V. Gautheron

Tibial intercondylar eminence fractures in children: The long-term perspective

PURPOSE OF THE STUDY To analyze objective and subjective results on medium-term follow-up of intercondylar fractures of the tibia in children. MATERIAL AND METHODS A retrospective, single-center study of 32 fractures (17 boys, 14 girls) was performed. Fractures were itemized on the Meyers and McKeever classification as modified by Zaricznyj: there were eight type-I, 17 type-II, five type-III and two type-IV fractures. Treatment was conservative for type-I and II fractures (with mild displacement) and for the others surgical. Seven patients were lost to follow-up and one had insufficient follow-up for inclusion. Thirteen patients were assessed on a KT 1000 arthrometer and a dynamometer, and on the IKDC and ARPEGE scoring systems. Ten patients chose to answer only the subjective IKDC questionnaire, by mail. RESULTS The mean IKDC score of subjects answering by mail was 91 and of those with clinical examination was 80. Mean ARPEGE score was 8.3. Subjective IKDC score classified four patients as A, four as B, four as C and one as D. Mean difference in tibial anterior translation between affected and unaffected knees was 0.88mm for type I fractures, 0.82mm for type II and 0.30mm for types III and IV together. DISCUSSION The mean difference in tibial anterior translation between affected and unaffected knees was greater in patients with conservative treatment (0.96mm for conservative vs. 0.29mm for surgical treatment). Seventy per cent of patients reported pain at follow-up. Only two had pathological knee laxity. Twelve out of thirteen had returned to sport activity, half of them at the same level as before injury. CONCLUSION The cases treated surgically had a better objective result than those treated conservatively. Nevertheless there was no correlation between subjective evaluation and degree of knee laxity. Overall, intercondylar fractures of the tibial eminence in children have good long-term prognosis, at least subjectively. This study shows that, in spite of a very satisfactory subjective result for most patients, results were not so good on objective measures. LEVEL OF EVIDENCE Level IV: retrospective study.

Effects of Backpack Carrying in Children

ORTHOPEDICS | www.orthobluejournal.com Back pain is an epidemic in the adult population with 60% of adults reporting having experienced back pain.1-3 Back symptoms are the second leading symptomatic reason expressed by patients in the United States for consulting physicians.4 The incidence of back pain in children and adolescents varies from 8%-84.1%.5-15 The reported incidence depends on the population studied and the definition used.16 The majority of low-back pain is mild.17 Growing concern exists among educators, health-care professionals, parents, and legislators that back pain is becoming a serious health issue in school-aged children due to the increased use of heavy backpacks.18 The carrying of heavy backpacks is common in the school-age population.2 Young children sometimes carry as much as 30%-40% of their body weight.2 The association of back pain with backpack use is controversial within the scientific literature with some studies finding no association and some finding an association. This review article studies the impact of backpack carrying on children and reviews the available scientific literature.

Cartable et pathologie rachidienne : Légende ou réalité ?

Resume Les rachialgies de l’adulte sont tres frequentes et celles de l’enfant aussi. Les facteurs de risque pour les rachialgies sont le sexe feminin, un mauvais etat de sante, des antecedents familiaux de rachialgies, un profil psychologique particulier, le temps passe a rester assis ou a regarder la television, le poids du cartable, la duree de port du cartable, des antecedents de traumatisme rachidien, une activite physique intense, la pratique de sports en competition et l’âge (plus frequent chez l’adolescent que chez l’enfant). Pour la plupart des auteurs, il existe une relation entre l’apparition de rachialgies et le port d’un cartable representant plus de 20 % du poids du corps. Beaucoup d’etudes fixent comme seuil conseille 10 % du poids du corps pour le cartable. Il semble que non seulement le poids du cartable mais la duree du port de celui-ci dans la journee soit un facteur favorisant pour l’apparition de rachialgies. Le mauvais positionnement du cartable peut modifier la posture et la marche. Le port du cartable sur les deux epaules entraine moins de modification de la posture et de la marche que le port du cartable sur une seule epaule. Il n’y a pas d’etude actuelle qui permette d’etablir une relation entre poids du cartable et developpement d’une deformation rachidienne structuralisee.

Computerized static posturographic assessment after treatment of equinus deformity in children with cerebral palsy.

Assessment of treatments in children with cerebral palsy has been well developed, especially in the gait laboratory. However, the prerequisite for walking is adequate postural control. We hypothesize that a treatment of an equinus deformity should improve postural control. Balance control was assessed by static posturography on the Balance Master. Nine diplegic children, six girls and three boys, participated in the study. Assessment was conducted before and after treatment of the equinus deformity. Two static tests (Weight Bearing Squat and the modified Clinical Test for Sensory Interaction on Balance), and two dynamic balance tests (Limits of Stability and Rhythmic Weight Shift) were performed on the Balance Master. After treatment, mean weight-bearing asymmetry measured by the Weight Bearing Squat was significantly improved at 30° of knee flexion. In the modified Clinical Test for Sensory Interaction on Balance, there was a significant improvement in two conditions (eyes closed on foam surface and the composite score). The Limits of Stability was very difficult to perform for almost all the children. In the Rhythmic Weight Shift, mean directional control improved significantly in three conditions (left/right weight shift at 1 s of transition, front/back weight shift at 2 s of transition and the composite score of the front/back direction). The Balance Master offers the opportunity for an objective and easy assessment of postural control in children with cerebral palsy.

Diurnal changes in postural control in normal children: Computerized static and dynamic assessments.

