Instructional practices at Farm Safety 4 Just Kids (FS4JK) safety day camps.

The instructional methods used with 1,347 youth in seven Farm Safety 4 Just Kids (FS4JK) day camp sessions conducted in five states during the summer and fall of 2002 were videotaped. The videotapes, instructor questionnaires, and day camp materials were analyzed using an observation protocol that focused on instructional practices and an interaction analysis of instructor-student talk during the sessions. Results showed that instruction focused on hazard recognition, a high level of participant attention during all the sessions observed, and safety day camp content relevant to rural participants regardless of whether they live or work on a farm. Recommendations for improving instructional practice include better use of print materials, more interactive, participatory activities for students, and reduction of instructor-centered, didactic approaches. Given the high level of students' attention, increased involvement of students in active, participatory approaches might enhance the effectiveness of the instruction by: (1) further engaging students through personalizing hazard recognition, (2) contextualizing reports of injuries, (3) examining the complexities of choosing safe behaviors, and (4) paying more attention to the consequences of injury events. Role-playing, narrative simulations, and other types of interactive and collaborative exercises are instructional approaches that support the inclusion of the pre-event contingencies and post-event consequences that are part of all injury events.

Acetabular dysplasia associated with hereditary multiple exostoses. A case report.

Hereditary multiple exostoses is an autosomal dominant disorder characterised by multiple osteochondromata, most commonly affecting the forearm, knee and ankle. Osteochondromata of the proximal femur have been reported to occur in 30% to 90% of affected patients with coxa valga in 25%. Acetabular dysplasia is rare but has been described. This is the first report of a patient requiring surgical intervention. A girl was seen at the age of nine with hereditary multiple exostoses and when 12 developed bilateral pain in the groin. Radiographs showed severely dysplastic acetabula with less than 50% coverage of the femoral heads and widening of the medial joint space. Large sessile osteochondromata were present along the medial side of the femoral neck proximal to the lesser trochanter, with associated coxa valga. The case illustrates the importance of obtaining initial skeletal surveys in children with hereditary multiple exostoses to identify potential problems such as acetabular dysplasia and subluxation of the hip.

Interobserver reliability and intraobserver reproducibility of the system of King et al. for the classification of adolescent idiopathic scoliosis.

The classification of adolescent idiopathic scoliosis with use of the system of King et al. has become widely accepted since its introduction. The purpose of the present study was to establish the interobserver reliability and intraobserver reproducibility of this classification system. The preoperative radiographs of sixty-three patients who were managed operatively for adolescent idiopathic scoliosis were classified by five observers with the system of King et al. Interobserver reliability was assessed by comparison of the classification of the curves among the observers, and intraobserver reproducibility was evaluated by comparison of the classifications of each set of radiographs by each observer on two occasions three weeks apart. The median interobserver reliability kappa coefficient for the classification system of King et al. was 0.44 (range, 0.28 to 0.50), and the median intraobserver reproducibility kappa coefficient was 0.64 (range, 0.44 to 0.72). According to the definition of Landis and Koch, the classification system of King et al. is substantially reproducible but is only moderately reliable. However, according to the stricter definition of Svanholm et al., its reproducibility is only fair and its reliability is poor.

Infantile dislocation of the elbow complicating obstetric palsy.

This is a report of three cases of complete dislocation of both the radius and ulna at the elbow in infants born with obstetric palsy. All three patients had painless elbow-flexion contractures. The pathologic anatomy included (a) medial and posterior displacement of the radius and ulna on the humerus, (b) laxity of the lateral capsule and collateral ligaments, (c) contracted medial capsule and collateral ligaments, (d) contracted biceps and triceps muscles, and (e) hypoplasia of the capitellum, trochlea, coronoid process, and olecranon fossa. Open reduction was attempted in all three of these patients and was successful in two.

An evaluation of the Adams forward bend test and the scoliometer in a scoliosis school screening setting.

We examined the ability of the Adams forward bend test and the scoliometer to detect truncal rotation or asymmetry in a school screening setting. Of 954 sixth graders examined with each test independently, 123 and 13 [using an angle of trunk rotation (ATR) of > 5 and 7 degrees, respectively] were found to be abnormal on scoliometer examination but appeared normal on the Adams test. Selecting children for scoliometer examination on the basis of the Adams test is not supported by our data and may not be consistent with generally accepted principles of public health screening.

Usefulness of magnetic resonance imaging for the diagnosis of acute musculoskeletal infections in children.

