What are the options of treatment?

a. Remanipulation and plaster

b. Manipulation and closed pinning

c. Manipulation with blunt wire and pinning and plaster

d Accept the reduction

Now watch the video in this link of a study from Hawaii titled

5 year old with injury to forearm due to fall in the playground

How do you manage these fractures?

a above elbow plaster

b below elbow plaster

c splints

How long will you continue immobilisation?

a 2 weeks

b 3 weeks

c 4 weeks

d 6 weeks

How often will you repeat the rays?

a. every week

b After 3 weeks

c. At week 1 and at plaster removal

Here is an attempt to find an answer to some of the questions…

What does the term tarus fractures mean

Torus is derived from Latin (tori) meaning a swelling or protuberance. Torus (buckle) fractures  of distal metaphysis of radius & ulna are the most common fractures of in lower forearm in young children

When the child falls on the outstretched hand, the bone buckles under the weight of the body.  Typically, you will see a slight bend in the bone, but only on one side.  It literally looks like the bone buckled, but didn’t break all the way through.

There is usually little if any deformity in the bone because the periosteum and cortex are intact on the side. Technically speaking, the bone has failed in ‘compression’, making the small ripple in the bone that you see on the x-ray.

Torus fractures hurt, but will not cause a visible deformity.  If you push directly on the arm where it is broken, it will hurt, and the child can localize the spot very clearly.  However, they can usually move the wrist joint without much trouble.  Because of this, many of these fractures are diagnosed late because it can be difficult for parents to tell if it is broken or not

These are generally stable fractures, meaning that the alignment will probably not change with protection such a a cast or splint.

What is the evidence from the literature

• Davidson (JBJS B 83-B 20011173-1175 ) did a RCT comparing treatment in traditional forearm cast V/S splint and concluded that there was no difference in the results of both the treatment methods.  In fact the splint treatment had major benefits in terms of cost and reduction of the number of attendances.
• Pint et al (Pediatrics. 2006 Mar;117(3):691-7) in a radomised control trial of 87 fractures : 42 in the splint group and 45 in the cast group concluded that children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures.
• Farbman KS 9Arch Pediatr Adolesc Med September 1999;153:923-5.) while evaluating the role of serial radiographs in the management of pediatric torus fractures concluded that radiographs after application of a cast for a nondisplaced torus fracture are not required. Clinical examination is appropriate during follow-up, with consideration given to repeat radiographs only at four weeks postfracture to document healing.

What are the pitfalls

• Greenstick fractures of lower radius: need to be reduced and put in cast as they can deform and redisplace. The failure in greenstick fractures in distraction and is on the side of angulation

• Eren (Journal of Pediatric Orthopaedics B:January 2009 – Volume 18 – Issue 1 – pp 35-36) reported onTorus fracture of the distal radius associated with distal radioulnar joint instability. They suggested that torus fractures of the children are not always innocent, and simple physical examination of the DRUJ for tenderness and instability is mandatory before and after roentgenographic evaluation to adequately treat these kinds of injuries and prevent malpractice. In cases of doubt, MRI examination of the wrist may also reveal the torn triangular fibrocartilage complex leading to instability.
• Some of the buckle fractures may have extension to the physis . Aminian A, Schoenecker PL (J Pediatr Orthop. 1995 Jul-Aug;15(4):495-8) reported on premature closure of the distal radial physis after fracture of the distal radial metaphysis.

So coming back to the case how do you manage the 5 year old child with the tarus fracture of distal radius and ulna?

Will wait for the responses from the readers…

References

Simple treatment for torus fractures of the distal radius

J. S. Davidson, FRCS Orth, Specialist Registrar in Orthopaedic Surgery; D. J. Brown, FRCS, Specialist Registrar in Orthopaedic Surgery; S. N. Barnes, FRCS, Specialist Registrar in Orthopaedic Surgery; and C. E. Bruce, FRCS Orth, Consultant in Paediatric Orthopaedics From Alder Hey Children’s Hospital, Eaton Road, West Derby, Liverpool L12 2AP, UK.

Journal of Bone and Joint Surgery – British Volume, Vol 83-B, Issue 8, 1173-1175.
doi: 10.1302/0301-620X.83B8.11451
Correspondence should be sent to Mr D. J. Brown at 6 Caldy Road, West Kirby, Wirral CH48 2HG, UK.

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money.

Over a six-month period, we randomised 201 consecutive patients with this injury to treatment with either a traditional forearm plaster-of-Paris cast or a ‘Futura-type’ wrist splint. All patients were treated for a period of three weeks, followed by clinical and radiological review.

There was no difference in outcome between the two groups, and all patients had a good result. Only one patient did not tolerate the splint which was replaced by a cast.

The questionnaire showed a marked variation in the way in which these injuries are treated with regard to the method and period of immobilisation, the number of follow-up visits and radiographs taken.