Mild traumatic brain injury (mTBI) causes postural control deficits and accordingly comparison of aberrant postural control against normal postural control may help diagnose mTBI. However, in the current literature, little is known regarding the normal pattern of postural control in young children. This study was therefore conducted as an effort to fill this knowledge gap. Eight normal school-aged children participated. Posture assessment was conducted before (7–8 a.m. in the morning) and after (4–7 p.m. in the afternoon) school on regular school days using the Balance Master® evaluation system composed of 3 static tests and 2 dynamic balance tests. A significant difference in the weight-bearing squats was detected between morning hours and afternoon hours (P < 0.05). By end of afternoon, the body weight was borne mainly on the left side with the knee fully extended and at various degrees of knee flexion. A significantly better directional control of the lateral rhythmic weight shifts was observed at the end of the afternoon than at morning hours (P < 0.05). In summary, most of our findings are inconsistent with results from previous studies in adults, suggesting age-related differences in posture control in humans. On a regular school day, the capacity of postural control and laterality or medio-lateral balance in children varies between morning and afternoon hours. We suggest that posturographic assessment in children, either in normal (e.g., physical education and sports training) or in abnormal conditions (e.g., mTBI-associated balance disorders), be better performed late in the afternoon.

Résection fémorale supérieure chez l’enfant polyhandicapé grabataire

INTRODUCTION Hip dislocation in nonambulatory multiply handicapped children (particularly in cerebral palsy [CP]) is a common and severe problem involving painful transportation and uneasy positioning, usually resulting from major anatomical osteoarticular and soft tissue disorders. Therefore, proximal femoral resection is seen as a salvage procedure whose primary purpose is to provide children and their caregivers with better comfort during activities of daily living thus allowing improved sitting tolerance in the wheelchair and painless nursing care. MATERIALS AND METHODS A series of 21 proximal femoral resections performed on 16 patients with a mean age at surgery of 12 years, and a follow-up period of 21 years (from 1984 to 2005) were retrospectively reviewed. All patients suffered from painful dislocation of the hip. Sixteen of the hips (76%) had been managed previously with bony and soft tissue surgery. Femoral resection was performed in the basicervical region in eight hips and distal to the lesser trochanter in 13 hips. RESULTS At a mean follow-up of five years and eight months, 18 of the 21 painful hips reported to be painless (86%). All preoperative stiffness and deformity of the hip joints was corrected, resulting in floppy, mobile hips with an increased range of motion after surgery. Femoral stump, regarding the acetabulum was above in three hips, at the same level in 18 and never below. The proximal end of the femoral shaft could often been palpated but did not reveal any skin irritation. The formation of heterotopic bone was discernible in five hips (24%). However, it did not affect the functional outcomes. DISCUSSION Soft-tissue releases combined with femoral and pelvic osteotomies have reported poor results with regard to their long-term inefficacy in children. The outcomes of our series support these findings, since surgical procedures had been performed previously in 76% of the hips. Therefore, we believe that proximal femoral resection is a promising and reliable surgical treatment option to address such failures, in case of severe and painful deformities of the hip. The success of our series corroborates Widemann, Mc Carthy and Abu-Rajab encouraging results on proximal femoral resection. Postoperatively, we advise placement of a hip spica cast immobilization with a soft cotton lining to prevent pressure sores from developing. This surgical procedure seems to be an appropriate management in nonambulatory multiply handicapped children reporting more promising results than other surgical treatment options such as rotational osteotomy, arthrodesis or even arthroplasty.

MémoireRésection fémorale supérieure chez l’enfant polyhandicapé grabataireProximal femoral resection in nonambulatory multiply handicapped child

INTRODUCTION Hip dislocation in nonambulatory multiply handicapped children (particularly in cerebral palsy [CP]) is a common and severe problem involving painful transportation and uneasy positioning, usually resulting from major anatomical osteoarticular and soft tissue disorders. Therefore, proximal femoral resection is seen as a salvage procedure whose primary purpose is to provide children and their caregivers with better comfort during activities of daily living thus allowing improved sitting tolerance in the wheelchair and painless nursing care. MATERIALS AND METHODS A series of 21 proximal femoral resections performed on 16 patients with a mean age at surgery of 12 years, and a follow-up period of 21 years (from 1984 to 2005) were retrospectively reviewed. All patients suffered from painful dislocation of the hip. Sixteen of the hips (76%) had been managed previously with bony and soft tissue surgery. Femoral resection was performed in the basicervical region in eight hips and distal to the lesser trochanter in 13 hips. RESULTS At a mean follow-up of five years and eight months, 18 of the 21 painful hips reported to be painless (86%). All preoperative stiffness and deformity of the hip joints was corrected, resulting in floppy, mobile hips with an increased range of motion after surgery. Femoral stump, regarding the acetabulum was above in three hips, at the same level in 18 and never below. The proximal end of the femoral shaft could often been palpated but did not reveal any skin irritation. The formation of heterotopic bone was discernible in five hips (24%). However, it did not affect the functional outcomes. DISCUSSION Soft-tissue releases combined with femoral and pelvic osteotomies have reported poor results with regard to their long-term inefficacy in children. The outcomes of our series support these findings, since surgical procedures had been performed previously in 76% of the hips. Therefore, we believe that proximal femoral resection is a promising and reliable surgical treatment option to address such failures, in case of severe and painful deformities of the hip. The success of our series corroborates Widemann, Mc Carthy and Abu-Rajab encouraging results on proximal femoral resection. Postoperatively, we advise placement of a hip spica cast immobilization with a soft cotton lining to prevent pressure sores from developing. This surgical procedure seems to be an appropriate management in nonambulatory multiply handicapped children reporting more promising results than other surgical treatment options such as rotational osteotomy, arthrodesis or even arthroplasty.