Treatments for paediatric femoral fractures: a randomised trial.

BACKGROUND: Treatments for femoral fractures in children vary widely and have been investigated only in case series. We did a multicentre randomised trial to compare malunion rates after external fixation and after early application of a hip spica cast for paediatric femoral shaft fractures. METHODS: All children aged 4-10 years with femoral fractures, admitted to four paediatric hospitals, were randomly assigned early application of hip spica or external fixation. The primary outcome was malunion at 2 years after the fracture. Secondary outcomes were scores on the RAND physical function child health questionnaire and the post-hospitalisation behavioural questionnaire, and parents' and children's ratings of overall satisfaction with treatment. Analysis was by intention to treat based on children who reached the 2 year evaluation. FINDINGS: Of 60 children assigned to the hip-spica group, 56 reached the 2-year assessment; of them, six (11%) required other forms of treatment because of unacceptable loss of reduction. Of 48 children assigned external fixation, 45 reached the 2-year assessment; two (4%) had refractures and five (11%) required operative adjustment of the fixator. The rate of malunion was significantly higher in the hip-spica group than in the external-fixator group (25/56 [45%] vs 7/45 [16%]; 95% CI for difference 12-46%; p=0.002). The two groups had similar mean scores for the RAND physical function health questionnaire (0.34 vs 0.45; 95% CI for difference, -0.57 to 0.34; p=0.61), for the post-hospitalisation questionnaire (106.8 vs 106.3; -4.9 to 5.9; p=0.86), and for parents' satisfaction (4.3 vs 4.2; -0.3 to 0.6; p=0.5) and children's ratings of happiness with treatment (6.9 vs 7.7; -2.2 to 0.5; p=0.21). INTERPRETATION: Early application of hip spica has a small role in the treatment of paediatric femoral fractures. Future trials need to compare external fixation with flexible intramedullary nails.

Tibiotalocalcaneal arthrodesis for severe calcaneovalgus deformity in cerebral palsy.

The authors studied the outcome of a consecutive series of nine tibiotalocalcaneal fusions for severe calcaneovalgus deformity in five adolescents with severe cerebral palsy. The indications for surgery were severe deformity, pain, brace intolerance, difficulties with shoe wear, and progressive loss of transfer, standing, or walking ability. The goals of surgery were deformity correction, reduced bracing, and ability to wear regular shoes and to maintain function. Successful correction of deformity was achieved in all patients. One patient had a stable fibrous ankylosis despite revision surgery. Functional goals were fully achieved in three patients and partially achieved in two patients. The authors conclude that tibiotalocalcaneal fusion is useful as a salvage procedure in a small group of adolescents to correct severe deformity and to maintain limited function. Isolated lengthening of the tendo Achillis had been performed in four of these patients and was a contributing factor to the development of this deformity.

Accuracy of intramuscular injection of botulinum toxin A in juvenile cerebral palsy: a comparison between manual needle placement and placement guided by electrical stimulation.

Most clinicians who perform botulinum toxin A injections for children with cerebral palsy do so using the "free-hand" or manual technique without using radiologic or electrophysiologic guidance to aid needle placement. The objective of this study was to investigate the accuracy of manual needle placement compared with needle placement guided by electrical stimulation. A total of 1,372 separate injections for upper and lower limb spasticity were evaluated in 226 children with cerebral palsy. The accuracy of manual needle placement compared with electrical stimulation was acceptable only for gastroc-soleus (>75%); it was unacceptable for the hip adductors (67%), medial hamstrings (46%), tibialis posterior (11%), biceps brachii (62%), and forearm and hand muscles (13% to 35%). The authors recommend using electrical stimulation or other guidance techniques to aid accurate needle placement in all muscles except the gastroc-soleus. Further study is needed to determine whether more accurate injecting will lead to better functional outcomes and more efficient use of botulinum toxin A.

The Functional Mobility Scale (FMS).

We devised a new Functional Mobility Scale (FMS) to describe functional mobility in children with cerebral palsy, as an aid to communication between orthopaedic surgeons and health professionals. The unique feature of the FMS is the freedom to score functional mobility over three distinct distances, chosen to represent mobility in the home, at school and in the wider community. We examined the construct, content, and concurrent validity of the FMS in a cohort of 310 children with cerebral palsy by comparing the FMS to existing scales and to instrumented measures of physical function. We demonstrated the scale to be both valid and reliable in a consecutive population sample of 310 children with cerebral palsy seen in our tertiary referral center. The FMS was useful for discriminating between large groups of children with varying levels of disabilities and functional mobility and sensitive to detect change after operative intervention.

Magnetic resonance imaging evaluation of surgical management in developmental dysplasia of the hip in childhood.

Magnetic resonance imaging (MRI) was performed on 73 hips in 59 children aged 3 to 16 months after surgical reduction of developmental dislocation of the hip. Twenty-seven hips in 22 children had repeat MRI 6 weeks after reduction, and 20 hips in 16 patients had further MRI at least 1 year later. Only 38% of hips appeared concentrically reduced on the initial MRI scan, but this increased to 90% by 1 year later, without intervention. The authors measured coronal plane acetabular index and transverse plane anterior, posterior, and axial acetabular indices, as well as acetabular version and anteversion. Persistent difference could be shown in the coronal plane acetabular index between the dysplastic and normal sides for the cartilaginous anlage and the bony model of the acetabulum in scans performed at least 1 year after reduction. However, 40% of cartilaginous coronal plane acetabular indices fell within the "normal" range at 1 year. No other parameters could be shown to be persistently different.

Gait patterns after fracture of the femoral shaft in children, managed by external fixation or early hip spica cast.

The authors prospectively studied three-dimensional kinematics and kinetics of gait in children recovering from a closed, isolated, nonpathologic fracture of the femoral diaphysis, who had been randomly assigned to management by monolateral external fixation or early hip spica casting. The aims were to investigate the gait patterns soon after injury and at 2 years after injury. Children treated with external fixation, walking with the external fixator in situ, demonstrated asymmetric gait abnormalities in all three anatomic planes affecting the trunk, pelvis, hip, knee, and ankle. This appears to be a strategy to minimize movement and pain at the fixator pin sites. The gait pattern normalized rapidly after removal of the external fixator with few kinematic or kinetic abnormalities and no clinically significant disturbances of gait at 2 years after injury. In contrast, children in the early hip spica cast group developed a "crouch gait" pattern in the sagittal plane, most likely due to weakness. They also had abnormal coronal plane kinematics related to shortening of the injured side. Gait patterns improved, but at 2 years there were some persistent gait deviations, probably related to residual limb length discrepancy.

Hip displacement in spastic cerebral palsy: repeatability of radiologic measurement.

Radiologic measures of migration percentage (MP) and acetabular index (AI) taken from plain radiographs of the pelvis are the most commonly used tools for determining hip displacement and management options in children with cerebral palsy and spastic hip disease. This study determined interrater and intrarater reliability of MP and AI on pelvic radiographs chosen to represent a wide range of age (11 months to 8 years 5 months), MP (0%-56%), and AI (9 degrees -33 degrees ). The study demonstrated that an experienced rater would be expected to measure MP on a single radiograph to within +/-5.8% of the true value and a change in MP between two radiographs taken at different times to within +/-8.3% of the true value. Similarly for AI, the measurement error for a typical rater would be within +/-2.6 degrees on a single reading and +/-3.7 degrees if recording change between two occasions. The authors believe that the results indicating true change are acceptable in clinical practice, provided treatment decisions are based on a series of radiographs taken at 6-month intervals, methods and training are standardized, and consistent raters are used.