Oblicuidad pélvica o contractura congénita en abducción de la cadera: una entidad poco conocida / Congenital pelvic obliquity or congenital hip’s abduction contracture: a little known entity

La oblicuidad pélvica congénita es una patología frecuente en el lactante y poco conocida por los pediatras. Se presentan cuatro casos de oblicuidad pélvica simple en lactantes mujeres. Se describen los hallazgos clínicos y radiológicos en el momento del diagnóstico, la actitud terapéutica y la evolución de cada uno de ellos. Los pediatras de Atención Primaria debemos estar atentos a los antecedentes, signos acompañantes y al diagnóstico de esta entidad, así como tener formación en la exploración de la cadera para detectar clínicamente una inestabilidad, preferentemente en la cadera aducta (opuesta a la contracturada). Es importante la interrelación entre Pediatría, Radiología Infantil, Traumatología Infantil y Rehabilitación (AU)

Congenital pelvic obliquity is frequent, although pediatricians are not used to diagnose it. We report four female infants with simple pelvic obliquity. We describe clinical and radiologic findings, their treatment and outcome. Primary care pediatricians must be alert looking for pelvic obliquity in infants. We need to improve our abilities in hip exploration, to detect instability in the adduct hip (in the opposite of the contractured hip). Is very important to work together: pediatricians, radiologist, orthopedist and rehabilitation physician (AU)

Osteoartritis rápidamente destructiva de cadera: a propósito de un caso / Rapidly destructive osteoarthritis of the hip: case presentation

La osteoartritis rápidamente destructiva de cadera es una variante de la osteoartritis caracterizada por dolor a nivel de cadera de uno a 12 meses de evolución asociada a una rápida destrucción de la cabeza femoral en ausencia de infección, enfermedad neurológica, metabólica e inflamatoria. Presentamos el caso de un varón de 66 años con EPOC severo que refería dolor en ambas caderas y dificultad para deambular de 6 meses de evolución. En la radiografía de pelvis se apreciaba la destrucción de ambas cabezas femorales. No tenía alteración analítica relacionada con enfermedad infecciosa, metabólica, inflamatoria y neurológica. El paciente fue intervenido quirúrgicamente sustituyendo ambas caderas por prótesis y posteriormente tratado con rehabilitación física presentando una notable mejoría (AU)

The rapidly destructive osteoarthritis of the hip is a variant of osteoarthritis that is characterized by hip pain during one to twelve months and rapid destruction of the femoral head, in absence of infectious, neurologic, metabolic or inflammatory disease. We present the case of a 66 year- old male with severe COPD that referred pain in both hips and was unable to walk. In the radiography of the pelvis complete destruction of both femoral heads was observed. The patient did not have abnormalities in blood tests that were related to infectious, neurologic or metabolic diseases. The patient underwent bilateral total hip replacement with prosthesis and physical therapy later. The patient functional status greatly improved with this treatment (AU)

Outcome of single-event multilevel surgery in untreated cerebral palsy in a developing country.

In developed countries, children with cerebral palsy are treated from the time of diagnosis. This is usually not the case in developing countries where such patients often present at an age when it is traditionally believed that if walking has not already commenced, it is unlikely to. This study reports the outcome of the surgical treatment of 85 spastic diplegic patients at a mean of 8.5 years (5 to 12). All presented as untreated non-walkers and had achieved sitting balance by the age of five to six years. They underwent single-event multilevel surgery followed by physiotherapy and orthotic support. For outcome assessment, a modified functional walking scale was used at a mean of 3.5 years (2 to 5) post-operatively. At all levels, static joint contractures had resolved almost completely. All patients improved and became walkers, 18 (21.2%) as exercise, 39 (45.9%) as household and 28 (33%) as community walkers. This study shows that children with cerebral palsy who cannot walk and have not been treated can be helped by single-event multilevel surgery, provided that inclusion criteria are followed and a structural, supervised rehabilitation programme is in place.

[Analysis of some related factors of effect on gluteus muscle contraction].