A 30-month prospective study was conducted on 43 children who presented with clinical findings suggestive of acute hematogenous musculoskeletal infection. Magnetic resonance imaging (MRI) was found to be extremely sensitive (0.97) and specific (0.92) in helping to diagnose these infections, with only one false positive and one false negative study. Bone scans are more likely to yield false positive and negative examinations. MRI is particularly useful in difficult cases in which there are conflicting clinical data or infection involving the spine or pelvis. After MRI demonstrates the location of the disease process, histologic and/or bacteriologic confirmation of the etiology is still mandatory.

Femoral head avascular necrosis associated with intramedullary nailing in an adolescent.

An adolescent developed avascular necrosis of the femoral head after intramedullary nailing for a femoral diaphyseal fracture. This complication is most likely secondary to injury to the posterior superior ascending branch of the medial circumflex artery at the time of rod insertion. This artery is situated close to the proximal insertion hole just posterior to the trochanteric notch and piriformis fossa. Other methods of fracture treatment, either operative or nonoperative, should be considered in skeletally immature patients.

Low-dose lidocaine intravenous regional anesthesia for forearm fractures in children.

Intravenous (i.v.) regional anesthesia with low-dose lidocaine (1 mg/kg) lidocaine 1% diluted to 0.125% vol) provided safe and effective anesthesia for closed reductions of pediatric forearm fractures in outpatients. This procedure was prospectively evaluated in 44 children at The Nemours Children's Clinic, Jacksonville, Florida. Forty-three of 44 patients achieved adequate anesthesia (minimal or no pain on closed reduction). No significant complications were noted. Both patients and physicians were satisfied with the procedure. Patient pain was objectively assessed with visual pain charts in the preanesthesic, immediate postanesthetic, and postreduction time periods. The technique was both safe and effective in providing pain relief for reduction of forearm fractures in children.

Ankle arthrodesis in children.

The indications, surgical technique, and long-term functional results for ankle arthrodesis differ between children and adults. In children, the reasons for performing a tibiotalar fusion include pain, most commonly from traumatic and septic arthritis, and instability from congenital anomalies or paralytic disorders. The most appropriate procedure is Chuinard's fusion, which achieves a tibiotalar fusion without causing a growth arrest of the distal tibial growth plate. In the long term, young patients with ankle arthrodesis function very well with minimal pain or disability. Stressful activities such as hill climbing, stair climbing, and running may be restricted or require compensatory movements.

Neurologic status of spina bifida patients and the orthopedic surgeon.

The purpose of this paper is to review recent developments in the neurologic assessment of spina bifida patients. Determination of the neurosegmental level of the lesion, recognition of spasticity and progressive paralysis, the potential for deformity, and functional expectations are described. The status of the neurologic deficit remains the most important factor in determining the myelomeningocele patient's ultimate functional abilities. Accurate neurologic assessment will assist in meeting the aims of orthopedic management, which include preventing joint contracture, correcting deformity, preventing skin sores, and obtaining the best possible locomotor function.

Swing-through vs. reciprocating gait patterns in patients with thoracic-level spina bifida.

Three thoracic level spina bifida patients were evaluated in a gait laboratory. The patients first were asked to walk with a swing-through gait pattern using conventional hip-knee-ankle-foot orthosis and then with a reciprocating gait pattern using the reciprocating gait orthosis (RGO). The reciprocating gait was modestly more efficient than the swing-through gait pattern. The average speed of free walking was 11.4 meters per minute with the swing-through pattern and 16.2 meters per minute with the reciprocating pattern. The stride length was 0.31 meters and 0.54 meters with the swing-through and reciprocating patterns respectively. The RGO needs further modifications to improve the walking ability of spina bifida patients. The hip joints permit only flexion and extension and no rotational movement. The lack of internal and external rotation inhibits hip movement, reduces stride length, reduces the speed of walking and causes the cables to bind and eventually break. With design changes, future bracing systems will permit improved walking in the high level spina bifida patients.

Quantitative evaluation of AFO use with myelomeningocele children.

Although the sample size is small, results are very positive for the use of AFO's with the myelomeningocele child. The increase in pertinent gait parameters in conjunction with a decrease in excess hip, knee, and ankle flexion demonstrate the benefits gained in using AFO's to assist the myelomeningocele child in ambulation. Further, the decrease in excess muscle activation time and co-contraction facilitate a decrease in energy expenditure, thus allowing for more ambulation the limited results from this study provide a basis from which further research may be gleaned. The use of quantitative measures in evaluating the benefits of AFO's provides objective data from which future design and application recommendations may be made.

