Electromyographic test to differentiate mild diplegic cerebral palsy and idiopathic toe-walking.

The purpose of this study was to determine whether children with mild spastic diplegic cerebral palsy (CP) could be differentiated from those with idiopathic toe-walking (ITW) based on an obligatory coactivation during voluntary contraction of the quadriceps or gastrocnemius. Twenty-four subjects participated in this study, eight children with mild spastic diplegia CP, eight with ITW, and eight age-matched controls. Measurements included passive range of motion and surface electromyographic recordings of the lateral quadriceps and lateral gastrocnemius. Electromyographic recordings were obtained during resisted knee extension with knee flexed 30 degrees, isometric quadriceps contraction with knee extended (quad set), active plantarflexion, and during gait. The range-of-motion values were not different between the CP and ITW subjects, with the exception of the popliteal angle, which was greater in subjects with CP, with an overlap in values. Gait electromyography showed premature firing of gastrocnemius in swing in both groups of subjects compared with controls. During resisted knee extension and quad set, the mean duration of gastrocnemius coactivation in subjects with CP was high: 86% and 86% compared with 20% and 35% for the subjects with ITW and 0.4% and 3% for controls, respectively. Voluntary plantarflexion did not consistently elicit coactivation of the quadriceps. The results suggest that electromyographic testing of resisted knee extension and quad set to identify gastrocnemius coactivation can help differentiate patients with mild CP from those with ITW.

Electromyographic differentiation of diplegic cerebral palsy from idiopathic toe walking: involuntary coactivation of the quadriceps and gastrocnemius.

Clinical differentiation of patients with mild diplegic cerebral palsy (CP) and idiopathic toe walking (ITW) can be difficult. However, an involuntary extensor pattern may be a distinguishing sign. The purpose of this study was to determine if selected gait parameters or patterns of electromyogram (EMG) timing of quadriceps, gastrocnemius, and tibialis anterior during knee extension while sitting can distinguish between these patients. The hypothesis was that EMG testing for selective control of the quadriceps and gastrocnemius could differentiate patients with diplegic CP from normal controls and from patients with ITW. We evaluated 10 control, eight CP, and eight ITW subjects. Measurements included walking speed, energy expenditure index (EEI), ankle position during stance, and EMG of the quadriceps, gastrocnemius, and tibialis anterior during gait and during knee extension while sitting. Dynamic EMG timing during gait showed significant differences in the mean onset of the gastrocnemius between subjects with CP and ITW, but there was considerable overlap. More consistent differences were found during active and active-resisted knee extension while sitting. Mean values for gastrocnemius EMG timing recorded as a percentage of duration of quadriceps EMG while sitting were 0 and 0.4% for controls, 0 and 3.9% for ITW subjects, and 84.3% and 93.4% for CP subjects. Patterns of EMG timing of the quadriceps and gastrocnemius during knee extension while sitting can help to differentiate patients with mild diplegic CP from those with ITW.

Analysis of radiographic measurements as prognostic indicators of treatment success in patients with developmental dysplasia of the hip.

Measurements were taken and statistically analyzed from the initial radiographs, the 1-year follow-up radiographs, and the most recent radiographs of 81 patients (103 hips) to determine which measurements could predict the success of treatment. The average follow-up was 49 months (range, 12-139 months), and the average age of the patients at the last follow-up was 65 months (range, 15-190 months). Analysis of the data showed that the measurement with statistically significant predictive value was the Tonnis grade of dislocation determined from the initial radiograph. A single unit increase in the Tonnis grade was associated with a doubling of the odds of failure in patients treated with a Pavlik harness (P < 0.04, odds ratio = 2.2) or a closed reduction (odds ratio = 2.0).

Effectiveness of ice packs in reducing skin temperature under casts.

Skin temperature lowering effects were measured after application of crushed ice packs to the surface of synthetic and plaster casts. The skin temperature of legs in synthetic casts decreased an average of 10.4 degrees C (range, 8.3 degrees-12.6 degrees) to a minimum temperature of 19.7 degrees C (range, 16.2 degrees-21.8 degrees), and the temperature of legs in plaster casts decreased an average of 11 degrees C to a minimum of 18.7 degrees C (range, 13 degrees-22.8 degrees). It took an average of 56 minutes (range, 40-80 minutes) for the legs in synthetic casts and 63.8 minutes (range, 26-116 minutes) for the legs in plaster casts to reach the minimum temperature. Cryotherapy is used clinically with the intention of lowering skin temperature and presumably decreasing the pain and swelling of a patient's injured extremity. The presence of a synthetic or a plaster cast does not eliminate the lowering effects of skin temperature when crushed ice packs are applied to the surface of the casts.

Gastrointestinal problems in patients who have type-III osteogenesis imperfecta.

