Comparison of Trunk Motion between Moderate AIS and Healthy Children.

Analysis of kinematic and postural data of adolescent idiopathic scoliosis (AIS) patients seems relevant for a better understanding of biomechanical aspects involved in AIS and its etiopathogenesis. The present project aimed at investigating kinematic differences and asymmetries in early AIS in a static task and in uniplanar trunk movements (rotations, lateral bending, and forward bending). Trunk kinematics and posture were assessed using a 3D motion analysis system and a force plate. A total of fifteen healthy girls, fifteen AIS girls with a left lumbar main curve, and seventeen AIS girls with a right thoracic main curve were compared. Statistical analyses were performed to investigate presumed differences between the three groups. This study showed kinematic and postural differences between mild AIS patients and controls such as static imbalance, a reduced range of motion in the frontal plane, and a different kinematic strategy in lateral bending. These differences mainly occurred in the same direction, whatever the type of scoliosis, and suggested that AIS patients behave similarly from a dynamic point of view.

Amyoplasia and distal arthrogryposis.

Arthrogryposis multiplex congenita (AMC) consists of congenital joint contractures that affect at least two joints. There are two types: in the first, arthrogryposis is an additional sign in the context of various pathologies (neuromuscular diseases); in the second, it is the main and constant symptom. In the first type, the progression of the causal underlying disease must be considered. In the second type, there are two specific forms: Amyoplasia corresponds to a significant congenital absence of muscles (epigenetic disease or vascular origin) while distal arthrogryposis has a genetic component and is transmissible. The orthopedic surgeon's purpose, which is usually to enhance movement, is not appropriate for an arthrogryposis patient. One must keep in mind that without muscle, movement is impossible. The goal differs between the upper and lower limbs: for the upper limb, it is to allow grasping, and, if possible, to bring the hand to the mouth; for the lower limb, it is to ensure ambulation with plantigrade support, and the knees extended, which is the only stable position possible with little to no muscles. The rehabilitation, orthoses and/or surgical techniques are chosen to achieve this singular aim. While it may appear modest, it is crucial for patients. The goal is to achieve useful mobility, not maximum mobility. This multidisciplinary treatment, which evolves over time, must be explained to the family to get its adherence.

Pediatric navicular dorsal osteochondroma: a rare case of navicular-cuneiform impingement.

Osteochondroma is one of the most common benign bone tumors; however, as it rarely affects any bones in feet, it may easily escape detection without rigorous examination. We present an exceptionally rare case of tarsal navicular dorsal osteochondroma diagnosed in an 11-year-old female child affected by chronic foot pain. Radiographs, MRI, and computed tomography scan revealed bony excrescences extending outward from the navicular bone. After conservative treatment failed, the navicular dorsal exostosis was excised in open surgery with complete resolution of symptoms. Navicular-cuneiform impingement was diagnosed by instrumental and intraoperative techniques. Histological analysis confirmed the diagnosis of navicular dorsal osteochondroma. This case report illustrates the necessity of particularly rigorous evaluation of the substrates of pediatric chronic foot pain.

Osteochondrosis of the medial malleolar epiphysis: A case report and review of the literature.

INTRODUCTION: Osteochondrosis is characterized by a disturbance of enchondral ossification in skeletally immature patients and should be investigated in children having a history of persistent foot and ankle pain. Involvement of the medial malleolar epiphysis is rarely reported. PRESENTATION OF CASE: We describe the case of a sporty 12-year-old male with osteochondrosis of the left medial malleolar epiphysis treated with a conservative management. DISCUSSION: Calcanear, navicular and metatarsal apophysis are the most common locations for osteochondrosis in ankle and foot. Anyway other osteochondrosis should be excluded. Medial malleolar osteochondrosis is occasionally described. We performed a review of the relevant literature and we summarized clinical aspects, radiological characteristics and reported management of this painful and probably underestimated condition. CONCLUSION: Medial malleolar osteochondrosis is a rare but well recognized condition. Only seven cases are described in literature.

A New Paradigm for the Management of Thoracolumbar Pediatric Spine Traumas.

