Escoliosis de aparición precoz. ¿Qué opciones tengo? / Early onset scoliosis. What are the options?

El pronóstico de los ni˜nos con escoliosis de aparición precoz progresiva ha mejorado considerablemente gracias a los recientes avances en las técnicas quirúrgicas y no quirúrgicas, y al reconocimiento de la trascendencia de preservar la cavidad torácica. La mejora de técnicas ya existentes y el desarrollo de otras nuevas han modificado sustancialmente el tratamiento de esta entidad. Los yesos derrotatorios pueden indicarse en ni˜nos con curvas < 60◦ y progresión constatada, a los que no se ha realizado tratamiento quirúrgico previo. Tanto los tallos de crecimiento únicos como dobles son eficaces, aunque los últimos parecen ofrecer un mejor resultado. Los sistemas híbridos se plantean como mejor opción en ni˜nos que requieren un anclaje proximal con un perfil bajo. El vertical expandable prosthetic titanium rib (VEPTR®) puede ser útil en pacientes que presentan escoliosis congénita con fusiones costales y síndrome de insuficiencia torácica asociado. Los ni˜nos no tributarios de elongaciones repetidas por sus comorbilidades pueden ser candidatos a una técnica de Shilla o trolley de Luque. La modulación del crecimiento utilizando grapas de memoria o tirantes resulta prometedora en curvas menores, aunque se requieren más trabajos para definir su indicación precisa (AU)

The prognosis of children with progressive early onset scoliosis has improved considerably due to recent advances in surgical and non-surgical techniques and the understanding of the importance of preserving the thoracic space. Improvements in existing techniques and development of new methods have considerably improved the management of this condition. Derotational casting can be considered in children with documented progression of a < 60◦ curve without previous surgical treatment. Both single and dual growing rods are effective, but the latter seem to offer better results. Hybrid constructs may be a better option in children who require a low-profile proximal anchor. The vertical expandable prosthetic titanium rib (VEPTR®) appears to be beneficial for patients with congenital scoliosis and fused ribs, and thoracic Insufficiency Syndrome. Children with medical comorbidities who may not tolerate repeated lengthenings should be considered for Shilla or Luque Trolley technique. Growth modulation using shape memory alloy staples or other tethers seem promising for mild curves, although more research is required to define their precise indications (AU)

[Early onset scoliosis. What are the options?]. / Escoliosis de aparición precoz. ¿Qué opciones tengo?

The prognosis of children with progressive early onset scoliosis has improved considerably due to recent advances in surgical and non-surgical techniques and the understanding of the importance of preserving the thoracic space. Improvements in existing techniques and development of new methods have considerably improved the management of this condition. Derotational casting can be considered in children with documented progression of a <60° curve without previous surgical treatment. Both single and dual growing rods are effective, but the latter seem to offer better results. Hybrid constructs may be a better option in children who require a low-profile proximal anchor. The vertical expandable prosthetic titanium rib (VEPTR(®)) appears to be beneficial for patients with congenital scoliosis and fused ribs, and thoracic Insufficiency Syndrome. Children with medical comorbidities who may not tolerate repeated lengthenings should be considered for Shilla or Luque Trolley technique. Growth modulation using shape memory alloy staples or other tethers seem promising for mild curves, although more research is required to define their precise indications.

Fracturas pediátricas de cabeza y cuello de radio / Radial head and neck fractures in children

