Geraldo De Coulon

MRI neurography and diffusion tensor imaging of a sciatic perineuroma in a child

Perineuroma, rare in children, presents as a painless mononeuropathy of a major nerve trunk. Resection of the lesion with end-to-end sural nerve grafting appears to be the treatment of choice. This technique is not recommended if the unhealthy segment of nerve is too long or if spinal roots are involved. However, in children, reports of direct MR evaluation of nerve trunks and of the exiting nerve roots are limited. We report a 7-year-old girl with an intramural sciatic nerve perineuroma in whom the diagnosis was made by MRI and confirmed by biopsy. The MR protocol combining 3-D T2-W STIR SPACE, fat-saturated gadolinium-enhanced T1-W images, and diffusion tensor imaging with tractography was a valuable tool for depicting peripheral nerve and roots in order to plan surgical treatment.

Trunk movements during gait in cerebral palsy

BACKGROUND Lower limb deficits have been widely studied during gait in cerebral palsy, deficits in upper body have received little attention. The purpose of this research was to describe the characteristics of trunk movement of cerebral palsy children in terms of type of deficits (diplegia/hemiplegia) and gross motor function classification system (1, 2 or 3). METHODS Data from 92 cerebral palsy children, which corresponds to 141 clinical gait analysis, were retrospectively selected. Kinematic parameters of trunk were extracted from thorax and spine angles in the sagittal, transverse and coronal planes. The range of motion and the mean positions over the gait cycle were analysed. Intra-group differences between the children with diplegia or hemiplegia, gross motor function classification systems 1 to 3 and typically developing participants were analysed with Kruskal-Wallis tests and post hoc tests. Pearson correlation coefficients between the gait profile score normalised walking speed and kinematic parameters of the thorax were assessed. FINDINGS The results revealed: 1) the range of motion of the thorax and spine exhibited more significant differences between groups than the mean positions; 2) greater levels of impairment were associated with higher thorax range of motion, and 3) the children with diplegia and gross motor function classification system 3 exhibited a greater range of motion for all planes with the exception of spine rotation. INTERPRETATION This study confirmed that greater levels of impairment in cerebral palsy are associated with greater thorax range of motion during gait. The thorax plays an important role during gait in cerebral palsy.

Cuboid nutcracker fracture due to horseback riding in children: case series and review of the literature.

We report 4 cases of nutcracker fractures of the cuboid resulting from equestrian sport in pediatric population. These lesions are often consistent with a trauma in forced abduction of the forefoot. The particular mechanism of the cuboid fracture due to horseback riding in children is discussed. The methods used to radiographically evaluate the compression fracture of the cuboid and its associated injuries are presented. Left untreated, these fractures can lead to severe alterations in foot mechanics and function, such as to severe pain. In addition, the surgical treatment to correct the nutcracker fracture of the cuboid in our patients is presented.

Recovery of physical activity levels in adolescents after lower limb fractures: a longitudinal, accelerometry-based activity monitor study

BackgroundIn adolescents, loss of bone mineral mass usually occurs during phases of reduced physical activity (PA), such as when an injured extremity spends several weeks in a cast. We recorded the PA of adolescents with lower limb fractures during the cast immobilization, at 6 and at 18 months after the fracture, and we compared these values with those of healthy controls.MethodsFifty adolescents with a first episode of limb fracture and a control group of 50 healthy cases were recruited for the study through an advertisement placed at the University Children’s Hospital of Geneva, Switzerland. PA was assessed during cast immobilization and at 6- and 18-month follow-up by accelerometer measurement (Actigraph® 7164, MTI, Fort Walton Beach, FL, USA). Patients and their healthy peers were matched for gender and age. Time spent in PA at each level of intensity was determined for each participant and expressed in minutes and as a percentage of total valid time.ResultsFrom the 50 initial teenagers with fractures, 44 sustained functional evaluations at 6 months follow-up, whereas only 38 patients were studied at 18 months. The total PA count (total number of counts/min) was lower in patients with lower limb fractures (-62.4%) compared with healthy controls (p<0.0001) during cast immobilization. Similarly, time spent in moderate-to-vigorous PA was lower by 76.6% (p<0.0001), and vigorous PA was reduced by 84.4% (p<0.0001) in patients with cast immobilization for lower limb injuries compared to healthy controls values. At 6 and 18 months after the fracture, the mean PA level of injured adolescents was comparable to those of healthy teenagers (-2.3%, and -1.8%, respectively).Importantly, we observed that time spent in vigorous PA, which reflects high-intensity forces beneficial to skeletal health, returned to similar values between both groups from the six month follow-up in adolescents who sustained a fracture. However, a definitive reduction in time spent in moderate PA was observed among patients with a lower limb fracture at 18 months, when comparing with healthy controls values (p = 0.0174).ConclusionsAs cast immobilization and reduced PA are known to induce bone mineral loss, this study provides important information to quantify the decrease of skeletal loading in adolescents with limb fractures. The results of this study demonstrate that the amount of skeletal loading returns to normal values in adolescents with lower limb fractures after bone healing and is probably linked to an overall better pattern of functional recovery among this age group. When comparing both populations of adolescents, a definitive decrease in time spent in moderate-to-vigorous PA was observed among patients with a lower limb fracture at 18 months and may suggest a modification of lifestyle. The high rate of missing data (26.5%) due to above all non compliance with monitor wearing among teenagers complicates the data analysis, and requires a more cautious interpretation of the results. Future studies using accelerometer to monitor PA in adolescents should therefore include strategies for improving the rate of adherence and minimizing the ratio of missing data.

Percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy in nonambulatory GMFCS level IV and V cerebral palsy patients: preliminary report on 30 operated hips

This study evaluated the outcome of severe cerebral palsy patients (Gross Motor Function Classification System level IV and V) treated by simultaneous percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy for hip subluxation or dislocation between 2002 and 2011. Twenty-four patients (30 hips) with an average age of 9.4 years (5–16.5) were reviewed at a mean follow-up of 35.9 months (6–96). Percutaneous pelvic osteotomy lasted on average 30 min/patient per side (25–40) and was always performed through a skin incision of 2–3 cm. The migration percentage and acetabular angle were assessed on plain radiographs. The mean Reimers’ migration percentage improved from 67.1% (42–100) preoperatively to 7.7% (0–70) at the last follow-up and the mean acetabular angle improved from 31.8° (22–48) to 15.7° (5–27). Five patients presented complications: one redislocation, one bone graft dislodgement, and three with avascular necrosis of the femoral head. This study should be considered as a pilot study. These results indicate that this combined approach is an effective, reliable, and minimally invasive alternative method for the treatment of spastic dislocated hips in severe cerebral palsy patients with an outcome similar to standard techniques reported in the literature.

Effects of contracture on gait kinematics: A systematic review.

BACKGROUND Contractures of a major joint in the lower limbs may impair human walking in addition to other daily living activities. A contracture is defined as the inability of a joint to perform the full range of motion and excessive resistance during passive mobilization of the joint. Few studies have reported methods describing how to evaluate contractures. Understanding the association among all of these studies seems essential to improve patient management. Therefore, we conducted a systematic review on this topic to elucidate the influence of contractures on gait kinematics. METHODS An electronic search in the literature will be conducted. Studies were screened by title and abstract and full texts were evaluated secondarily for definitive inclusion. The quality of the included studies was assessed independently by the two review authors with the Modified Quality Assessment Checklist. The included studies were separated into three categories: pathological contracture versus healthy controls (descriptive), simulated contracture versus healthy controls (experimental), and pre- and post-kinematics after surgical muscle lengthening (surgery). FINDINGS From a total of 4402 references, 112 original articles were selected, and 28 studies were identified in this systematic review. No significant difference between raters was observed on the total score of the Modified Quality Assessment Checklist. INTERPRETATION Contractures influence walking depending on the location (muscle) and the contracture level (muscle-tendon length). After giving a definition of contracture, this review identified some contracture alterations, such as plantarflexion, knee flexion and hip flexion contractures, with a kinematic description and presented possible different compensations.

Primary epiphyseal or apophyseal subacute osteomyelitis in the pediatric population: a report of fourteen cases and a systematic review of the literature.