OBJECTIVES: The transient breath holding sign (TBHS) is a clinical sign often associated with magnetic resonance imaging (MRI) spine traumatic lesions. The aims of this study were to prospectively evaluate the TBHS in the detection of thoracolumbar lesions in a large cohort of children and to establish a comprehensive strategy on the use of MRI in spine traumas in children. STUDY DESIGN: All conscious 5- to 16-year-old patients admitted for a spine trauma in our institution were prospectively included in the study. All patients were asked for the TBHS and underwent a full spine MRI. Sensitivity and specificity of the TBHS were derived from the confusion matrix. All MRI lesions were analyzed and classified. RESULTS: One hundred ninety-eight patients were included. The sensitivity of the TBHS was 92%, the specificity was 83%, the positive predictive value was 83%, and the negative predictive value was 91%. The x-rays missed 67% of the vertebrae injured in the MRI. The MRI lesions consisted in an upper end plate injury, in the sagittal plane only, in 90% of the cases. The vertebral canal and the spinal cord were never injured. CONCLUSIONS: This study confirms that the TBHS is a relevant clinical tool that should be added in the routine questionnaire after any trauma at admission. Magnetic resonance imaging should be restricted to patients with a TBHS positive at admission. A single T2 Short T1 Inversion Recovery (STIR) sagittal sequence seems sufficient to make the diagnosis and could replace the use of standard x-rays in pediatric spine traumas.

Osteochondral alteration in a child treated with levetiracetam: a rare case of juvenile osteochondritis dissecans of the talar head.

Levetiracetam is a relatively novel antiepileptic drug used for the treatment of partial and generalized seizures in adult and children. Several animal studies describe a possible drug adverse effect on skeletal growth and metabolism. We present a case report of a 10-year-old female child who underwent a prolonged 7-year treatment with levetiracetam for sporadic secondary convulsions secondary to enterovirus encephalitis at the age of 15 months. This patient developed an osteochondritis dissecans lesion (OCD) of the talar head well treated conservatively. Only a few cases have been described of this rare type of OCD. We hypothesize a possible association between levetiracetam therapy and OCD development, suggesting the importance of long-term control of bone growth in levetiracetam-treated pediatric populations.

A thoracic spinal bone giant cell tumor in a skeletally immature girl. A case report and literature review.

PURPOSE: Giant cell tumors (GCT) are benign primary bone tumors, locally aggressive, affecting in long bones in young adults during the third decade. It is rare to experience this lesion in skeletally immature patients. GCT are related to a risk of local recurrence and malignant transformation. METHOD: We report a rare case of a giant cell tumor of the thoracic spine in a skeletally immature girl presenting with a painful right scoliosis. RESULTS: MRI, CT scan, and bone scintigraphy were discordant and the percutaneous biopsy non-contributive. CONCLUSION: A marginal "en bloc" resection was performed and revealed the GCT. Based on a literature review, the diagnosis and the surgical management of this case are discussed.

Growth tethering devices for idiopathic scoliosis.

Adolescent idiopathic scoliosis is a 3D spine deformity that worsens during the whole growth. The treatments available are bracing during the whole growth to avoid progression of the deformity and surgical fusion of the spine at skeletal maturity for the most severe curves. Recent advances in flexible spinal implants have given rise to new expectations in the management of progressive scoliosis with growth modulation without fusion. For the first time, treatment allows us to expect a correction of progressive curves without fusion. This review discusses the recent developments in the field of spinal growth modulation techniques and discusses the pros and cons of the medical devices used in this indication.

Vertebroplasty for vertebral hemangioma in children: a report of two cases with 2-year follow-up.

PURPOSE: To describe two cases of a dorsal vertebral hemangioma diagnosed in a 12- and 14-year-old child successfully treated with vertebroplasty. METHOD: Cases reports. RESULTS: Two cases of aggressive vertebral hemangiomas were diagnosed and treated in two independent institutions. Percutaneous vertebroplasty was then decided. Bipedicular vertebroplasty was performed under general anesthesia, under biplanar fluoroscopic guidance. The injection of acrylic cement filled the entire vertebral body without significant leakage. At last follow-up, the clinical and radiographic outcome was very good. In one patient, last control radiographs showed a gap between the end plates and the cement, spinal growth seemed to have resumed. CONCLUSION: Vertebral hemangioma is rare in pediatric patients, and its diagnosis requires meticulous and regular clinical examinations and a combination of imaging studies, particularly an MRI and a CT scan, which can assess the aggressiveness of the lesion. Vertebroplasty seems to be an effective and safe treatment of this benign tumor in children with stable outcome at 2-year follow-up. Spinal growth may resume despite the aggressiveness of both the tumor and the treatment.