We suggest that a ‘Futura-type’ wrist splint can be used to treat these fractures. The patient should be reviewed on the following day to confirm the diagnosis and to give appropriate advice. There is no evidence that further follow-up is required.

This simple treatment has major benefits in terms of cost and reduction of the number of attendances.

A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.

Abstract

OBJECTIVE:

Wrist buckle fractures are a frequent reason for emergency department visits. Although textbooks recommend 2 to 4 weeks of immobilization in a short arm cast, management varies. Treatment with both casts and splints is common, and length of immobilization varies. The objective was to determine if children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical functioning than those treated with a short arm cast for 3 weeks.

METHODS:

This was a randomized, controlled trial in the emergency department of an academic, tertiary care children’s hospital. Participants were children 6 to 15 years of age with distal radius and/or ulna buckle fractures who were randomly assigned to treatment with a short arm cast for 3 weeks or a removable splint. Cast removal was at 3 weeks. A validated self-reported outcome tool, the Activities Scales for Kids performance version (ASKp), was used to measure physical functioning over a 4-week period. The main outcome was the ASKp score at 14 days postinjury.

RESULTS:

We randomly assigned 113 patients, and 87 were included in the final analysis: 42 in the splint group and 45 in the cast group. Study groups were similar in age, gender, bone fractured, and dominant hand injured. There were significant differences in ASKp score at day 14 and change in ASKp from baseline at days 14 and 20, indicating better functioning in the splint group. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures.

CONCLUSIONS:

Children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast.

Are Serial Radiographs Needed in Torus Fractures in Children?

Pediatric Orthopedic Surgeon

www.ipodindia.org

The Guru Mantra

“The risks of delayed drainage far outweigh

the benefits of waiting and watching for a response to antibiotics.”

The Facts and figures

The knowledge of these general facts regarding pattern of involvement may be invaluable in diagnosis of the condition.

1.     Septic arthritis is more common than osteomyelitis in infancy and childhood.

2.     Most common joints-the hip and knee – 60 % cases

3.     Polyarticular in about 5 percent

4.     Age group 75 percent occur in children below 5 years

Pathophysiology

The organisms

It has been a traditional teaching that the most common organisms are gram-positive aerobes (80%) and approximately 20% of cases are caused by gram-negative anaerobes with Staphylococcus aureus the most common among the gram positive with less commonly implicated bacteria include  group A and group B streptococci, Streptococcus pneumoniae and Haemophilus influenza. Neonates are more susceptible to group B streptococcal infection.

Over recent years, the microbes isolated in bone and joint infections have changed. In the 1970s and 1980s. The introduction of the Haemophilus influenzae type B vaccine has resulted in a vast reduction in cases secondary to hemophilus, but a number of new organisms have appeared. Recent publications would suggest that perhaps only 40% of infections are the result of S. aureus. We have noticed a  recent upsurge of septic arthritis caused by methicillin-resistant strains of Staphylococcus aureus (MRSA). Although these infections were once thought to be predominantly hospital acquired, but of late, several cases of community-acquired MRSA also have been identified

Diagnosis

Need for an early diagnosis

The damage to the cartilage, growth plate and bone due to avasularity and enzymatic distruction sets in early.The cartilage destruction starts as early as 8 hours following the onset.The avascularity sets in within 24-48 hours of the temponade. The biggest challenge is therefore to control the  infection and drain the joint before the damage takes place

The challenges of diagnosis septic arthritis

-No single test can be relied upon

-Inflamatory markers may be normal or only slightly elevated early in the disease

-The xrays may be normal early in the disaease

-The imaging modalities such as xrays, ultrasound, bone scan  or MRI  suggest a process of inflammation and effusion but can not diagnose septic arthritis

-The laboratory investigations such as blood counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may help in suggesting that there is an infective process going on but cannot definitely confirm the diagnosis of septic arthritis.

-The only way the joint infection can be conclusively diagnosed is by demonstrating bacteria in

the fluid removed from the joint. However, an organism may only be cultured in approximately 60 percent of cases of true septic arthritis.

-Knee jerk antibiotics may blunt clinical preasentation

– Realizing the limitations of investigations in confirming the diagnosis of septic arthritis, it is imperative that treatment is commenced on the basis of a high index of suspicion. Definitive treatment

should not be withheld for want of confirmatory laboratory tests.

On the basis of a careful clinical examination, a tentative diagnosis of septic arthritis needs to be made. If joint aspiration does not yield fluid with bacteria demonstrable either in a Gram-stained smear or on culture, a presumptive diagnosis may be made with the help of the results of other laboratory tests in conjunction with clinical findings.

Kocher’s cliteria

Kocher et al  identified clinical and laboratory predictors of septic arthritis:

1.     history of fever

2.     inability to bear weight on the limb

3.     ESR _40 mm/hour

4.     White blood cell (WBC) count 12 000/mL.

The predicted probability of septic arthritis was 0.2 if none of these predictors was present. This means if none of the factors were present there was only 2 % chance of the condition being septic arthritis

The probability of a diagnosis of septic arthritis was 40, 93.1 and 99.6 percent if two, three or four of these predictors, respectively, were present.