OBJECTIVE: To study some related factors of effect on gluteus muscle contraction and provide the therapeutic basis. METHODS: The curative effect was assessed in 154 patients who were classified by age, patient's condition, orthopedic degree in operation and rehabilitation with an average follow-up period of 25 months(ranging from 5 to 36 months). RESULTS: The excellent rate of 18-24 years old (25/30) was lower than that of 5-17 years old(120/124) (P < 0.05); the excellent rate of slight patients was higher (107/109) than that of serious patients (38/45) (P < 0.01); the excellent rate from higher orthopedic degree was higher (111/113) than that from lower orthopedic degree (34/41) (P < 0.01); and the excellent rate of rehabilitation was much higher (107/110) than that of general treatment (38/44) (P < 0.05). CONCLUSION: Age, patient's condition, orthopedic degree in operation and rehabilitation are important factors to affect the curative effect on gluteu muscle contraction.

Contractura en abducción de la cadera / Abduction contracture of the hip

La contractura en abducción de la cadera es una entidad que se detecta por debajo del año de edad, no es habitual ver en una consulta de Rehabilitación general y de la que existe poca literatura. Presentamos una niña que a la edad de 4 meses fue remitida al Hospital tras observar su Pediatra una dismetría de miembros inferiores (MMII). En la exploración se constató tendencia a la flexión y abducción de la cadera derecha, asimetría de los pliegues glúteos, descenso de la hemipelvis derecha con alargamiento aparente del miembro inferior derecho, y una limitación de la adducción de la cadera derecha de unos 20° sin limitación de la movilidad de la izquierda. Asociaba ligera plagiocefalia y tendencia a la rotación derecha del cuello. La radiografía inicial de caderas se encontraba dentro de los límites normales. Efectuó ejercicios de estiramientos, mejorando en gran medida tras 2-3 meses de tratamiento. La asimetría de los pliegues glúteos y la dismetría relativa de los MMII, explorados en decúbito prono y con fijación de los MMII en extensión, debe hacer sospechar una contractura en abducción de la cadera del miembro más largo. En algunas series de casos se ha observado asociada con plagiocefalia, tortícolis, escoliosis, deformidades en los pies, y limitación de la abducción y/o displasia de la cadera contralateral elevada. Existe una maniobra exploratoria que permite cuantificar el grado de contractura en abducción de la cadera, y también un programa sencillo de ejercicios de estiramiento que puede contribuir a su resolución (AU)

Use of a prone transfer technique in patients with severe hip-flexion restrictions: a report of 3 cases.

We report 3 cases in which the prone transfer technique improved the functional status of patients with postoperative restriction of hip flexion. All 3 patients, who had undergone a different type of surgery, were unable to get out of bed without a tilt table, and therefore could not be discharged home. The prone transfer technique enables patients to move from a lying to a standing position with or without the use of a flat board. All 3 patients were discharged home when they could perform this transfer without assistance. It required 10 to 18 sessions of therapy training, which took place in 5 to 9 days. With advancements in surgical techniques, postoperative joint-motion restriction may be seen more frequently in community settings. Prone transfer may provide a low-cost, low-technologic way to mobilize patients with hip-flexion restriction.

[Is surgery of the hip adductor muscles justified in children with cerebral palsy?]. / La chirurgie des adducteurs de la hanche est-elle justifiée chez l'enfant infirme moteur cérébral?

