Referrals from scoliosis screenings.
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Adolescent↗
Biomedical subjects
D L Skaggs
Publications and source records attributed to D L Skaggs.
Increased body weight and decreased radial cross-sectional dimensions in girls with forearm fractures.
A large number of children sustain fractures after relatively minor trauma and several investigators have associated these fractures to a deficient accumulation of bone during growth. This study was conducted to better characterize the skeletal phenotype associated with low-energy impact fractures of the forearm in girls. The densities of cancellous, cortical, and integral bone and the cross-sectional area were measured in the radius of 100 healthy white girls (aged 4-15 years) using computed tomography (CT); 50 girls had never fractured and 50 girls had sustained a forearm fracture within the previous month. Fractured and nonfractured groups were matched for age, height, weight, and Tanner stage of sexual development. Compared with controls, girls with fractures had, on average, 8% smaller cross-sectional area at the distal radius (1.82 +/- 0.50 cm2 vs. 1.97 +/- 0.42 cm2; p < 0.0001) but similar cancellous, integral, and cortical bone densities. Neither radial length nor the amount of fat or muscle at the midshaft of the radius differed between girls with and without fractures. Both study subjects and matched controls were overweight. Although mean height was at the 50th percentile, mean weight was at the 90th percentile for age-adjusted normal values. Girls who sustain forearm fractures after minor trauma have small cross-sectional dimensions of the radius and tend to be overweight. The smaller cross-sectional area confers a biomechanical disadvantage that, coupled with the greater body weight, increases the vulnerability to fracture after a fall.
Absorptiometry, Photon↗
Access to orthopedic care for children with medicaid versus private insurance in California.
OBJECTIVE: To compare the availability of timely orthopedic care to a child with a fractured arm insured by Medi-Cal (California state Medicaid) and by private insurance. STUDY DESIGN: Fifty randomly chosen offices of orthopedic surgeons were telephoned with the following scenario: "My 10-year-old son broke his arm last week during a vacation" followed by a request for an appointment that week. Each office was called twice with an identical script except for insurance status: once with Medi-Cal and once with private insurance. RESULTS: All 50 offices offered an appointment to see the child with private insurance within 7 days. Only 1 of the same 50 offices offered an appointment to see the child with Medi-Cal within 7 days. Of the offices that would not see a child with Medi-Cal, 87% were unable to recommend an orthopedic office that accepted Medi-Cal. CONCLUSIONS: Timely access to orthopedic care was available in 100% of offices polled to a child with private insurance versus in 2% of offices to a child with Medi-Cal. This is a significant difference. Lack of timely orthopedic care may result in poor outcome, ie, if a fracture is not properly aligned in the first few weeks, a permanent deformity may result. Although causation cannot be established from this study, we suspect that Medi-Cal reimbursement rates below the cost of office overhead may be of significance. Although federal guidelines require that payments must be sufficient to enlist enough providers so that services to Medi-Cal recipients are available to the same extent as those available to the general population, this study finds that that children with Medi-Cal insurance have significantly less access to timely orthopedic care.
Appointments and Schedules↗
Differentiation between bone infarction and acute osteomyelitis in children with sickle-cell disease with use of sequential radionuclide bone-marrow and bone scans.
BACKGROUND: The differentiation of bone infarction from acute osteomyelitis in patients with sickle-cell disease is challenging, as the clinical presentations of the two conditions are similar and imaging and laboratory studies are of limited value. METHODS: A combination of radionuclide bone-marrow and bone scans was performed sequentially within a twenty-four-hour period (with one exception) to aid in the differentiation between bone infarction and osteomyelitis in seventy-nine consecutive episodes of acute bone pain in children with sickle-cell disease. RESULTS: Seventy cases of bone infarction were diagnosed on the basis of decreased uptake on the bone-marrow scan and abnormal uptake on the bone scan at the site of pain. Antibiotic administration was discontinued in sixty-six of the seventy cases after the imaging results were obtained, and the bone pain resolved. In four of the seventy-nine cases, there was normal uptake on the bone-marrow scan and abnormal uptake on the bone scan at the site of pain, findings that were suggestive of acute osteomyelitis. In three of these cases, osteomyelitis was proven by culture, and the symptoms in all four resolved with antibiotic treatment. In five of the seventy-nine cases, the bone-marrow and bone scans were normal and thought to indicate neither osteomyelitis nor bone infarction; in all of these cases, the symptoms resolved without the use of antibiotics. CONCLUSIONS: These findings suggest that osteomyelitis can be differentiated from bone infarction in children with sickle-cell anemia and acute bone pain by a combination of sequential bone-marrow and bone scintigraphy.