Desmoplastic fibroma of the ilium.

INTRODUCTION: The desmoplastic fibroma is a rare locally invasive bone tumour. Surgical resection with minimal margins is recommended. PRESENTATION OF CASE: A 15 year-old boy was referred with chronic left thigh pain. MRI revealed a bone lesion within the cavity of the inner table of the left iliac wing without invasion of the underlying bone marrow. A surgical biopsy revealed a desmoplastic bone fibroma. A partial resection of the inner table of the iliac wing sparing the outer table was performed. At the latest follow-up the initially spared iliac wing had needed further resection. The reason proposed for this is devascularisation by substantial periosteal stripping causing partial resorption initially, then necrosis and ultimately ulceration through the skin necessitating further surgical resection. DISCUSSION: The technique of resection of a pelvic desmoplastic fibroma sparing the outer table of the iliac wing has not previously been reported. The objective of a limited resection was to minimize the risk of a postsurgical limp caused by weakness of the gluteus medius muscle. However we report that this technique did not work in this case. A wider resection of the iliac wing as it is recommended for a malignant tumour would have yielded a similar final outcome. CONCLUSION: A partial resection of the iliac wing seemed an appealing technique for a benign tumour of the inner table of the iliac wing. However, considering the complications encountered, the authors advise a simple "en bloc" resection of the iliac wing for this type of tumour in this location.

Ureteral injury after percutaneous iliosacral fixation: a case report and literature review.

We report a case of right ureter injury in an 11-year-old girl after a percutaneous iliosacral screwing with non-computer-assisted fluoroscopic guidance. The indication was a pelvic ring fracture, C1-1 in the Tile modified AO classification (J Am Acad Orthop Surg. 1996;4:143-151). The mechanism was a ski accident. A percutaneous iliosacral screwing was performed to stabilize the right iliac wing fracture. Twelve days after the initial trauma, a right ureter tear was highlighted, just opposite the fourth lumbar vertebra. Uneventful spontaneous healing of the ureteral injury site occurred following double J-stent catheterization.

Percutaneous aspiration irrigation drainage technique in the management of septic arthritis in children.

BACKGROUND: Septic arthritis in childhood is a therapeutic emergency. The authors present their experience using an intermediate technique with the advantages of the percutaneous aspiration irrigation drainage: joint aspiration, irrigation, and declivious drainage. METHODS: All children were treated by joint aspiration under fluoroscopic control, large volume irrigation, and declivious nonsuction drainage associated with immobilization and intravenous antibiotics during 8 days to 10 days. The draining system was removed when clinical improvement (namely apyrexia) and the decrease of biological inflammatory response were obtained. A late follow-up phone interview was made for each patient. Fifty-two patients were included in this study, with a mean age of 4.3 years. The most common sites of arthritis were the hip (19 of 52, 36%) and the knee (17 of 52, 32%), but ankle (8 of 52, 15%), shoulder (12%), and elbow (3%) were also involved. RESULT: Apyrexia was obtained after a mean period of 2 days. The mean draining duration was 4.5 days. On the last follow-up visit (at 21 months on average; range, 12-56 months), all patients except one were totally painless and had no limitation of physical activity. CONCLUSION: Percutaneous aspiration irrigation drainage assured very good results in this study population, with rapid clinical and biological improvement and the absence of long-term sequelae. The advantages of this technique include permanent joint access and control of synovial effusions, with only one general anesthesia and minimal iatrogenic morbidity.

Lumbopelvic stabilization with external fixator in a patient with lumbosacral agenesis.