We performed a study of forty-three patients who had type-III osteogenesis imperfecta. Our purpose was to determine the frequency and severity of abdominal problems and the relationship between these problems and pelvic deformity. Twelve patients had had recurrent episodes of abdominal pain. Eleven of them had a history of chronic constipation, and five had been treated for fecal impaction. Radiographs had been made for ten of these patients, and eight of them had radiographic evidence of pelvic deformity with severe acetabular protrusion. Chronic constipation and recurrent abdominal pain are more frequent in patients who have osteogenesis imperfecta and acetabular protrusion than in those who do not have protrusion. These patients may benefit from early attention to a bowel program and referral to a gastrointestinal specialist.

Advances in management of idiopathic scoliosis.

Management rests on two critical questions: whether the curve is likely to progress before cessation of growth, and whether further progression can be expected in the mature patient. With regard to both questions, we have learned a number of important lessons from mass screening and its follow-up. Along the way, a number of questionable technologies have been discarded.

Pericardial tamponade secondary to perforation by central venous catheters in orthopaedic patients.

Pericardial tamponade from an indwelling central venous catheter developed in four orthopaedic patients. Two of these patients died acutely, and the other two sustained severe anoxic brain injury. The early signs of tamponade include tachycardia, hypotension, and increased central venous pressure. The outcome most often is fatal. When a central venous catheter has been placed incorrectly or has migrated, it can perforate the heart and produce pericardial tamponade. To avoid this complication, the tip of the catheter must be placed within the superior vena cava rather than the right atrium, and the position of the catheter must be ascertained with a radiograph of the chest. Prompt recognition and treatment of pericardial tamponade are imperative if a disastrous outcome is to be prevented.

Transverse cervicopertrochanteric hip fracture.

A 3-year-old boy sustained a previously undescribed transverse hip fracture that involved the cervical, cervicotrochanteric, and intertrochanteric regions. The fracture was successfully treated with skeletal traction for 4 weeks using a Steinmann pin placed through the distal femoral metaphysis followed by spica cast immobilization. The 3-year follow-up examination demonstrated satisfactory growth and remodeling of the proximal femur with no evidence of osteonecrosis, premature physeal closure, or coxa vara.

Simple method of documenting metatarsus adductus.

A simple, accurate, and inexpensive method of documenting metatarsus adductus involves taking photocopies of the foot in the weightbearing position. Subsequently, treatment progress can be assessed objectively by reviewing serial photocopies. Some caution is urged because the strength of the glass copying surface of photocopying machines is unknown.

Arthropathy of the ankle in hemophilia.

Seventy-five patients who had hemophilia were followed clinically and roentgenographically to assess the prevalence of hemarthrosis and the prevalence and severity of arthropathy of the ankle. The mean age of the patients at the time of follow-up was twenty-two years and seven months. The patients were divided into four age-groups: less than ten years (eleven patients), ten to nineteen years (twenty-one patients), twenty to thirty years (twenty-four patients), and more than thirty years (nineteen patients). Intra-articular bleeding occurred more frequently in the joints of the lower extremities than in the joints of the upper extremities. During the second decade of life, hemarthroses occurred more often in the ankle than in the knee. A history of recurrent bleeding into the ankle joint, chronic synovitis, and overgrowth of the medial portion of the distal tibial epiphysis was associated with an early onset of arthropathy. In older patients, compression arthrodesis of the ankle joint was helpful in eliminating pain, recurrent bleeding, and equinus deformity.

Simultaneous correction of pelvic obliquity, frontal plane, and sagittal plane deformities in neuromuscular scoliosis using a unit rod with segmental sublaminar wires: a preliminary report.

Ten patients with neuromuscular scoliosis and pelvic obliquity had segmental spinal instrumentation using a unit Luque rod with sublaminar wires and fixation into the pelvis. Nine of the 10 patients also had anterior spinal fusion without instrumentation before the posterior procedure. Average preoperative pelvic obliquity was 42 degrees which was corrected to 6 degrees (82% correction). Average preoperative scoliosis was 92 degrees, which was corrected to 16 degrees (81% correction). Complications included a wound hematoma in one patient and a superficial wound dehiscence in another. There have been no pseudarthroses or hardware failures to date. Excellent correction of the pelvic obliquity and the spinal curve in neuromuscular scoliosis can be obtained with use of a unit rod and without use of anterior instrumentation.

Surgery of spinal deformity in cerebral palsy. Twelve years in the evolution of scoliosis management.

