Art and Pediatric Orthopaedics: Repin and Inclusiveness.

A famous painting of the 19th century, by Ilia Repin, of a religious procession depicts the pageantry of the event but also draws the attention of the viewer to the exclusion of a disabled child from the festivities.

Art and Pediatric Orthopaedics: Cot and the Crutch.

Pierre Auguste Cot's painting, "Mireille giving alms at the door of Saint-Trophime," depicts a wealthy lady giving alms to a crippled beggar boy. The beautiful painting portrays the striking contrast between the rich and the poor. The painting also draws attention to the crude crutch the boy was using. This type of crutch was used over the centuries; improvements in the design of the axillary crutch occurred only in the 20th century.

Back to Carracci.

Annibale Carracci's sketch of a boy with a hunchback conveys the boy's emotions remarkably well. The possibilities of the underlying cause of the spinal deformity and its neurologic complications are discussed.

Art and Pediatric Orthopaedics: "Arm-twisting" by Wyspianski, the Poet, Actor, and Artist.

Stanislaw Wyspianski, a multifaceted Polish artist painted "A Girl with a Red Hat", which portrays a young girl with an obviously deformed right upper limb. The pattern of deformities is suggestive of either athetoid hemiplegic cerebral palsy or Erb's palsy.

Art and Paediatric Orthopaedics: A Sixteenth Century Lie-down Comedian.

This outstanding painting, by an unknown artist, of a man with multiple deformities compatible with a diagnosis of arthrogryposis multiplex congenita induces the viewer to think deeply about the artist's portrayal of the subject.

Copping Coping With the Braced Limbs.

Harold Copping illustrated an edition of Charles Dickens' classic, "A Christmas Carol." One of the paintings of Bob Cratchit and Tiny Tim in the book shows Tiny Tim wearing braces on his lower limbs. Several diagnoses of Tiny Tim's ailment have been suggested in the past but based on the details of Copping's painting we suggest that he had rickets. The above-knee braces with uprights only on the lateral side of the limbs may have been given to prevent genu valgum, a common deformity in childhood rickets.

Collins, Bruegel, and the Games They Play.

William Collins and Pieter Bruegel the Elder in their respective paintings, "Happy as a King" and "Children's Games" show children playing outdoors. The types of injuries these children could sustain in the 16th and 19th centuries are contrasted with sports related pediatric fractures in the present day.

Raphael at the Temple.

Raphael, in his painting "Healing of the Lame Man" shows one lame man encountering St. Peter and St. John while another lame man waits his turn. Children with unusually muscular bodies are also depicted in the painting. The possible causes of lameness in the men and muscle hypertrophy in the children are discussed.

Art and Pediatric Orthopaedics: Velazquez, an Artist of Stature.

Diego Velazquez painted several dwarfs employed at the Royal Court of Spain and one of the best known among them is the painting of Sebastian de Morra, a court jester. The clarity of the painting enables the reader to make a diagnosis of achondroplasia.

Art and Pediatric Orthopaedics: Monet and a Twist in Time.

The work of art by Monet shows a young child sitting with the toes turned inwards. The cause is probably due to femoral anteversion.

Bruegel and the Cost of the Bended Knee.

In Pieter Bruegel's painting, "The Seven Acts of Charity" he portrays 2 subjects with flexed knees. One of them cannot walk while the other can walk but does so with excessive energy expenditure.

Carry on With Raja Ravi Varma, Mary Cassatt, and Renoir.

Raja Ravi Varma's painting "There Comes Papa" depicts his daughter carrying her son astride her hip. The positive implication of the posture of the hips of the child while being carried in this manner on acetabular development is discussed.

Metaphyseal fragmentation with physiologic bowing: a finding not to be confused with the classic metaphyseal lesion.

OBJECTIVE: The purpose of this study was to describe the varied appearances of metaphyseal fragmentation associated with physiologic bowing and to estimate their frequency in children undergoing radiographic evaluation. CONCLUSION: The results of this study suggest that metaphyseal fragmentation is occasionally encountered in children with physiologic bowing. Results of a systematic imaging assessment should minimize confusion of this innocent radiologic alteration with the classic metaphyseal lesion of child abuse.

Surgical dislocation in the management of pediatric and adolescent hip deformity.

The surgical dislocation approach is useful in assessing and treating proximal femoral hip deformities commonly due to pediatric conditions. We sought to demonstrate the efficacy and problems associated with this technique. Diagnoses included slipped capital femoral epiphysis, Perthes disease, developmental dysplasia of the hip, osteonecrosis, and exostoses. Through this approach, femoral head-neck osteoplasty (22), intertrochanteric osteotomy (eight), femoral head-neck osteoplasty plus intertrochanteric osteotomy (15), femoral neck osteotomy (five), open reduction and internal fixation of an acute slipped capital femoral epiphysis with callus resection (five), open reduction and internal fixation of an acetabular fracture (one), trapdoor procedure (one), and acetabular rim osteoplasty (one) were performed. The average patient age was 16 years. The minimum followup was 12 months (average, 41.6 months; range, 12-73 months). Patients with Perthes disease and SCFE had preoperative and postoperative WOMAC scores of 9.6 and 5.1, and 7.9 and 3.5 respectively. In patients with unstable SCFEs, the average postoperative WOMAC score was 1.2. Seven patients underwent THAs and two patients underwent hip fusion. Complications in the 58 procedures included four cases of osteonecrosis: three after femoral neck osteotomy and one after intertrochanteric osteotomy. The surgical dislocation technique can be utilized to effectively treat these deformities and improve short-term symptoms. Although the technique is demanding, we believe surgical dislocation offers sufficient advantages in assessing and treating these complex deformities that it justifies judicious application.