A case of caudal regression syndrome in which rehabilitation was obtained by lumbopelvic distraction and stabilization with external fixation Orthofix(®) is presented. The objective of the study is to describe the benefit of spine external fixator in caudal regression syndrome. Caudal regression syndrome is a rare and sporadic neural defect of distal spinal segments affecting the development of the spinal cord. It is characterized by vertebropelvic instability and essentially manifests as neurological deficit in the lower limbs and absence of bladder and bowel control. Pluridisciplinary management of this affection is complex. The clinical presentation and treatment of caudal regression syndromes are reviewed. A case of a boy for whom physical rehabilitation was obtained with external fixation Orthofix(®) is presented. Lumbopelvic stabilization was performed with autograft and allograft bone. A spine distraction was performed with external fixation with pedicular screws in L1 and L2 and in the pelvis bone. An elongation of 19 mm was obtained in 35 days. The external fixator was removed after 4 months and a spine cast was applied during 8 months. This treatment resulted in lumbopelvic nonunion of very low mobility. Lumbopelvic stability and the disappearance of pain were achieved. Sitting position was stable without hand support. At 14 years of follow-up, his condition is stable with possible deambulation at home with crutches. Lumbopelvic arthrodesis in caudal regression syndrome is difficult to obtain. The use of spine external fixator, however, allows trunk elongation and can achieve a stable sitting and upright position.

Elastic stable intramedullary nailing of tibial shaft fractures in children.

PURPOSE: Tibial fractures in the skeletally immature patient are usually treated without surgery. Elastic stable intramedullary nailing (ESIN) is commonly used for other diaphyseal fracture locations. Its advantages are minimally invasive surgery with a short hospitalisation duration, primary bone union and early weight bearing. The purpose of this study was to assess the use of ESIN in displaced tibial fractures in children over 6 years old and in cases of polytrauma. METHODS: This study was carried out over a 6-year period. The protocol consisted in ESIN of shaft tibial fractures in children over 6. Frontal and sagittal angulation, shortening and lengthening were measured on days 0, 2, 15, 30 and 45. At 6 months, 1 and 2 years, the femoro-tibial axis and eventual shortening or lengthening were assessed. RESULTS: The study involved 86 children (average age 11.8 years). As early as day 30, all patients had normal knee mobility and symmetrical foot progress angle. At 2-year follow-up, frontal angulation and leg length discrepancy had decreased and affected 2% of patients. Four patients (5%) suffered from superficial infections. There were no cases of osteomyelitis or refracture. CONCLUSIONS: The fixation of paediatric diaphyseal tibial fractures with ESIN is a rapid, well-codified and effective method for treating long-bone closed fractures in children. Advantages over other fixation techniques include a lower infection rate, a lower refracture rate, ease of management, and an aesthetically pleasing scar.

Evolution of a patient with Bohring-Opitz syndrome.

We detailed the story from birth to the age of 5 years 9 months, of the oldest patient reported with a Bohring-Opitz syndrome with the three main diagnostic criteria: characteristic facial appearance, fixed contractures of the upper limbs and severe feeding difficulties. The facial anomalies described in our patient were microcephaly, bitemporal narrowing, "puffy" cheeks, forehead naevus flammeus, hypoplastic orbital ridges, prominent eyes, broad nasal bridge, high arched palate, buccal-alveola frenula and retrognathism. The magnetic resonance imaging (MRI) of the brain showed a hypoplastic corpus callosum and a narrowed upper cervical canal; and the cervical MRI showed a malformation of the atlas consisting in an agenesis of the anterior arch and an anterior slip of the posterior arch. We focused on her neurological and nutritional evolution. Despite the gastrostomy and a Nissen fundoplication at age 7 months, she still had developmental growth delays overall (<3rd centile). At 3 years 9 months of age, she began to put on weight quickly, which seemed to be atypical. Meanwhile she developed epilepsy, which was controlled with specific drugs. Currently, she is 5 years 9 months old and has significant psychomotor retardation, although this disease is often fatal in early childhood, due to obstructive apnea and unexplained bradycardia.

Pediatric intervertebral disk calcification in childhood: three case reports and review of literature.

