PEARLS AND RESOURCES Growth and DevelopmentZCongenital Conditions

Pearls

■ An embryologic alteration of the musculoskeletal system often is a superficial marker for embryologic alterations in other organ systems.

■ Deferring radiography until a minimum of 6 months in age, allowing bones to ossify, is generally a good idea.

■ Malformations of the radius are more common and associated with more syndromes than malforma­tions of the ulna.

■ To be a clubfoot, there must be hindfoot varus and adduction.

■ Cavus feet always need an explanation and can be a superficial sign of an underlying neurologic diagnosis.

Resources

Paley D, Bhavee A, Herzenberg JE, et al. Multiplier method for predicting limb length discrepancy. J Bone Joint Surg Am. 2000;82:1432-1446.

Abel MF. Orthopedic Knowledge Update. Rosemont, IL: American Academy of Orthopedic Surgeons;2006.

Ponseti IV. Congenital Clubfoot: Fundamentals of Treatment. Oxford: Oxford University Press;1996.

Coleman SS, Chestnut WJ. A simple test for hind­foot flexibility in the cavovarus foot. Clin Orthop. 1977;123:60-62.

Robinson RO. Arthrogryposis multiplex congenita: feeding, language and other health problems. Neuropediatrics. 1990;21:177.

Brachial Plexus Palsy

Pearls

■ The most common risk factors for a baby having a birth brachial plexus palsy (BBPP) are shoul­der dystocia, large birth weights, and multiparous mothers.

■ It is critical for the caregivers to have the baby/tod- dler see/use the arm with BBPP as much as possible to minimize learned disuse.

■ A key difference between acquired BPP and BBPP is pain in the former and no pain in the latter (at least after the first two weeks).

■ Neuropraxia has no permanent anatomical changes and will resolve; axonotmesis (partial) and neurot­mesis (complete) anatomical severance each has long-lasting sequelae.

■ Sensory nerve conduction studies in someone from an insensate area with intact SNAP indicate a pre­ganglionic lesion.

Resources

Asa J, Wilbourn MD. Plexopathies. Neurol Clin. 2007;25: 139-171.

Gilbert A, Pivato G, Kheiralla T. Long-term results of primary

repair of brachial plexus lesions in children. Microsurgery. 2006:26:334-342.

Lee MY, Nelson M, Lee CE. Evaluation and manage­ment of brachial plexus injury. In: Lazar RB, ed. Principles of Neurologic Rehabilitation. New York” McGraw-Hill;1998: 230.

Seddon HJ. Three types of nerve injury. Brain. 1943; 66:34.

Waters PM. Comparison of natural history, the out­come of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone J Surg Am. 1999;81:649-659.

Children With Rheumatic Disease

Pearls

■ Juvenile idiopathic arthritis (JIA) occurs in children before the age of 16 years, persists at least six weeks, and has had other known conditions excluded.

■ Treatment of children with JIA is a team approach that focuses on eliminating inflammation, promot­ing developmentally appropriate function and activ­ity, and minimizing complications.

■ JIA or its treatment can cause local or systemic abnormalities, including micrognathia, leg-length inequalities, muscle atrophy, short stature, osteopo­rosis, and increased risk of infection.

■ Enthesitis, uveitis, rash, fever, or lymphadenopathy may be the earliest signs/symptoms in children with JIA and/or juvenile ankylosing spondylitis.

■ Pediatric physiatrists can play a key role in the com­prehensive management of the child with rheumatic conditions to maximize age-appropriate function, prevent deformity, and manage pain.

Resources

Cassidy JT, Petty RE, Laxer RM, et al. Textbook of PediatricRheumatology. 5thed.Philadelphia:Elsevier; 2005.

Davis PJC, McDonagh JE.Principles of management of musculoskeletal conditions in children and young people. Best Pract Res Clin Rheumatol. 2006; 20(2):263-278.

Szer IS, Kimura Y, Malleson PN, et al. Arthritis in Children and Adolescents.

Wallace CA. Current management of juvenile idio­pathic arthritis. Best Pract Res Clin Rheumatol. 2006; 20(2):279-300.

Burn Injuries

Pearls

■ Children under 5 are more likely to sustain scald or contact burns, while older children and adolescents are more likely to sustain burns from flames.

? Refer to a burn center when a child has chemical, electrical, or third-degree burns; partial-thickness burns to 10% total BSA; burns to sensitive body parts; inhalation injury; or complicating medical factors.

■ About 10% of burn admissions in children are related to child abuse, and about 10% of all child abuse cases include burn injuries.

■ Silicone dressings may help prevent hypertrophic scars in those at risk as well as to improve scar elas­ticity in already existing symptomatic scars.

■ The most common complication of burns is abnor­mal or hypertrophic scarring that may cause con­tractures and impaired function.

Resources

Celis MM, Suman EO, Huang TT, et al. Effect of a supervisedexercise and physiotherapy program on surgical interventions in children with thermal injury. J Burn Care Rehabil. 2003;24:57.

Martin-Herz SP, Patterson DR, Honari S, et al. Pediatric pain control practices of North American burn cen­ters. J Burn Care Rehabil. 2003;24:26.

Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110:560.

O'Brien L, Pandit A. Silicon gel sheeting for prevent­ing and treating hypertrophic and keloid scars. The Cochrane Library. 2007;4.

Sheridan RL, Remensnyder JP, Schnitzer JJ, et al. Current expectations for survival in pediatric burns. Arch Pediatr Adolesc Med. 2000;154:245.