Acute Disease↗
Bilateral hip dislocations in a father and son with Ehlers-Danlos syndrome.
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Adult↗
Elbow aspiration and arthrogram: an alternative method.
We describe a posterior elbow-aspiration approach that is safe, easy, and effective in all settings, including trauma.
Arthrography↗
Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement.
BACKGROUND: The commonly accepted treatment of displaced supracondylar fractures of the humerus in children is fracture reduction and percutaneous pin fixation; however, there is controversy about the optimal placement of the pins. A crossed-pin configuration is believed to be mechanically more stable than lateral pins alone; however, the ulnar nerve can be injured with the use of a medial pin. It has not been proved that the added stability of a medial pin is clinically necessary since, in young children, pin fixation is always augmented with immobilization in a splint or cast. METHODS: We retrospectively reviewed the results of reduction and Kirschner wire fixation of 345 extension-type supracondylar fractures in children. Maintenance of fracture reduction and evidence of ulnar nerve injury were evaluated in relation to pin configuration and fracture pattern. Of 141 children who had a Gartland type-2 fracture (a partially intact posterior cortex), seventy-four were treated with lateral pins only and sixty-seven were treated with crossed pins. Of 204 children who had a Gartland type-3 (unstable) fracture, fifty-one were treated with lateral pins only and 153 were treated with crossed pins. RESULTS: There was no difference with regard to maintenance of fracture reduction, as seen on anteroposterior and lateral radiographs, between the crossed pins and the lateral pins. The configuration of the pins did not affect the maintenance of reduction of either the Gartland type-2 fractures or the Gartland type-3 fractures. Ulnar nerve injury was not seen in the 125 patients in whom only lateral pins were used. The use of a medial pin was associated with ulnar nerve injury in 4% (six) of 149 patients in whom the pin was applied without hyperflexion of the elbow and in 15% (eleven) of seventy-one in whom the medial pin was applied with the elbow hyperflexed. Two years after the pinning, one of the seventeen children with ulnar nerve injury had persistent motor weakness and a sensory deficit. CONCLUSIONS: Fixation with only lateral pins is safe and effective for both Gartland type-2 and Gartland type-3 (unstable) supracondylar fractures of the humerus in children. The use of only lateral pins prevents iatrogenic injury to the ulnar nerve. On the basis of our findings, we do not recommend the routine use of crossed pins in the treatment of supracondylar fractures of the humerus in children. If a medial pin is used, the elbow should not be hyperflexed during its insertion.
Bone Nails↗
Prediction of postoperative gait velocity in cerebral palsy.
Preoperative and postoperative gait analyses were reviewed for 47 patients with cerebral palsy in an attempt to ascertain predictors of surgical outcome as measured by gait velocity. Higher postoperative velocity correlated with higher preoperative velocity and younger age. Observed velocities in older children were smaller than predicted values. Older children showed either an average decline in velocity from normal for age or no change. Younger children showed an average increase in velocity toward normal for their age. Diagnosis, type of surgery, number of procedures performed and level of ambulation preoperatively were not predictive of postoperative velocity. These results suggests that gait velocity cannot be reliably increased in all children with cerebral palsy undergoing surgery, especially those older than age 12.
Adolescent↗
Respiratory failure in postpneumonectomy syndrome complicated by thoracic lordoscoliosis: treatment with prosthetic implants, partial vertebrectomies, and spinal fusion.
STUDY DESIGN: This study investigated the case of a 17-year-old girl with postpneumonectomy syndrome, complicated by a thoracic lordoscoliosis, who was successfully treated with prosthetic implants, partial vertebrectomies, and anteroposterior spinal fusion. OBJECTIVE: To report a unique case and describe the authors' method of treatment. SUMMARY OF BACKGROUND DATA: Postpneumonectomy syndrome is an uncommon complication of pneumonectomy. Many case reports describe successful treatment with insertion of prosthetic implants into the empty hemithorax to shift the mediastinum to its original position. Thoracic lordoscoliosis reportedly has contributed to pulmonary compromise, but no cases have shown its occurrence in the setting of postpneumonectomy syndrome. METHODS: The patient was observed at the National Children's Hospital in Tokyo, referred to Children's Hospital in Los Angeles, California for surgical correction, and followed in Tokyo for the next year. RESULTS: Two prosthetic implants with an injection port for further expansion were positioned in the right hemithorax to restore the mediastinum to its normal position. Anterior discectomies, partial vertebrectomies, and fusion of T5-T10 was performed concurrently. Then 5 days later, posterior spinal fusion of T1-T12 with instrumentation and bone graft were performed to correct the thoracic lordoscoliosis and increase the chest cavity space. At 1 month after the surgery, the patient was extubated after being ventilator dependent for 5 months. At the time of operation, the girl was ventilator dependent and nonambulatory, but 1 year later could participate in all activities of daily living without any oxygen supplementation. CONCLUSIONS: Postpneumonectomy syndrome can be treated successfully with prosthetic implants to restore the normal position of the mediastinum. Thoracic lordoscoliosis can complicate the syndrome and may be corrected to help restore normal pulmonary function.