Coaptive film versus subcuticular suture: comparing skin closure time following identical, single-session, bilateral limb surgery in children.

BACKGROUND: This study is a randomized controlled trial comparing skin closure time between coaptive film and subcuticular monocryl sutures in children undergoing identical single session, bilateral limb multiple soft tissue releases. METHODS: Eight children less than 18 years of age (mean 14.5) with cerebral palsy underwent identical, single session bilateral multiple soft tissue releases in the lower limb from August 2005 to March 2007. There were 50 incisions in all in which 25 incisions were closed with 4-0 intracuticular monocryl sutures and 25 were closed with coaptive film (Steri Strip S; 3M company). Time taken for closure using either technique was recorded. A blinded plastic surgeon used a visual analog scale to assess the cosmetic results at the end of a 3 month follow-up. RESULTS: The average length of incisions closed with coaptive film was almost identical to the corresponding incision on the contralateral limb that was closed with subcuticular monocryl suture (4.45 and 4.81 cm, P=0.66). The average time for skin closure using monocryl sutures was 167.04 seconds compared with the average time of 79.36 seconds when using coaptive film (P <0.0001). There was no significant difference in the cosmetic results or the number of wound complications using either technique. CONCLUSION: Coaptive film is an attractive and cost-effective option for skin closure after pediatric surgery. CLINICAL RELEVANCE: The time saved, comparable cosmetic results and lack of complications makes coaptive film an attractive option for skin closure in the pediatric age group.

Triple pelvic osteotomy in complex hip dysplasia seen in neuromuscular and teratologic conditions.

BACKGROUND: The site of acetabular deficiency in hip dysplasia associated with neuromuscular or teratologic conditions is described as posterolateral or global unlike the anterosuperior location in developmental dysplasia of the hip. The triple pelvic osteotomy is a redirectional osteotomy that provides complete control over acetabular fragment placement and can be used to optimize coverage in complex hip dysplasia in skeletally immature hips in which other pelvic osteotomies are ineffective, incomplete, or counterproductive. METHODS: Thirty-one hips in 26 patients (11 females and 15 males) that had complex hip dysplasia associated with neuromuscular or teratologic conditions were treated with triple pelvic osteotomies. The patients were divided into 2 groups: spastic and nonspastic. Nine of the 15 spastic patients were nonambulatory whereas 1 of the 11 nonspastic patients was nonambulatory. The average age of the patient was 9.6 years and time since surgery was 3 years. Preoperative and postoperative migration index, lateral center-edge angles, and changes in Shenton's line were noted. Computed tomography scans were also compared when available. The surgical technique is described. RESULTS: The average preoperative lateral center-edge angles and migration index were 1.1 and 42.8 and postoperatively were 39 and 3.7. There was 1 nonunion of the pubic ramus with sciatic nerve palsy. Two patients continued to have persistent hip subluxation. CONCLUSIONS: We conclude that triple pelvic osteotomy provides adequate mobility of the acetabular fragment to optimize coverage and improve stability in skeletally immature individuals with complex hip dysplasia associated with neuromuscular and teratologic conditions. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The use of a working model for teaching functional and applied surgical anatomy of the subtalar joint.

BACKGROUND: Some aspects of functional and applied anatomy may be difficult to conceptualize if taught by conventional methods. In such situations, alternative methods of teaching may need to be adopted. This study was undertaken to evaluate whether a working model can facilitate understanding of the functional and applied surgical anatomy of the subtalar joint. METHODS: A working model of the articulated talus and calcaneus was constructed and used to explain the mechanics of motion of the subtalar joint, the rationale of release of structures to correct hindfoot deformity in clubfoot, principles of tendon transfers, and the rationale of extra-articular subtalar joint arthrodesis. Twenty-four orthopedic residents were divided into two groups (A and B). Group A was taught these specific concepts of functional and applied anatomy with the help of the model, while Group B was taught the same concepts with a written text and diagrams. The level of knowledge of both groups was evaluated by a test with multiple-choice questions. A week later, Group A was given the text while Group B was shown the model. Both groups then answered a questionnaire assessing the value of the model in enhancing their understanding of the subject. RESULTS: In the test, the performance of students in Group A was better than those in Group B. Students of both groups felt that the model gave them a much clearer understanding of the functional anatomy of the subtalar joint. CONCLUSIONS: We conclude that this simple, inexpensive model is a valuable teaching aid that helps students to understand the surgical anatomy of the subtalar joint. CLINICAL RELEVANCE: Surgeons can use this model to effectively teach trainees in this field about the mechanics and anatomy of the subtalar joint and other relevant applications.

Broken bones: common pediatric fractures--part I.

Musculoskeletal injuries are one of the most frequently encountered problems in pediatric practice, with fractures accounting for a surprisingly large percentage of these injuries. A fracture occurs when bone is subjected to more energy than it can absorb. Pediatric healthcare providers must have a good understanding of normal bone growth and development and must recognize common mechanisms of injury and fracture patterns seen in children. Nearly 20% of children who present with an injury have a fracture, and it is estimated that 42% of boys and 27% of girls will sustain a fracture during childhood (Wilkins, 1996). The immature skeleton has several unique properties that directly affect the management of fractures in children.