In order to assess the lessons learned from 12 years of surgery on patients with cerebral palsy and spinal deformity, the cases may be divided into three groups classified according to type of posterior spinal fusion, instrumentation, and time period. Group I (1976-1980) included patients who had Harrington rods, usually with Dwyer instrumentation. Group II (1980-1985) consisted of patients with unlinked Luque or wired-in Harrington rods. Group III (1985-1988) comprised patients with a unit Luque rod extending to the pelvis. Most patients were retarded nonwalkers who had total body involvement, pelvic obliquity, and severe thoracolumbar curves (Group I average, 97 degrees; Group II average, 72 degrees; Group III average, 89 degrees). The frontal plane correction at follow-up study averaged 51% in Group I, 47% in Group II, and 76% in Group III. The correction of the pelvic obliquity averaged 71% in Group I, 58% in Group II, and 86% in Group III. The general trend was toward longer fusion, use of the unit 0.625-cm Luque rod, and first-stage anterior discectomy and fusion without anterior instrumentation. The second-stage posterior arthrodesis and fusion is now performed only one week after the first-stage anterior procedure. Skeletal traction has been abandoned. The Luque rod instrumentation without fusion has also been abandoned.

Established hip dislocations in children with cerebral palsy.

Hip dislocation in children with cerebral palsy is caused by a combination of factors, including spastic muscle imbalance, persistent fetal femoral geometry, acetabular dysplasia, and flexion-adduction contracture. The incidence of dislocation correlates with the severity of the spasticity, and the prevalence is close to 50% in neurologically immature, spastic quadriplegic children. Successful hip reductions improve muscular balance, provide satisfactory reduction of the femoral head, and establish good pelvic coverage. In 31 occurrences of established hip dislocation in 24 patients, the most successful operations used a combined procedure consisting of soft-tissue release, open reduction, femoral varus derotation and shortening osteotomy, and pelvic osteotomy.

Gait electromyograms and surgical decisions for paralytic deformities of the foot.

Twenty-one patients who had 23 gait electromyographic (EMG) examinations for paralytic deformities of the foot had surgical procedures performed. Outcome of the surgery was analysed with respect to the value of the pre-operative gait studies in deciding on appropriate surgical procedures. When outcome at follow-up (mean 3.6 years) was satisfactory and surgery had been in accordance with the EMG findings, or when outcome was unsatisfactory when the EMG had been disregarded, the value was deemed positive. Conversely, if the EMG data had been disregarded but outcome was satisfactory, the value was negative. Using these criteria, 70 per cent of the EMGs of the four muscles tested (tibialis anterior and posterior, peroneal and gastrocnemius) were a positive contribution to the evaluation and decision for the particular surgical procedure.

Trapeziometacarpal abnormalities in Ehlers-Danlos syndrome.

We studied 24 patients with Ehlers-Danlos syndrome with particular attention to the thumb and the trapeziometacarpal joint. The 11 males and 13 females had a mean age of 15.9 years. Symptomatic complaints included pinch, grip and twisting weakness; measurements showed dominant hand strength deficits of 71% for tip pinch, 55% for palmar pinch, 46% for key pinch, and 70% for grip. All finger joint ranges of motion were increased. Sixty-six percent of all the patients had trapeziometacarpal subluxation; 29% had dislocation. Sixteen percent had radiographic evidence of arthritis. Early occupational therapy evaluation and education can help these patients better understand and adapt to their limitations.

Complications of intramedullary rods in osteogenesis imperfecta: Bailey-Dubow rods versus nonelongating rods.

Twenty-nine patients with osteogenesis imperfecta underwent 108 intramedullary roddings with 42 Bailey-Dubow rods and 66 nonelongating rods. The average age at insertion of the first rod was 5 years; average follow-up was 3.1 years (range 1-9 years). The overall complication rate was 60%-69% for Bailey-Dubow rods and 55% for nonelongating rods. Forty-seven percent of bones receiving rods required reoperation. Nonelongating rods had a 29% reoperation rate and a 24% replacement rate; Bailey-Dubow rods had a 19% reoperation rate and a 12% replacement rate.

Orthopaedic aspects of central core disease.

We studied the cases of fifteen patients who had central core disease, a non-progressive congenital myopathy that is usually inherited as an autosomal dominant trait. As infants, the patients had poor muscle tone and developmental delay, and as adolescents and adults, they had varying degrees of proximal muscle weakness and tended to use the Gower maneuver. The most common musculoskeletal problems were dislocation or subluxation of the hip, pes planus, and hypermobility of the joints. The most serious orthopaedic problems were in the hips: ten patients had a total of nine dislocations and six subluxations, nine being present at birth and six developing later. Only nine hips were stable after the initial treatment, and there was a propensity for hip-joint contractures. Scoliosis and patellar instability were also seen. Although patients who have central core disease have been reported to be at increased risk for malignant hyperthermia, this did not occur in our patients.

Kingella kingae infection in healthy children.

Kingella kingae is a gram-negative occasional, but normal, inhabitant of the nasopharynx. We present two new cases of this infection that occurred in previously healthy children, and compare and contrast them to other cases reported in the literature. K. kingae osteomyelitis generally has an insidious, subacute onset, whereas septic arthritis has an acute presentation. To date, all strains of K. kingae have been sensitive to penicillin, and no residual damage has been reported following osteomyelitis or septic arthritis, except that residual disk space narrowing did occur after K. kingae discitis.