Adolescent↗
Complications of posterior iliac crest bone grafting in spine surgery in children.
STUDY DESIGN: The perioperative and postoperative complications associated with harvesting posterior iliac crest bone graft in children were reviewed. A retrospective study was performed and a questionnaire interview conducted. OBJECTIVES: To determine the morbidity associated with posterior iliac crest bone graft in children. SUMMARY OF BACKGROUND DATA: Iliac crest bone is commonly used as a source of bone graft in spine surgery. Although there are multiple reports of complications in adults, there are no reports in children. METHODS: A retrospective chart review was performed of 214 consecutive children who underwent spinal fusion with posterior iliac crest bone graft from 1990 through 1996. An interview was conducted of 87 patients with normal mental status, predominantly those with idiopathic scoliosis with a minimum of 2 years' follow-up (mean, 55 months). RESULTS: The review showed one (0.5%) instance of arterial injury in the sciatic notch. Two (1%) patients had infections, both of which resolved with a single irrigation and débridement. There was one documented instance of sacroiliac penetration that did not cause clinical problems. The chart review showed three (1.4%) instances of continued pain and one (0.5%) of numbness. By contrast to the few reports of pain in the chart review, responses to an interview of 87 patients showed 21 (24%) children reporting pain at the iliac crest site, with 13 (15%) reporting problems with daily activities. The self-reported pain, on a scale of 1 to 10, ranged from 1 to 10 with a mean of 4. Nonsteroidal anti-inflammatory drugs (NSAIDS) were taken by eight (9%) children for pain at the bone graft site. Five (6%) reported skin irritation, and 18 (20%) mentioned numbness surrounding the scar. CONCLUSION: The perioperative rate of complications in iliac crest bone grafting in children is low (2%). The complication of pain (24%) and pain that is severe enough to interfere with daily activity (15%) is significant at a mean follow-up of more than 4 years. The true extent of pain and numbness after posterior iliac crest bone grafting in children was severely underreported in the medical records and may be underrecognized.
Adolescent↗
Evaluation of the acutely limping child.
A limp may be defined as any asymmetric deviation from a normal gait pattern. The differential diagnosis of a limp includes trauma, infection, neoplasia and inflammatory, congenital, neuromuscular or developmental disorders. Initially, a broad differential diagnosis should be considered to avoid overlooking less common conditions such as diskitis or psoas abscess. In any patient with a complaint of knee or thigh pain, an underlying hip condition should be considered. The patient's age can further narrow the differential diagnosis, because certain disease entities are age-specific. Vigilance is warranted in conditions requiring emergent treatment such as septic hip. The challenge to the family physician is to identify the cause of the limp and determine if further observation or immediate diagnostic work-up is indicated.
Adult↗
The effect of preoperative gait analysis on orthopaedic decision making.
The impact of preoperative gait analysis on the orthopaedic care of 97 patients (101 gait analyses) at the authors' institution was evaluated. For the 70 patients for whom a specific treatment plan had been outlined before the preoperative gait study, the treatment plan was altered in 62 (89%) after the gait analysis study. In 10 of the 70 patients with specific treatment plans before the gait study, the referring physician also served as the physician in the gait laboratory; ultimate treatment was changed in nine of these 10 patients. Of the 273 surgical procedures recommended before the gait study in the 70 patients, 106 (39%) of these procedures were not done when the gait laboratory data were considered. An average of 1.5 procedures per patient that were planned before the gait study ultimately were not deemed necessary by the treating physician after the addition of the gait data. An additional 110 procedures (1.6 per patient) that had not been recommended before the gait study ultimately were performed after addition of the gait laboratory data. This study shows that ultimate surgical intervention frequently is altered by the addition of gait laboratory data.
