Shevaun M. Doyle

Resection arthroplasty of the hip for patients with cerebral palsy: an outcome study.

Thirteen patients (18 hips) with cerebral palsy and painful hip subluxation or dislocation underwent proximal femoral resection-interposition arthroplasty (PFRIA) as a salvage procedure for intractable pain or seating difficulty. Eleven patients (14 hips) had a prior failed soft-tissue or bony reconstruction. The average age at surgery was 26.6 years (range, 10.7-45.5 years), and average follow-up was 7.4 years (range, 2.2-20.8 years). All patients/caregivers noted significant improvement in subjective assessment of pain after the surgery. Upright sitting tolerance improved from an average preoperative value of 3.2-8.9 h postoperatively (p < 0.01). Four patients who were unable even to sit in a customized wheelchair before the operation could be easily seated in a custom chair after surgery. Hip range of motion including flexion, extension, and abduction was significantly improved postoperatively (p < 0.05). Single-dose radiation therapy was used postoperatively for five hips and resulted in a significantly lower grade of heterotopic ossification at final follow-up (p < 0.005). Skeletal traction in the postoperative period did not prevent proximal migration of the femur compared with skin traction. Maximal pain relief was achieved at an average of 5.6 months postoperatively (range, 0.03-14 months). Complications included transient postoperative decubitus ulceration (four patients), pneumonia (two patients), and symptomatic heterotopic bone (two patients). The significant improvements in pain management, sitting tolerance, and range of motion suggest that PFRIA is a reasonable salvage procedure for the painful, dislocated hip in cerebral palsy. Resolution of pain may not be immediate, as was noted in this series.

Measurement of bone density in the pediatric population.

Purpose of review The purpose of this review is to provide a comprehensive synopsis of pediatric bone density. Osteoporosis of the adult is a well established clinical problem, and algorithms to diagnose and treat this disease are recognized throughout the medical community. Osteoporosis or ‘low bone mass’ in pediatrics, on the other hand, is a rather new and evolving area, with certain unique diagnostic and clinical challenges. Recent findings Recent findings in the literature include benefits and limitations of pediatric bone densitometry techniques, proper interpretation of the results of these various techniques, efforts to establish standards and guidelines for diagnosing low bone mass in children and adolescents, optimization of bone growth and mineral accrual for life, pediatric bone mineral density and fracture risk prediction, as well as a clearer awareness of bone fragility in children. Summary Throughout the last decade, great strides have been made in our understanding of pediatric metabolic bone disease. These will be the focus of this review.

Internet search term affects the quality and accuracy of online information about developmental hip dysplasia.

Background: The recent emphasis on shared decision-making has increased the role of the Internet as a readily accessible medical reference source for patients and families. However, the lack of professional review creates concern over the quality, accuracy, and readability of medical information available to patients on the Internet. Methods: Three Internet search engines (Google, Yahoo, and Bing) were evaluated prospectively using 3 difference search terms of varying sophistication (“congenital hip dislocation,” “developmental dysplasia of the hip,” and “hip dysplasia in children”). Sixty-three unique Web sites were evaluated by each of 3 surgeons (2 fellowship-trained pediatric orthopaedic attendings and 1 orthopaedic chief resident) for quality and accuracy using a set of scoring criteria based on the AAOS/POSNA patient education Web site. The readability (literacy grade level) of each Web site was assessed using the Fleisch-Kincaid score. Results: There were significant differences noted in quality, accuracy, and readability of information depending on the search term used. The search term “developmental dysplasia of the hip” provided higher quality and accuracy compared with the search term “congenital hip dislocation.” Of the 63 total Web sites, 1 (1.6%) was below the sixth grade reading level recommended by the NIH for health education materials and 8 (12.7%) Web sites were below the average American reading level (eighth grade). Conclusions: The quality and accuracy of information available on the Internet regarding developmental hip dysplasia significantly varied with the search term used. Patients seeking information about DDH on the Internet may not understand the materials found because nearly all of the Web sites are written at a level above that recommended for publically distributed health information. Clinical Relevance: Physicians should advise their patients to search for information using the term “developmental dysplasia of the hip” or, better yet, should refer patients to Web sites that they have personally reviewed for content and clarity. Orthopaedic surgeons, professional societies, and search engines should undertake efforts to ensure that patients have access to information about DDH that is both accurate and easily understandable.

Evaluation and treatment of symptomatic pes planus.

Purpose of review To provide the pediatrician with a comprehensive synopsis of pediatric pes planus, also known as flatfoot. The term pes planus is a physical finding that generates some confusion in the medical community because it describes a spectrum of conditions that are diagnosed and managed differently. Recent findings Some of the recent data incorporated in this review come from pediatric, orthopaedic, and podiatric literature. These sources describe the clinical features and the latest treatment options for pes planus. Summary This article will provide some guidance to evaluate and treat the many causes of pediatric pes planus. Nonsurgical and operative management will be discussed.

The shorthand bone age assessment: a simpler alternative to current methods.