INTRODUCTION: Intervertebral disk calcification is a rare childhood disease. The etiology of disk calcification in children remains unclear. CASE REPORTS: We report three cases of children with cervical disk calcification. Their clinical manifestations are very different. The first patient mainly had a neurological deficiency. The second had neck pain and muscular deficit of the left musculus deltoideus. The third had isolated strong neck pain. By presenting these three cases, we want to recall the different symptoms that correspond to this disease and discuss the decisions to be made in regard to radiological investigation and treatment. DISCUSSION: Healing takes place spontaneously after several days, and the calcifications disappears after about 6 months after a stage of fragmentation. Conservative treatment by immobilization of the spine and analgesic therapy are sufficient. Operative treatment should be reserved for severe radicular pain or for significant and persistent sensorimotor deficits from either root or spinal cord compression.

Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old.

BACKGROUND: Femoral shaft fractures occur very frequently in children, and their prognosis usually is good. Nonoperative treatment is the gold standard for children under 6 years because of the excellent bony union and the remodelling qualities. PURPOSE: The aim of this study was to compare two orthopaedic therapeutic methods: skin traction versus immediate reduction. MATERIALS AND METHODS: The study involved 35 children, divided into two groups: in group 1, treatment consisted of skin traction for 21 days followed by hip spica casting; in group 2, an immediate reduction with early hip spica casting was performed. The ranges of motion, the delay before weight bearing, the hospitalisation duration and the required amount of painkillers were recorded. We compared initial shortening, axial, sagittal and rotational alignment, and femoral length discrepancy. We calculated the injured femoral diaphysal overgrowth and correlated it to the fracture type and location and to the initial shortening. Economical variables were also studied. RESULTS: The mean overgrowth was 8.9 mm in group 1 and 8.5 mm in group 2. Three years after the trauma, length discrepancy was 4 mm in group 1 and 1 mm in group 2. Hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration and pain. The cost of treatment with skin traction was four times higher (24,472 euros) than that of immediate reduction (6,384 euros). DISCUSSION: Our results are in accordance with the literature. The femoral overgrowth was proportional to the initial shortening. Masculine gender, an oblique fracture and injury of the lower third of the femur were associated with the greatest femoral overgrowth. During the first year of follow-up, the femoral length discrepancy hardly varied after immediate reduction (4 mm), whereas the overgrowth reached 6 mm after skin traction. Overall, immediate hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration, complications and costs, while having similar clinical results as traction.

Residual hip growth after pinning of slipped capital femoral epiphysis.

Screwing of slipped capital femoral epiphysis must prevent its further slipping by prematurely fusing the physis. Whichever material is used, persistent femoral growth has been described, thereby increasing the risk of bone deformation. The objective of this study is to evaluate the residual growth after screwing of slipped capital femoral epiphysis. This study concerned 26 children, among which 13 children have been included, and 13 children excluded because of an incomplete clinical or radiological follow-up, or treatment by another technique. The pathological hip was treated with one screw (in eight cases) or two screws (in five cases). The controlateral hip was fixed with one screw. The different measures were taken on anteroposterior radiographs done the days after surgery, and on the first radiograph on which the growth plate had fused. Growth plate fusion was obtained after an average of 20 months. Each patient had presented a residual growth of at least one hip, thus 85% of the 26 fixed screws. Among the four hips, which did not grow, three were pathological, and were fixed by one screw (in one case) or two screws (in two cases), in a central or medial position. There was not any statistical relationship between the growth persistence and the other studied criteria. These results, proving the growth persistency, suggest that the follow-up must be extremely careful, as the number of threads crossing the growth plate will decrease, with the risk of loss of mechanical stability and reappearance of the femoral epiphysis slippage.

A too-long anterior process of the calcaneus: a report of 31 operated cases.

A too-long anterior process of the calcaneus is one of the causes of repeated sprained ankles or painful feet in the child or adolescent that is often ignored and misdiagnosed. Among 31 cases of adolescents having consulted for these symptoms, a too-long anterior process of the calcaneus was discovered on radiographs, and explored in detail with a computed tomography scan or an MRI. The decision for surgical resection was taken considering the discomfort expressed by these children. The intraoperative observation corroborated the radiological findings and permitted a better understanding of the mechanisms responsible for the pain, the repeated sprained ankles and other instabilities. The surgical resection, which is a simple procedure, gave very good results. One must nevertheless be aware of the possible secondary lesions because of repeated sprained ankles: breakage of the lateral ligaments of the ankle and external malleolus nonunion or talus osteochondritis, which can compromise the operation's result, if they are not treated simultaneously.