Adolescent↗
Impact of postoperative gait analysis on orthopaedic care.
The impact of postoperative gait analysis on the ongoing orthopaedic care of 38 consecutive patients with a static encephalopathy was evaluated. Of the 38 postoperative gait analyses, 32 (84%) resulted in recommendations of a change in patient care. Surgery was recommended in 16 of 38 (42%) cases, bracing in 20 (53%) cases, and specific physical therapy regimens in eight (21%) cases. Eleven of the 38 (29%) patients had changes recommended in at least two of the three areas (surgery, bracing, and therapy). The results of this study suggest that postoperative gait analysis serves not only as a measure of treatment outcome, but also as a useful tool in planning ongoing care for these patients.
Brain Injuries↗
A simplified valgus osteotomy of the proximal femur in children.
Valgus osteotomy of the hip is required in a number of orthopedic conditions in children. We present a simplified valgus osteotomy in which a dynamic compression plate is used. This technique has the advantages of using easily available equipment, requiring only one osteotomy, and providing immediate rigid fixation while not violating the proximal femoral physis. We have used this simplified technique for valgus osteotomy in six hips in four children with excellent fixation, good maintenance of correction, and no complications.
Child↗
Mild gait abnormality and leg discomfort in a child secondary to extradural ganglioneuroma.
Ganglioneuromas are benign and slow-growing tumors that most commonly originate from the sympathetic trunk. Ganglioneuromas often decrease in size and rarely require reoperation. Changes in gait or the onset of limb pain without a discernible local cause are indications for investigation of patients for possible intraspinal pathology. We report the case of a 5-year-old boy who presented with seemingly static symptoms, while the slow-growing tumor had enveloped nerve roots and caused bone destruction of the vertebrae.
Biopsy↗
Dysplasia epiphysealis hemimelica of the acetabulum. A report of two cases.
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Acetabulum↗
Unilateral absence of the clavicle with rapidly progressive scoliosis in an 8-year-old.
We report a possible association of unilateral absence of a clavicle with rapidly progressive scoliosis. Cleidocranial dysplasia (CCD) is an autosomal dominant disorder that is characterized by defective bone formation. The clavicle, pelvis, and skull are the most commonly affected bones. A review of the literature found two cases of CCD and scoliosis. Unilateral absence of the clavicle in association with rapidly progressing scoliosis has not been previously reported. Review of the patient's charts and radiographs from age 8 to 17 years, 5 years after treatment with posterior spinal instrumentation is presented, together with a review of the literature. Our patient initially presented without any spinal deformity until age 9, when she had a 10 degree curve between C-8 and L-T. Eighteen months later, the curve progressed to 52 degrees, Risser 1. Associated anomalies include posterior-element hypoplasia of the thoracic spine and posterior fusion of C4-6. She was treated with posterior spinal instrumentation from C-8 to L-4 without complications. Correction was maintained at 5-year follow-up. There may be an association between unilateral absence of the clavicle and rapid progression of scoliosis in immature children. We hypothesize that the asymmetrical influence of the unilateral absent clavicle may have played a causative role in her rapidly progressive scoliosis.
Cervical Vertebrae↗
Lengthening of pediatric forearm deformities using the Ilizarov technique: functional and cosmetic results.
Eight patients (average age, 10 years) had a unilateral forearm lengthening procedure using the technique developed by Ilizarov. The procedure was performed in 4 patients with radial agenesis, in 2 with multiple hereditary exostosis, in 1 with ulnar agenesis, and in 1 with multiple enchondromatosis. Patients underwent distraction osteogenesis through either a unifocal or bifocal corticotomy. Forearm length increased on average 6.0 cm (range, 3.6-8.1 cm) or 54% (range, 21% to 94%) with a lengthening index of 1.3 months per centimeter (range, 0.6-1.9 months per centimeter). The length of follow-up averaged 4.5 years and involved office examinations with task evaluation and a questionnaire addressing function and appearance. Limb length discrepancy at follow-up measured 3.7 cm (range, 0.0-8.0 cm). Lengthening of the forearm was found to improve upper extremity function; it allowed the patient to reach distant body parts and to perform select activities requiring near-equal arm length. Forearm lengthening also improved the appearance of the arm if adequate soft tissue was preserved. Full restoration of arm length was not a requirement for a successful outcome and patient satisfaction with the results of the procedure was high.
Adolescent↗