Objetivo. Analizar los casos de fractura de cabeza y cuello de radio en pacientes pediátricos y compararlos con los de la bibliografía. Material y métodos. Estudio retrospectivo y descriptivo de 21 pacientes pediátricos con fractura de cabeza y cuello de radio, en los que se recogieron los siguientes parámetros: datos demográficos, afección asociada, tipo de fractura, tratamiento, necesidad de rehabilitación, déficit de balance articular, tiempo de recuperación y complicaciones. Resultados. Del total de la serie, 11 eran varones. La edad media fue de 8,3 años. En 14 pacientes el lado lesionado fue el derecho. Doce casos asociaron lesiones en codo ipsilateral. Según la clasificación de Chambers, 15 casos pertenecieron al grupo A, mientras que en la clasificación de Steele-Graham, 12 casos fueron del grupo I. Once pacientes se trataron solo con inmovilización, 4 percutáneamente y 6 mediante reducción abierta y fijación interna (RAFI). Once casos precisaron rehabilitación, de los que 8 no recuperaron movilidad completa. El tiempo medio para obtener el mayor arco de movilidad fue de 4,71 meses. Ocho pacientes presentaron complicaciones, destacando neuroapraxia y la deformidad en valgo del codo. Discusión y conclusiones El tratamiento de la fractura de cabeza y cuello de radio en pacientes pediátricos ha de ser escalonado, desde la simple inmovilización, reducción manual y/o percutánea, hasta la RAFI, la cual cada vez está menos indicada. En este aspecto, debe evitarse la colocación de una aguja transcapitelar y/o la exéresis de la cabeza radial. La complicación más frecuente es el déficit de pronosupinación, sobre todo en casos tratados mediante RAFI. Del resto de las complicaciones observadas, la neuroapraxia del interóseo posterior fue la más común (AU)

Objective. To analyse cases of radial head and neck fractures in children and compare them with the literature. Method. Retrospective and descriptive study of 21 children with radial head and neck fractures. The following parameters were collected: demographics, comorbidity, classification, treatment, need for rehabilitation, lack of range of motion (ROM), time for recovery and complications. Results. The series included 11 males, and the mean age was 8.3 years. The right side was affected in 14 patients. Twelve cases had an associated ipsilateral elbow injury. According to the Chambers classification, 15 cases belonged to group A, while in the Steele-Graham classification, 12 cases were in group I. Eleven patients were treated with immobilization only, 4 percutaneously, and 6 by open reduction and internal fixation (ORIF). Eleven of them needed rehabilitation and despite this, 8 did not achieve full mobility. The mean time to obtain the greatest ROM was 4.71 months. Eight patients had complications, with the most common being neuroapraxia and valgus deformity of the elbow. Discussion and conclusions. Treatment of paediatric radius head and neck fractures must be step-wise, from immobilization only, manual and/or percutaneous reduction, to ORIF, whichever is less indicated. In this respect, both the transcapital needle and/or removal the radius head should be avoided. The most common complication is lack of supination, especially in cases treated by ORIF. The posterior interosseous neuroapraxia was the most common of the rest of complications (AU)

Densidad mineral ósea en la población con afectación severa por parálisis cerebral infantil / Bone mineral density in a population with severe infantile cerebral palsy

Objetivo. Determinar los valores de densidad mineral ósea (DMO) en niños y adolescentes con afectación moderada y severa, por parálisis cerebral infantil (PCI) de nuestra área de referencia, y comparar estos valores con pacientes sanos. Material y método. Estudio de pronóstico de casos y controles para la valoración de la DMO en pacientes con PCI de 2 a 18 años pertenecientes a los grupos IV y V de la clasificación Gross Motor Function Classification System (GMFCS). Las mediciones de DMO se realizaron a nivel del fémur distal, se dividió esta región en 3 zonas siguiendo el protocolo de antebrazo. Resultados. En la muestra final de 69 pacientes se objetivan valores de DMO para cada una de las regiones estudiadas muy por debajo de los niveles de referencia. Existe una diferencia estadísticamente significativa (p<0,05) entre los valores de DMO en los 2 subgrupos estudiados. Discusión. La mayor afectación desde el punto de vista neurológico en los pacientes del grupo V condiciona una situación de muy baja DMO respecto a pacientes de igual edad y sexo. En pacientes con PCI la adquisición de capital óseo no se realiza siguiendo el patrón de normalidad de la población sana (AU)