INTRODUCTION: Restricted passive hip abduction in children with cerebral palsy (CP) may be caused by uninhibited resting contractions and/or retractions, i.e., shortened muscle body or tendons. Pathological short tendons require surgical intervention, but lack of muscle body elasticity responds to physiotherapy or a postural splinting. Clinical examination can distinguish between short tendons and short muscle body. The thigh is slowly and passively extended while palpating the tendon. Tension is detected in the tendon when the leg is at angle Ao. The elastic tension of the muscle body then increases until no further movement is possible, at angle Amax. The difference Amax-Ao is an index of the structural length of the muscle body. If this difference is reduced during passive straightening there is shortening of the muscle body; if it is displaced it indicates shortening of the tendon. The value Ao indicates the muscular or tendon origin of the retraction for a given passive limitation (Amax). This study defines the physiological values of Ao and the relative precisions of chemical and instrumental measurements. MATERIALS AND METHODS: A total of 30 children aged 9-11 years, 10 CP patients (7 girls and 3 boys, mean age 10.3 years) and 20 controls (11 girls and 9 boys, mean age 10.5 years) were studied. All the CP children had lower limb spasticity and adopted an adduction posture. None had undergone hip muscle surgery. Ao and Amax were measured clinically with a goniometer and EMG to monitor muscle silence, and experimentally using a deformable parallelogram and force transducers. RESULTS: The minimum physiological value of Ao was 8 degrees with the knee flexed and 0 degree with the knee extended. Smaller values of this angle indicated tendon retraction. The difference between Ao and Amax in the controls and CP children was < or = 10 degrees; the reproducibilities of the clinical measurement of Ao and Amax were very similar. DISCUSSION: Clinical examination provides an acceptably accurate method of distinguishing between tendon and muscle body retraction of adductor muscles in CP children. The conditions required for successful measurement are: careful examination with strict positional reference and sufficiently relaxed pelvic muscles. A hip extension angle Ao of less than 8 degrees with the knee flexed or 0 degree with the knee straight indicates tendon retraction requiring tendon surgery, otherwise, the retraction involves only the muscle body. This reduced elasticity can be overcome by prolonged extension (at least 6 hours/24). Effective muscle extension may be hindered by non-suppressed adductor contractions. This must be overcome prior to physiotherapy by surgery of the ramus ant. n. obturatorii. CONCLUSION: Clinical measurement of Ao of adductor muscles is a reliable way of distinguishing between tendon retractions requiring surgery and muscle body retractions resulting from staying too long in a position with the muscle shortened. This muscle body shortening can be due to lack of physiotherapy or a stretching apparatus treatment, pathological contractions, or compensation for disorders of the controlateral limb.

Influence of surgical treatment of scoliosis in children with spina bifida on ambulation and motoric skills.

The influence on motoric skills of surgical treatment of scoliosis in 14 children with myelomeningocele was studied. Fifty percent of the children had increased flexion contractures of the hips at follow-up, and all but one patient had impaired motor ability. There was no influence on activities of daily life, but 57% of children had lost some of their ambulation capacity. Postoperative physiotherapy is highly advisable. Intensive attempts to treat these children conservatively to prevent scoliosis progression is suggested.

Natural history of flexion deformity of the hip in myelodysplasia.

For definition of the incidence and natural history of hip flexion contracture, 5,147 serial measurements of the range of hip extension in 966 patients with spina bifida were analyzed. Contractures were generally present in the first few months of life (physiologic flexion posture); this then diminished during the first 27 months in all but those with thoracic lesions. Hence, surgical management is seldom appropriate until after that age. In general, contractures reappear or worsen between the ages of 3 and 6 years, but few patients with sacral lesions develop this deformity. Our findings also demonstrate that hip flexion contracture is not merely due to muscle imbalance, sitting posture, or these factors in combination.

Electric cart modification for boy with hip extension contractures.

A 7-year-old boy with Schwartz-Jampel syndrome was evaluated for a mobility and seating device. Assessment results indicated reduced upper and lower extremity function due to tight stiff muscles, labored and slow movements, hip extension contractures, asthmatic and restrictive pulmonary disease, and normal intelligence. Due to the combination of severe musculoskeletal and pulmonary disease, he had not been able to attend school or interact normally with his environment. Ambulation for more than a few feet was precluded by reduced pulmonary capacity and stiff, slow muscle movements which did not improve with medication. Because of hip extension contractures, he could not sit upright in a chair. An Amigo electric cart with a modified straddle seat enabled the patient to sit upright, attend school, and explore his environment with greater mobility. The unit is simple to operate, adaptable, and cost effective.

Treatment of extension contracture of the hip in cerebral palsy.

Twenty patients with cerebral palsy had a total of 35 extension contractures of the hip, resulting from tightness of the gluteus maximus or hamstring muscles, with associated quadricepts muscle spasticity. Associated deformities included anteriorly dislocated hips, patella alta, lumbar lordosis, thoracic kyphosis and calcaneus feet. Active and passive exercises, surgical release of contractures and reduction of anteriorly dislocated hips improved function. Hip flexor or adductor tenotomies must be considered cautiously for patients with spastic hip extensor muscles, because severe extension constricture may develop after either procedure.

Extension contracture of the hip due to idiopathic fibrosis of the gluteus maximus.

Extension contracture of the hip in our case was produced by a thick fibrous band in the substance of the gluteus maximus. The patient had never received an injection around this hip. Z-plasty of the fibrous band led to immediate and full flexion of the hip and the patient was relieved of her symptoms.