valgus in these patients. Five patients had progressive hindfoot or ankle deformity at latest follow-up. All five of these patients were spastic quadriplegics. There was no recurrence in the 17 patients who were less severely involved than the quadriplegic patients.

Ultrasound of the navicular during the simulated Ponseti maneuver.

Nonoperative treatment of the equinovarus foot has had a recent resurgence because of popularization of the Ponseti casting method. This method is based in part on reducing the talonavicular joint by moving the navicular laterally and the head of the talus medially. This study dynamically demonstrates the effect of a simulated Ponseti manipulation on the navicular.

The Arthrogrypotic Foot Plan of Management and Results of Treatment

Fifty-one arthrogrypotic feet have been treated and followed by the Pediatric Orthopaedic Unit, Tufts New England Medical Center, (1970–1980). Forty of the 51 feet presented as equinovarus with the residual divided among metatarsus adductus, vertical tali, and calcaneo-valgus. Equinovarus deformities are the most resistant in all cases. Corrective casts are applied for at least the first 3 months of life. Surgical procedures were then initiated with any evidence of lack of progression of treatment. Varus and equinus were treated by an extensive posterior and medial release. Lateral soft tissue releases in addition to calcaneocuboid fusion or cuboid osteotomy were necessary in 24 of the 70 operations. Recurrence rate has been a problem in the simple type of posterior release including only an Achilles tendon lengthening, and posterior capsulotomy of the ankle and subtalar joint. Tal-ectomy has been carried out in four feet and appears to be one type of reasonable salvage procedure in smaller children with recurrent varus. Treatment is difficult in these patients but a plantigrade foot should be achieved in all cases.

Serial ultrasound evaluation of pediatric trigger thumb.

Background: The etiology of pediatric trigger thumb is unknown, although ultrasound in adults has shown thickening of the A1 pulley leading to constriction of the flexor pollicis longus (FPL) tendon. The purpose of this study is to characterize the underlying cause of the pediatric trigger thumb and factors responsible for resolution utilizing sonography. Methods: A prospective analysis of children with trigger thumbs was conducted from May 2008 through June 2010. All children were initially treated with splinting. Surgical release of the A1 pulley was performed at the family’s request. Bilateral dynamic ultrasonography was performed at presentation and follow-up until resolution of triggering. Ultrasound images were evaluated for tendon gliding, echotexture, cross-sectional area, and anatomic variations. Results: There were 35 trigger thumbs in 28 patients. Ten thumbs resolved spontaneously. Eight patients (9 thumbs) underwent surgical release of the A1 pulley. One child who underwent bilateral release achieved only unilateral resolution. Ultrasound imaging of all 56 thumbs demonstrated normal echotexture of the FPL without evidence of inflammation or trauma. Triggering always occurred at the A1 pulley, and there was focal enlargement of the FPL but no definite ultrasound abnormality of the A1 pulley. Surgical release allowed the thickened tendon to pass smoothly, which coincided with resolution of triggering. Two of 3 patients with unilateral triggering presenting with a trigger ratio (cross-sectional area of involved maxFPL to uninvolved FPL) <1.5 converted to bilateral trigger thumbs. An FPL size for age graph was created for nontriggering thumbs in unilateral patients. Conclusions: The pediatric trigger thumb is a developmental condition with normal echotexture noted in all FPL tendons without inflammation or trauma. Triggering occurs when the cross-sectional area of the FPL exceeds the cross-sectional area at the A1 pulley, and it resolves when this size disparity is eliminated. Patients with unilateral triggering and a trigger ratio <1.5 on the uninvolved thumb are at risk for developing triggering bilaterally. Level of Evidence: Level 2 diagnostic study.

A comparison of hip dislocation rates and hip containment procedures after selective dorsal rhizotomy versus intrathecal baclofen pump insertion in nonambulatory cerebral palsy patients.