Objective. To determine the bone mineral density (BMD) values in children and adolescents with moderate and severe infantile cerebral palsy (ICP) in our catchment area, and compare these values with a healthy population. Material and method. A prognostic study of cases and controls for the assessment of BMD in patients from 2 to 18 years old with infantile cerebral palsy belonging to the Gross Motor Function Classification System (GMFCS) Groups IV and V. The BMD measurements were performed at distal femur level, dividing this region into 3 areas following the forearm protocol. Results. The BMD for each of the three areas studied results in the final sample of 69 patients were much lower than the reference levels. There was a statistically significant difference (P<.05) between the BMD values in the two sub-groups studied. Discussion. The greater the involvement, from a neurological point of view, in patients classified as Group V shows a very low BMD compared to patients of similar sex and age. The acquisition of bone capital in patients with ICP does not follow the normal pattern of the healthy population (AU)

[Radial head and neck fractures in children]. / Fracturas pediátricas de cabeza y cuello de radio.

OBJECTIVE: To analyse cases of radial head and neck fractures in children and compare them with the literature. METHOD: Retrospective and descriptive study of 21 children with radial head and neck fractures. The following parameters were collected: demographics, comorbidity, classification, treatment, need for rehabilitation, lack of range of motion (ROM), time for recovery and complications. RESULTS: The series included 11 males, and the mean age was 8.3 years. The right side was affected in 14 patients. Twelve cases had an associated ipsilateral elbow injury. According to the Chambers classification, 15 cases belonged to group A, while in the Steele-Graham classification, 12 cases were in group I. Eleven patients were treated with immobilization only, 4 percutaneously, and 6 by open reduction and internal fixation (ORIF). Eleven of them needed rehabilitation and despite this, 8 did not achieve full mobility. The mean time to obtain the greatest ROM was 4.71 months. Eight patients had complications, with the most common being neuroapraxia and valgus deformity of the elbow. DISCUSSION AND CONCLUSIONS: Treatment of paediatric radius head and neck fractures must be step-wise, from immobilization only, manual and/or percutaneous reduction, to ORIF, whichever is less indicated. In this respect, both the transcapital needle and/or removal the radius head should be avoided. The most common complication is lack of supination, especially in cases treated by ORIF. The posterior interosseous neuroapraxia was the most common of the rest of complications.

[Bone mineral density in a population with severe infantile cerebral palsy]. / Densidad mineral ósea en la población con afectación severa por parálisis cerebral infantil.

OBJECTIVE: To determine the bone mineral density (BMD) values in children and adolescents with moderate and severe infantile cerebral palsy (ICP) in our catchment area, and compare these values with a healthy population. MATERIAL AND METHOD: A prognostic study of cases and controls for the assessment of BMD in patients from 2 to 18 years old with infantile cerebral palsy belonging to the Gross Motor Function Classification System (GMFCS) Groups IV and V. The BMD measurements were performed at distal femur level, dividing this region into 3 areas following the forearm protocol. RESULTS: The BMD for each of the three areas studied results in the final sample of 69 patients were much lower than the reference levels. There was a statistically significant difference (P<.05) between the BMD values in the two sub-groups studied. DISCUSSION: The greater the involvement, from a neurological point of view, in patients classified as Group V shows a very low BMD compared to patients of similar sex and age. The acquisition of bone capital in patients with ICP does not follow the normal pattern of the healthy population.

Pulgar en resorte en niños. Comparación de resultados entre la liberación percutánea y la cirugía abierta / Trigger thumb in children: comparison of results between percutaneous release and open surgery