Developmental Conditions

Pearls

■ Observation is the rule in Legg-Calve-Perthes dis­ease, with minimal pain, good ROM, and a strong lateral bony column.

■ Overweight, adolescent, altered gait, and hip pain— think slipped capital femoral epiphysis (SCFE).

■ Typical DDH, if not detected and aggressively treated prior to 18 months, portrays a much higher risk of lifelong disability and degenerative arthritis.

■ If idiopathic toe walking doesn't improve within a few months of aggressive conservative care, a life­long presentation is likely present.

■ In-toeing in the otherwise able-bodied child gener­ally gets better over time, with or without correction of the bony torsional abnormalities.

Resources

Barch JG: Instructional Course Lectures Pediatrics. Rosemont, IL: American Academy of Orthopedic Surgeons, 2006.

Catterall A. The natural history of Perthes disease. J Bone Joint Surg Br. 1971;53:37-53.

Shipman SA, Helfand M, Moyer VA, et al. Screening for developmental dysplasia of the hip: A systematic lit­erature review for the US preventative services task­force. Pediatrics. 2006;117(3):E557-E576.

Staheli LT. Fundamentals of Pediatric Orthopedics. 4th ed. Philadelphia, Lippincott, Williams and Wilkins, 2008.

Sutherland DH, Olshen R, Cooper L, et al. The devel­opment of mature gait. J Bone Joint Surg Am. 1980;62:336.

Scoliosis

Pearls

■ If pain is associated with scoliosis, check for other etiology, including neoplasm and infection. Scoliosis in children is typically not painful.

■ Steroids reduce the incidence of scoliosis in Duchenne’s muscular dystrophy, as well as delay loss of muscle strength and ambulation.

■ Surgical fusion into the pelvis is generally performed in the nonambulatory child and those with signifi­cant pelvic obliquity.

■ Atypical left thoracic curves in individuals with idiopathic scoliosis require investigation for spinal pathology, including MRI imaging.

■ Scoliotic curvatures 50 degrees or greater have a tendency to progress, averaging about a degree per year over a lifetime.

Resources

Dorman J. Pediatric Orthopaedics: Core Knowledge in Orthopedics. 1st ed. Philadelphia, Elsevier Mosby, 2005.

Driscoll SW, Skinner J.

Larsson E, Normelli H, Oberg B. Long term follow-up of functioning after spinal surgery in patients with neu­romuscular scoliosis. Spine. 2005. 30(19):2145-2152.

Murphy N, Firth S, Jorgensen T, Young P. Spinal sur­gery in children with idiopathic and neuromuscu­lar scoliosis: What’s the difference? J Ped Orthop. 2006;23(2):211-220.

Toree-Healy A, Samdani AF. Newer technologies for the treatment of scoliosis in the growing spine. Neruosurg Clin N Am. 2007;18(4):697-705.

Leg Length Inequality

Pearls

■ Leg length discrepancy of 2 cm or less is common, treated with a shoe lift or observed, depending upon functional preference.

Resources

McCarthy JJ, MacEwen GD. Management of leg length and equality. J South Orthop Assoc. 2001;10(2):73-85; discussion 85.

Constitutional or Intrinsic Bone

Conditions

Pearls

■ Multiple epiphyseal dysplasia and Legg-Calve- Perthes disease both involve the capital femoral epiphysis, but Legg-Calve-Perthes disease is never symmetrical and rarely bilateral.

■ Involvement of the atlantoaxial and atlantooccipital articulations always need to be considered in condi­tions of constitutional bone.

■ Little people of adult age almost always have normal intel­lect and psychosocial being requiring treatment as such, despite a physical stature that might suggest otherwise.

■ Macrocephaly in individuals with achondroplasia needs to be followed carefully, including serial head circumferences and surgical referral for symptom­atic hydrocephalus.

■ Despite atlantoaxial instability, progressive spastic­ity, and mental deterioration all common to individ­uals with a mucopolysaccharidoses syndrome, life expectancy can reach into the fifth decade.

Resources

Barbier O, Allington N, et al. Reflex sympathetic dys­trophy in children: review of a clinical series and description of the particularities in children.

Baujat G, Legeai-Mallet, et al. Achondroplasia: Best Practice and Research. Clinical Rheumatology. 2008;22(1):3-18.

Danielpour M, Wilcox WR, et al. Dynamic cervi- comedullary cord compression and alterations in cerebrospinal fluid dynamics in children with achon­droplasia. J Neurosurg: Pediatrics. 2007;107:504-507.

Horton WA, Hall JG, et al. Achondroplasia. Lancet. 2008;370:162-172.

Newton AW, Vandeven AM. Update on child mal­treatment. Curr Opin Pediatr. 2008;20(2):205-212.

Young G, Toretsky JA, et al: Recognition of common childhood malignancies. Am Fam Physician. 2000; 61:2144-2154.

Musculoskeletal Pain and Child Abuse

Pearls

■ Back pain in children, although relatively uncom­mon, if not improving within a couple weeks of conservative care needs aggressive investigation for potential life-threatening etiologies.

■ Multiple injuries in various stages of healing or those inconsistent with developmental level, blamed on siblings or unwitnessed, should increase suspi­cion for child abuse.

Resources

Griffin LY. Essentials of Musculoskeletal Care. 3rd ed. Rosemont, IL: American Academy of Orthopedic Surgeons, 2005.

Siambanes D, Martinez JW, Butler EW, et al. Influence of school backpacks on adolescent back pain. J Pediatr Orthop. 2004;24:211-217.

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