Rehabilitation of pediatric musculoskeletal sport-related injuries: a review of the literature.

AIM: The recent increase in sports participation in children and adolescents has resulted in the increase of sport-related injuries and the need for rehabilitation. The purposes of this study were to review studies involving rehabilitation of pediatric musculoskeletal sport-related injuries to determine the study design (level of evidence), inclusion of a reference to skeletal immaturity, adequacy of the description of the rehabilitation program and treatment outcome. METHODS: Medline(1950-June 2009), CINAHL(1982-June 2009), Cochrane and journals (sports, physical therapy, pediatric orthopedic) were searched using the terms: physical therapy or rehabilitation plus sports/athletic injuries or individual sports plus pediatrics, adolescent, children, youth and young. Inclusion criteria were: published in English peer-reviewed journal, examined rehabilitation/management, subjects

Effect of articular step-off and meniscectomy on joint alignment and contact pressures for fractures of the lateral tibial plateau.

OBJECTIVES: To determine the effects of intraarticular step-off and lateral meniscectomy on the alignment of the articular axis, contact area, and pressures for lateral tibial plateau fractures. DESIGN: Biomechanical cadaver study. INTERVENTION: Six fresh cadaveric knees were used. A simulated split fracture of the lateral tibial plateau was reproducibly created by osteotomies, and articular step-offs of zero, one, two, four, and six millimeters were achieved by using support shims. The knee was loaded with 500 newtons in 0 degrees and 350 newtons in 30 degrees of flexion. A digital camera determined changes in the alignment of the articular axis, and F-Scan sensors were inserted into the medial and lateral joint compartments to determine the pressures and pressure distributions. MAIN OUTCOME MEASUREMENT: Each specimen was tested at step-offs of zero, one, two, four, and six millimeters, with the presence or absence of the lateral meniscus. The changes in alignment of the articular axis, the contact area, and the average and maximum contact pressures for each condyle were obtained. RESULTS: Increased articular step-off heights progressively increased valgus angulation and average and maximum contact pressures and progressively decreased contact areas in lateral compartment. At a six-millimeter step-off with 0 degrees of flexion, the valgus angle increased an average of 7.6 degrees, and average contact pressures and maximum contact pressures increased an average of 208 percent and 97 percent, respectively, and contact area decreased an average of 33 percent (p < 0.05). Meniscectomy increased valgus angles by an average of 38 percent and contact pressures by an average of 45 percent and decreased contact areas by 26 percent in the lateral compartment at the same articular step-off heights (p < 0.05). CONCLUSION: The results of this study show the importance of decreasing articular step-off heights in treating lateral tibial plateau split fractures, particularly if a meniscectomy is performed.

Intrathecal baclofen in X-linked adrenoleukodystrophy.

X-linked adrenoleukodystrophy is a progressive neurodegenerative disorder involving the destruction of white matter in the brain and adrenocortical hormone deficiency. Clinical symptoms first appear between 4 and 8 years of age and include spasticity, visual loss, dysphagia, and seizures. In this report, continuous infusion of intrathecal baclofen was used to treat the severe spasticity of an 8-year-old patient with X-linked adrenoleukodystrophy. The improvement in this patient's quality of life, including the elimination of pain and the increased ease of care, suggests that intrathecal baclofen should be considered as part of the treatment strategy for spasticity associated with X-linked adrenoleukodystrophy and other neurodegenerative disorders in children and adults.

Tethered cord in a patient with multiple vertebral segmentation defects: a case report.

Short trunk dwarfism with multiple vertebral segmentation defects (MVSD) represents a heterogeneous group of disorders characterized by the presence of multiple vertebral and rib abnormalities. A two and one-half year-old female with the spondylothoracic dysostosisform of MVSD is presented. In addition to skeletal anomalies, a lumbar hemangioma, bilateral foot deformities, distal leg atrophy and weakness, and areflexia at the ankles were present. An underlying neuropathic process was suspected. Results of urodynamic studies were suggestive of a neurogenic bladder. Magnetic resonance imaging of the spine demonstrated a tethered spinal cord. Although various brain and spinal cord anomalies have been described in MVSD, this is the first reported case, to our knowledge, of a tethered spinal cord in a patient with MVSD. We recommend that the management of patients with MVSD include comprehensive neurological evaluation and monitoring with appropriate electrodiagnostic, urodynamic, and neuroimaging studies.

Crutch handle design: effect on palmar loads during ambulation.