Objetivo. Evaluar las diferencias entre la liberación abierta y percutánea del pulgar en resorte en niños. Material y métodos. Hemos realizado un estudio descriptivo retrospectivo de los niños intervenidos desde enero de 2000 hasta febrero de 2009 en nuestro centro. Se excluyeron aquellos pacientes con afectación de dedos largos (no pulgares), intervenidos simultáneamente de otras patologías o ingresados por otros motivos, así como aquellos que rechazaron el tratamiento propuesto. Se realizó una u otra técnica quirúrgica, así como las revisiones posteriores, según las preferencias del facultativo que atendía al paciente. Resultados. Encontramos 176 pulgares en resorte (159 niños), con una edad media de 2,58 años, siendo la mayoría unilaterales (n=142). Hemos encontrado diferencias estadísticamente significativas entre ambos tratamientos con respecto al tiempo quirúrgico (p<0,01), siendo menor en la polectomía percutánea (14,56min) respecto a la cirugía abierta (33,49min). Conclusión. La polectomía percutánea en niños es una buena alternativa, sencilla, económica y rápida pero, requiere la colaboración familiar para evitar las recurrencias y obtener el éxito completo (AU)

Objective. Assess the differences between open and percutaneous release of trigger thumb in children. Material and methods. We performed a retrospective study of all the patients operated on at our institution between January 2000 and February 2009. Our exclusion criteria were: patients with trigger fingers other than the thumb, that were being operated on simultaneously of another condition, admitted for other reasons or refused treatment. The surgical technique was left to the preference of the attending physician. Results. We found 176 trigger thumbs (159 children), with a mean age of 2.58 years, the majority being unilateral (n=142). Statistically significant differences between the two treatments were only found regarding surgical time (p<0.01); percutaneous release (14,56min) was less time-consuming than the open technique (33,49min). Conclusion. Percutaneous release in children is a good, simple, cheap and fast alternative but it requires compliance of the parents in order to avoid recurrence and to obtain complete success (AU)

Lesión de Monteggia inveterada. Resultados con la técnica de Bell-Tawse modificada en tres casos / Inveterate Monteggia Injury. Results with the modified Bell-Tawse procedure in three cases

Objetivo: La lesión de Monteggia es poco frecuente (el 2% de las fracturas de la región del codo) y los casos inveterados son muy raros. A continuación se presentan 3 casos tratados mediante reducción abierta y reconstrucción del ligamento anular con fascia tricipital. Casos clínicos: La edad media de los 3 sujetos era de 7 años (rango de 5 a 9), 2 de ellos eran varones y todos presentaban lesiones tipo i de Bado en el lado derecho. Los 3 recibieron tratamiento mediante técnica de Bell-Tawse modificada por Lloyd-Roberts y Bucknill; en un enfermo se asoció osteotomía cubital. Resultados: No se presentaron complicaciones. Tras un seguimiento medio de 35 meses (rango de 9 a 84) todos los sujetos consiguieron un arco de flexoextensión funcional con una pérdida leve de pronosupinación, pero no se detectaron restricciones en las actividades de la vida diaria ni déficit funcional. Conclusiones: La técnica de Bell-Tawse modificada es un método efectivo, aun cuando produce una pérdida leve de movilidad, especialmente de pronosupinación. Los resultados a largo plazo de esta técnica son mejores que los que se consiguen con la escisión tardía de la cabeza radial luxada (AU)

Purpose: Monteggia injuries are a rare occurrence (2% of all elbow fractures), and inveterate cases are extremely unusual. We present 3 cases treated by means of open reduction and reconstruction of the annular ligament with a strip of triceps fascia. Case reports: The mean age of the 3 patients was 7 years (range: 5–9). Two of them were male and all presented with type 1 Bado injuries on the right side. All 3 were treated by means of the Bell-Tawse technique as modified by Lloyd-Roberts and Bucknill; one of the patients was also subjected to ulnar osteotomy. Results: There were no complications. After a mean follow-up of 35 months (range: 9–84) all patients achieve a functional flexion-extension range. They experienced a slight loss of pronosupination but they reported no restrictions to their activities of daily living or any functional impairment. Conclusions: The modified Bell-Tawse technique is an effective method, even if it leads to a slight loss of mobility, especially in terms of pronosupination. The long-term results of this technique are better than those achieved with a late excision of the dislocated radial head (AU)