Background: Spasticity is the major etiology for hip dislocation in nonambulatory cerebral palsy patients. Selective dorsal rhizotomy (SDR) was used to control lower extremity spasticity, but is now done infrequently in nonambulatory cerebral palsy. Current surgical treatment is usually intrathecal baclofen pump (ITBP) placement. A major theoretical difference between SDR and ITBP is the effect on the iliopsoas through the L1 nerve root. This study compares the rate of hip dislocation and the need for further hip surgeries in SDR and ITBP patients. Methods: All nonambulatory cerebral palsy patients who had either an SDR or ITBP and had minimum follow-up of 2 years were retrospectively reviewed for demographic data and timing, total number, and type of hip procedures (soft tissue vs. bony), and occurrence of hip dislocation. &khgr;2 test was used to assess for statistical significance. Results: Sixty-nine patients who underwent SDR (40 males) and 50 patients who underwent ITBP (27 males) were included in the study. Average age at spasticity intervention was 6 years 11 months for SDR and 9 years 8 months for ITBP. In the SDR group, 25% of hips underwent reconstruction versus 32% of hips in the ITBP group. There were a total of 19 hip procedures in the SDR group and 20 in the ITBP group (P=0.15). Seventeen soft-tissue procedures were performed in both SDR and ITBP groups (P=0.265). Six bony procedures (0 salvage) were performed in the SDR group and 10 in the ITBP group (4 salvage; P=0.075). At final follow-up the hip dislocation rate was 10.6% in the SDR group and 7.4% in the ITBP group. Conclusions: There was no significant difference in the rate of secondary hip reconstructive surgery or dislocation between nonambulatory cerebral palsy patients who underwent SDR versus ITBP. Reconstruction was required for 25% to 32% of hips despite spasticity intervention with either procedure. This suggests that the L1 nerve root alone does not play a major role in the progression of hip dislocation. Level of Evidence: Level 3—therapeutic study.

Radiographic assessment of pediatric proximal radius fractures: interrater and intrarater reliability.

Three methods of measuring pediatric proximal radius fracture radiographs were compared using injury films of 32 patients. Angulation and displacement were independently measured by four physicians. One physician measured the films by each method a second time 2 months later. Values for interrater and intrarater reliability were determined using inter- and intra-class coefficients (ICC). Interrater reliability was poor for methods using the axis of the proximal radial fragment or the proximal radial physis as a reference (ICC = 0.47 and 0.42, respectively). Measurement of the angle between a line parallel to the proximal radius articular surface and the radial shaft had the highest interrater reliability (0.76); measurement of displacement had the lowest interrater reliability (0.09). The intrarater reliability was excellent for all methods (0.93-0.99) and was also highest when the proximal articular surface reference was used. Of described methods, use of the proximal radius articular surface and the radial shaft as references had the highest interrater and intrarater reliability.

Orthopedic aspects of musculoskeletal disease in children.

New information affecting the diagnosis and treatment of a wide variety of musculoskeletal conditions in children was published within the past year. A new etiology for acquired torticollis as well as a test to distinguish ocular and muscular torticollis were described. Familial predisposition for successful nonoperative treatment of interventional disk herniation was reported. Bone scintigraphy was shown to be helpful in defining the cause of occult gait disturbances, and accurate mapping of premature growth plate closure may soon be possible with magnetic resonance scans.

HIP INJURIES IN CHILDREN AND ADOLESCENTS

Hip injuries in children present a wide spectrum of problems. Frequently because of the severity of the trauma involved, other injuries may take precedence and may require modification of the usual approaches to treatment. However, certain precepts are essential to the successful treatment of these injuries and should be kept in mind regardless of the milieu in which they are found. In the child with a hip dislocation, the potential presence of an acetabular, femoral head, femoral shaft, patellar or tibial plateau fracture must always be considered. Specialized x-ray views are necessary for this evaluation. Laminography and arthrography may also be required. The essential feature of successful subsequent treatment is a gentle closed reduction performed within 24 hours of injury. Treatment of displaced fractures of the femoral neck remains an unresolved issue. Accurate reduction held with adequate internal fixation would appear to offer the best chance for a successful result. The possible complications of avascular necrosis, delayed union and non-union, coxa vara, premature closure of the epiphyseal plate, and shortening should be appreciated. Early institution of appropriate treatment may mitigate the ultimate effect of these potentially devastating problems.