OBJECTIVE: To compare loads, load distributions, pressures, and areas of weight-bearing on the palm for forearm crutches with cylindrical and wide handles during ambulation to determine if one handle type produced greater loads on the carpal tunnel region. DESIGN: Single-group repeated measures of normal adults; descriptive study of patients who were long-term crutch users. Data were collected from six palmar regions using an F-Scan system. SETTING: Center for neuromuscular disorders in a hospital. PARTICIPANTS: Thirty normal volunteers and 6 patients. MAIN OUTCOME MEASURE: Differences in loads for the palmar regions between the two handles, particularly the carpal tunnel region. RESULTS: For the normal adults, significantly greater loads were found in two distal regions for the cylindrical handle and in one proximal region for the wide handle. Distribution of weight-bearing loads showed a similar pattern for both handles with the palm's proximal and distal radial sides having the greatest loads and the carpal tunnel region having the third highest load. The area of weight-bearing was significantly greater for the wide handle than for the cylindrical. CONCLUSIONS: Cylindrical and wide crutch handles have similar load distributions, making it impossible to recommend one type over the other to reduce the occurrence of carpal tunnel syndrome. The wide handle distributes the loads over a greater surface area, producing less focal pressure.

Postoperative weight-bearing after a fracture of the femoral neck or an intertrochanteric fracture.

Sixty patients who had had operative treatment of a fracture of the femoral neck or an intertrochanteric fracture were allowed to bear weight as tolerated on the injured limb. The average age was seventy-seven years. Computerized gait-testing was performed at one, two, three, six, and twelve weeks postoperatively to quantify weight-bearing. For the purpose of analysis, the patients were divided into three groups according to whether they had internal fixation of a stable fracture, internal fixation of an unstable fracture, or a primary hemiarthroplasty. Thirty-two patients completed the entire twelve-week study. The average amount of weight that these patients placed on the injured limb increased progressively with time. The average load supported by the injured limb was 51 per cent that of the uninjured limb at one week, and it gradually increased to 87 per cent at twelve weeks. During the first three weeks, the patients who had had internal fixation bore substantially less weight than those who had had a hemiarthroplasty. By six weeks, we could detect no significant differences, with the numbers available, among the groups with regard to weight-bearing or other measured gait parameters. We concluded that elderly patients who are allowed to bear weight as tolerated after operative treatment of a fracture of the femoral neck or an intertrochanteric fracture appear to voluntarily limit loading of the injured limb.

Developmental implications of idiopathic toe walking.

OBJECTIVE: To determine whether children with persistent toe walking, without suspected developmental problems, and with normal results after neurologic examination, who were seen in an orthopedic clinic demonstrate delays in language development, gross or fine motor skills, visuomotor development, sensory integration function, or evidence of behavioral problems through a comprehensive multidisciplinary evaluation. STUDY DESIGN: A prospective, descriptive study of 13 children (mean age = 3.9 years) referred for idiopathic toe walking. Each child was evaluated by a pediatric neurologist, developmental pediatrician, speech/language pathologist, occupational therapist, and physical therapist. RESULTS: On developmental screening, 7 of 13 children demonstrated delays and 3 were questionably delayed; all 10 had speech/language deficits. Speech/language evaluation showed that 10 of 13 (77%) had receptive or expressive language delays or both. Occupational and physical therapy evaluations found 4 of 12 (33%) had fine motor delays, 4 of 10 (40%) had visuomotor delays, and 3 of 11 (27%) had gross motor delays. CONCLUSIONS: Idiopathic toe walking was most often associated with speech/language delays, but delays in other areas were also present. We suggest that idiopathic toe walking should be viewed as a marker for developmental problems and recommend that any child with this condition should be referred for a developmental assessment.

Equinus deformity in cerebral palsy: recurrence after tendo Achillis lengthening.

Twenty-seven patients with cerebral palsy (CP) were recalled and studied in detail 2 to 9 years post tendo Achillis lengthening (TAL). The recurrence rate of equinus deformity was 22.2%. Multiple clinical characteristics and follow-up examination findings were analyzed to determine their relation to recurrence. The recurrence group had a significantly (P<0.05) smaller preoperative popliteal angle, a greater popliteal angle at follow-up, and a greater change in popliteal angle from preoperative to follow-up than the non-recurrence group. This indicated that increasing hamstring contracture was the major factor influencing recurrence. Spasticity of tibialis posterior and leg-length discrepancy may be related factors as well.

A simple technique for assessing heel contact in orthoses.

Orthoses are used by patients with neuromuscular disorders to control their ankle and foot position. Heel contact inside an orthosis is difficult to determine. A simple, inexpensive device was constructed that could be positioned between the heel and the inside of the orthosis. It consists of a thin, single-cell pressure sensor connected to a low-cost, digital multimeter. The resistance reading was used to determine the presence or absence of heel contact during a controlled standing protocol. The device was evaluated in 23 patients. The majority of patients did not weightbear on their heels. The heel contact of five patients was reassessed by using a computerized F-scan system, which determines plantar weightbearing forces. A 100% agreement was found between the single-cell sensor and the F-scan system. This single-cell sensor is a simple, inexpensive, and easily used device to determine the presence or absence of heel contact within an orthosis.