BACKGROUND Primary epiphyseal or apophyseal subacute osteomyelitis (PEASAO) is a rare condition that typically has mild symptoms and lack of a systemic reaction, according to opinions, case reports, and case series. We reviewed fourteen consecutive cases of PEASAO treated at our institution over a thirteen-year period to characterize this disorder. METHODS We retrospectively reviewed the medical records of all children and adolescents who had been surgically managed for PEASAO at our institution from January 2000 to December 2012. A systematic review of the literature was also performed to identify trends in causative organisms and formulate evidence-based recommendations for diagnosis and treatment. RESULTS Fourteen children (median age, 27.8 months) with PEASAO were included in the study. Fever (rectal temperature, >38°C) was present at admission in two children, C-reactive protein was within the normal range (<10 mg/dL) in eleven, the erythrocyte sedimentation rate was >20 mm/hr in eight, and the white blood-cell count was normal in all. The pathogen was not identified on blood cultures in any child and was identified on classical cultures of bone samples in only one. Use of PCR (polymerase chain reaction) assays allowed the pathogen to be identified in an additional eight children. The pathogen was Kingella kingae in eight and methicillin-sensitive Staphylococcus aureus in one. DISCUSSION The use of organism-specific real-time PCR assays markedly improves the detection rate of the pathogen responsible for PEASAO, and K. kingae is the most commonly detected pathogen. The literature highlights a biphasic age distribution of PEASAO in children. The infantile form affects children from one to less than four years of age, accounting for approximately 75% of all PEASAO cases. The second form, in older children, is more likely to be associated with fever and systemic symptoms. The femur and the tibia are the most commonly affected long bones. Laboratory data are usually noncontributory for diagnosing PEASAO, and blood cultures are often sterile. Although K. kingae is the most commonly detected microorganism in children less than four years of age, S. aureus is responsible for most PEASAO in older children. Antibiotic treatment is usually sufficient to eradicate the pathogen.

Are clinical measurements linked to the Gait Deviation Index in cerebral palsy patients

OBJECTIVE From a dataset of clinical assessments and gait analysis, this study was designed to determine which of the assessments or their combinations would most influence a low gait index (i.e., severe gait deviations) for individuals with cerebral palsy. DESIGN A retrospective search, including clinical and gait assessments, was conducted from August 2005 to September 2009. POPULATION One hundred and fifty-five individuals with a clinical diagnosis of cerebral palsy (CP) (mean age (SD): 11 (5.3) years) were selected for the study. METHOD Quinlans Interactive Dichotomizer 3 algorithm for decision-tree induction, adapted to fuzzy data coding, was employed to predict a Gait Deviation Index (GDI) from a dataset of clinical assessments (i.e., range of motion, muscle strength, and level of spasticity). RESULTS Seven rules that could explain severe gait deviation (a fuzzy GDI low class) were induced. Overall, the fuzzy decision-tree method was highly accurate and permitted us to correctly classify GDI classes 9 out of 10 times using our clinical assessments. CONCLUSION There is an important relationship between clinical parameters and gait analysis. We have identified the main clinical parameters and combinations of these parameters that lead to severe gait deviations. The strength of the hip extensor, the level of spasticity and the strength of the tibialis posterior were the most important clinical parameters for predicting a severe gait deviation.

Vitamin D deficiency: A forgotten treatable cause of motor delay and proximal myopathy

We report a four-year-old African boy referred for proximal muscle weakness, fatigability and episodic limb pain. Classical causes of structural and metabolic myopathy were initially considered before clinical and biological features of vitamin D deficiency rickets were identified. Prompt treatment with vitamin D and calcium supplementation led to a complete reversal of the muscle symptoms. Rickets-associated myopathy should be included in the differential diagnosis of proximal myopathy, especially in at-risk individuals. Vitamin D deficiency and its prevention remain important health issues in industrialized countries.

Talonavicular Arthrodesis for the Treatment of Neurological Flat Foot Deformity in Pediatric Patients: Clinical and Radiographic Evaluation of 29 Feet

Background Patients with cerebral palsy, syndromes, myopathies, and other forms of neurological impairment can develop planovalgus foot deformity of variable degrees of severity. Several techniques have already been described to resolve the deformity with variable results. Talonavicular arthrodesis is a well-known technique in adult patients, but to our knowledge, it has not been described in children with neurological impairment. Methods We performed a retrospective chart and radiographic review of 18 neurological patients (10 boys, 8 girls) with a mean age of 11.3±2.6 years (range, 7 to 19 y) who underwent talonavicular arthrodesis for flat foot deformity between 1998 and 2009, at our center. Results Of a total of 29 feet, talonavicular arthrodesis was judged satisfactory in 28 feet, whereas 1 had unsatisfactory results according to the Yoo clinical outcome scoring scale. Subjective observations reported that 3 feet from 2 patients were painful preoperatively and none after last follow-up. Functionally, 2 of 13 patients were able to stop using braces after surgery. The significant improvement achieved postoperatively in radiographic measurement angles was maintained at last follow-up without any loss of angle correction. Conclusions Talonavicular arthrodesis seems to achieve a reliable hind foot fixation in flat foot in patients with neurological impairment. Level of Evidence IV Case series.