Background: Radiographic assessment of skeletal age in pediatric patients is a common practice among orthopaedic surgeons. Current methods of assessment remain labor intensive and require special resources. This study sought to investigate a novel, abridged method of bone age assessment that may serve as a simpler and more efficient alternative to the current standard. Methods: A shorthand bone age (SBA) method developed at our institution was compared against the Greulich and Pyle method from which it was derived. Standard left hand bone age radiographs of 140 male and 120 female patients, previously assigned skeletal ages ranging from 12.5 to 16 years in males and 10 to 16 years in females by musculoskeletal radiologists using the Greulich and Pyle radiographic atlas, were read using the shorthand method by 3 attending pediatric orthopaedic surgeons and an orthopaedic surgery resident. The shorthand method utilizes a single, univariable criterion for each age, rather than a multivariable subjective comparison to a radiographic atlas. All reviewers were blinded to the original bone age determination. Interobserver reliability, intraobserver reliability, and agreement with the previous records utilizing the atlas were calculated using weighted &kgr;. Results: The SBA method readings demonstrated substantial agreement with readings by the Greulich and Pyle atlas, demonstrating weighted &kgr; values ranging from 0.71 to 0.75. The SBA method also demonstrated substantial to almost perfect interobserver and intraobserver reliability, with values ranging from 0.77 to 0.87 and from 0.87 to 0.95, respectively. Conclusions: These results are comparable or superior to previous reports which investigate the validity and reliability of other skeletal age assessment tools. The SBA assessment tool offers a simple and efficient alternative to current methods. Level of Evidence: Diagnostic study, level III.

Symptomatic talonavicular coalition.

Talonavicular coalition is reported as an asymptomatic congenital anomaly of the foot that is noticed incidentally on radiographs of the foot, and is often associated with symphalangism, clinodactyly, ball-and-socket ankle joint, a great toe that is shorter than the second toe, and an autosomal dominant inheritance pattern. We describe here three patients with five involved feet. All three patients had chronic foot pain not secondary to trauma, and all five feet required treatment to alleviate the pain.

Pediatric upper extremity stress injuries.

Purpose of review To provide primary care physicians with strategies to evaluate and manage pediatric upper extremity stress injuries related to overuse with a focus on anatomic location, patient history, physical examination, and imaging. Recent findings Children are susceptible to stress injuries due to their open physes. The physeal cartilage of epiphyses and apophyses is the weakest structure in the developing skeleton. The differential diagnosis for pediatric stress injuries includes injury to the bone, physis, epiphysis, and apophysis. Most stress injuries in children improve with rest. Missed or misdiagnosed stress injuries can lead to growth abnormalities and potential malalignment. Summary Awareness of stress injuries is important for timely diagnosis and prevention of sequelae. A thorough history, focused physical examination, and proper imaging studies are crucial steps to identify upper extremity stress injuries in the pediatric population.

Osteochondroses: a clinical review for the pediatrician

The purpose of this article is to provide the pediatrician with a thorough review of the variety of osteochondroses that affect children and adolescents. These conditions present in all different parts of the body in a wide range of patients: from the sedentary to athletic, the toddler to the pre-teen. The osteochondroses often are self-limiting and resolve with nonoperative management, but there are a few circumstances when operative treatment may be required. Recent literature confirms the heterogeneity of these conditions with respect to the clinical presentations and musculoskeletal manifestations. We think this article will heighten awareness of these disorders in the pediatric community, so that prompt intervention may be rendered.

Severity of injury and the decision to arrest in cases of intimate partner violence

From a victims physical health perspective, at the centre of any case of intimate partner violence (IPV) is the degree of trauma imparted on that victim by the offender. Yet, the implementations of state-level ‘Mandatory Arrest’ and ‘Preferred Arrest’ laws encourage arrests decisions in cases of IPV typically without regard to the level of trauma severity found in each case. And, despite these well-meaning implementations and the gravity of their consequences, the importance of evaluating trauma severity in victims of IPV remains largely overlooked. The goal of this study was to correlate police arrest decisions in cases of IPV to a trauma severity score generated from established clinical protocols in the treatment of trauma. A Trauma Severity Quantification Table (TSQT) was created in order to quantify the major factors of an incident of IPV: anatomical location of attack, method of attack, facilitating weapon/object and resulting trauma. A total of 256 cases of IPV reported to six police departments in Idaho, a state with a discretionary arrest law in domestic violence cases, in the calendar year 2000 were processed using the TSQT. A statistically significant difference was found between arrests (mean 17.96, standard deviation [SD] 5.90) versus no arrest (mean 16.13, SD 5.67) outcomes (P = 0.03). It is suggested that trauma severity is a factor in police arrest decisions in a discretionary state sample, but that more attention needs to be brought to this method of analysis and its implications for future arrest decisions.

Orthopedic aspects of collagen disorders.

Purpose of review The purpose of this article is to provide the pediatrician with a review of disorders that have the orthopedic manifestation of joint hypermobility. Hypermobility, also termed ligamentous laxity, may present in different parts of the body at different times throughout childhood and adolescence. It may be symptomatic or incidentally found on the physical examination. Many conditions that cause joint hypermobility resolve with nonoperative management, but occasionally operative intervention is required for the best patient outcome. Recent findings In addition, hypermobility may be associated with collagen disorders that affect vital organ systems. Recognition of hypermobility combined with a thorough patient evaluation may be the initial opportunity for the pediatrician to uncover disease that may be managed promptly. Summary Heightened awareness of subtle hypermobility or symptomatic joint laxity on physical examination facilitates optimal management and favorable outcomes in children with this condition.