Calcaneal gait in spastic diplegia after heel cord lengthening: a study with gait analysis.

Calcaneal gait or deformity can be a significant complication after heel cord lengthening. After heel cord lengthening, 20 children with spastic diplegia were evaluated by gait analysis to define calcaneal gait objectively and describe associated morbidity. Mean age was 5 years 2 months (range 2 years 7 months to 8 years 2 months), and mean length of follow-up was 5 years 8 months (range 1 years 1 month 11 year 3 months). Calcaneal gait was defined as dorsiflexion 1 SD beyond the mean in the sagittal plane for all phases of stance. Increased ankle dorsiflexion during mid-stance most accurately predicts calcaneal gait. Through gait analysis, a 30% (6 of 20) prevalence of calcaneal gait suggests that an increased incidence of calcaneal gait may be present after heel cord lengthening.

Orthopaedic management of high-level spina bifida. Early walking compared with early use of a wheelchair.

To determine whether it is worth while to encourage patients who have high-level spina bifida to walk at an early age, we compared the cases of thirty-six patients who had participated in a walking program with those of thirty-six patients for whom a wheelchair had been prescribed early in life. The patients in the two groups were matched for age, sex, level of the lesion, and intelligence. Only twelve of the patients who had been able to walk at an early age were still able to do so effectively at the time of this study, when their ages ranged from twelve to twenty years, but still these patients fared somewhat better than the other patients did. The patients who walked early had fewer fractures and pressure sores, were more independent, and were better able to transfer than were the patients who had used a wheelchair from early in life. However, during childhood and early adolescence, the patients who had always used a wheelchair had spent fewer days in the hospital than did those who had participated in the walking program. There were no major differences between the two groups with regard to skills of daily living, function of the hands, and frequency and severity of obesity.

Impaired mental capabilities and hand function in myelomeningocele patients.

Hand function and intelligence were evaluated in 82 spina bifida cystica patients, aged 9 to 20 years. The patients required significantly more time to complete hand function tests and had significantly lower IQs than the test standardization populations. Inverse relationships were found between hand function times and IQ scores; patients with lower IQs (especially those with IQ scores less than 80) took significantly longer to complete the hand function tests. Patients with three or more shunt operations for correction of hydrocephalus required more time to complete the hand function tests and had lower IQs than patients with no shunt operations. Patients with higher level spinal cord deficits (particularly those with thoracic level lesions) required more time to complete the hand functions tests and had significantly lower IQ scores than patients with lower level lesions.

Hand function in patients with spina bifida cystica.

The Jebsen-Taylor hand function test was performed on 143 patients with myelomeningocele, 8-35 years of age. Compared with normal individuals, matched for sex and age, patients with myelomeningocele demonstrated impaired hand function. Thoracic level and high lumbar level patients exhibited poorer hand function than low lumbar and sacral level patients. Patients who required more than three shunt operations for continued control of hydrocephalus were more likely to have abnormal hand function. Awareness of such deficiencies should enable orthopedic surgeons, therapists, and parents to establish realistic functional expectations and management aims for these children.

The significance of spasticity in the upper and lower limbs in myelomeningocele.

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients.

The intrinsic vasculature of developing vertebral end plates and its nutritive significance to the intervertebral discs.

The structure and anatomical relationships of cartilage canals in the developing vertebral endplates of rabbits and humans are described in this study. In newborn rabbits, we observed a similar morphology and topologic arrangement to that in human fetal spines. Each vascular organ consisted of an arteriole, a glomerular tuft of sinusoidal capillaries, recurrent venules, and supporting loose connective tissue. Because the canals terminate adjacent to the intervertebral discs, they may provide an important source of nutrition to the disc during development when it is sandwiched between two layers of thick hyaline cartilage and contains no intrinsic vascular supply.

Femoral neck abnormalities in spina bifida.

Femoral neck abnormalities in spina bifida can be of two types: Type A, consisting of widening of the physis and often associated with varus deformity, and Type B, characterized by marked narrowing of the femoral neck, resulting in a typical mushroom appearance. The Type A deformity is usually associated with an abduction contracture of the hip. This physeal lysis seems to be secondary to microtrauma sustained during persistent exercise done by the parents and therapist to overcome the abduction contracture. No treatment is required, even when varus deformity is present. These patients require an orthosis with a pelvic band for ambulation, and their mobility will not be affected by the deformity.