Although Kocher noted these four risk factors and validated these risk factors in a subsequent report,  other centers have found that these four factors may not have as high a predictive value in determining a septic hip as was originally thought. In a recent paper from Melbourne it was noted that a significant number of patients had normal parameters and suggested that clinical acumen still plays a crucial role in management

Cliteria of Jung et al:

The following were identified as were identified as independent multivariate predictors of septic arthritis.

Temperature>37°C

ESR > 20 mm/hour

CRP> 1 mg/dL

WBC> 11 000/mL

An increased joint space>2 mm

Radiology

X-rays are findings are often normal.Look for soft tissue swelling around the joint, widening of the joint space, and displacement of tissue planes.

Ultrasound is very sensitive in detecting joint effusions generated by septic arthritis. It also  can be used to define the extent of septic arthritis and help guide treatment. Sometimes Ultrasound helps to differentiate septic arthritis from other conditions (eg, soft tissue abscesses, tenosynovitis) in which treatment may differ.

MRI Can show changes of marrow edema and help to differentiate between transient synovitis, inflammatory arthritis and septic arthritis by virtue of changes in marrow edema and synovial lining. It can also diagnose additional osteomyelitis. In a recent study markers of SA on MRI included  bone marrow oedema  and absence of T1-weighted and T2-weighted low signal intensity synovial tissue. Furthermore, soft-tissue oedema and reduced contrast enhancement in the epiphyses were more frequent in children with SA.

Differential diagnosis

Conditions that Mimic infection

• Transient synovitis: May be difficult to differentiate early on. The lab reports, presence of mixed echogenesity on US and severity of symptoms and signs point to infective process. When in doubt a joint aspiration should be performed
• Inflamatory arthritis: Fluid out of proportion to symptoms
• Other conditions to keep in mind
  • Malignancies:leukemia, Ewing’s sarcoma, Metastasis
  • Langerhans cell histiocytosis
  • Sickle cell disease and bone infarct
  • Storage disorders: Gaucher disease

Management

Antibiotic therapy

Aim

To control and eradicate the infective process

Which antibiotic

The antibiotic selected should be effective against the organism responsible for the infection. Since

Gram-positive organisms are most frequently responsible for the infection, an antibiotic that is

effective against these organisms should be started empirically. In hospital acquired infection a combination broad spectrum antibiotic is started to be effective against gram positive and gram negative organisms

How long?

In the past it was recommended that treatment with antibiotics should be continued for six weeks.

However, recent studies suggest that the duration of medication may be reduced to four weeks or

less without adverse outcome in the long term

To start with an IV route is preferred  Once the clinical signs improve and CRP levels touch baseline

the antibiotic may be given orally.

Monitoring the treatment

1Clinical parameters: Fever, heart rate, Pain, range of movements,Weight bearing status

2. Lab p[arameters: ESR, TC/DC, CRP Among this CRP is the best indicator of response to therapy.

3. USG to look for reduction in joint effusion

4. Xrays To look for lytic areas and joint position

Failure of CRP to fall by 1 week

1 Recollection

2. Missed multifocal septic arthritis

3. Systemic infection- pneumonitis, pleuritis, pyelonephritis, peritonitis

4. Wrong antibiotic, resistant organism

5. Associated osteomyelitis

Shortened antibiotic course

A recent paper from Melbourne suggests a shortened antibiotic regimen of 3 days Iv antibiotic with 3 week oral antibiotics in patients with childhood septic arthritis and osteomyelitis. After 3 full days of intravenous antibiotics the patients were assessed with regard to converting to oral therapy. An improvement in symptoms (pain, movement), normalization of temperature, and stabilizing CRP were defined as prerequisites for conversion. Persistent pain, fever, and rising inflammatory markers dictated that therapy should continue and that surgical exploration could be indicated. All patients were kept in hospital for 1 day after conversion to oral therapy to ensure tolerance. Oral antibiotics were continued for 3 weeks, usually at half the intravenous dose if tolerated. They found that a temperature of greater than 38.4 on admission and CRP greater than 100 were the best predictor of needing antibiotics for more than 3 days The addition of ESR, WCC, or both did not help in determining which patients will require prolonged therapy. They could successfully convert 59% of patients by day 3 and 86% by day 5 resulting in only 14% of patients requiring intravenous therapy for 6 days or more.

Surgical Intervention

Aim

1.     Joint decompression: To reduce temonade, relieve pain and spasm, and obtain sample for smear and culture

2.     Joint lavage: To washout the enzymes and debris harmful to joint cartilage

Methods

1.     Aspiration and lavage:  Minimally invasive. Repeated joint aspirations are not a good option for hip joint as it does not decompress joint adequately, prolongs antibiotic therapy and hospital stay

2.     Arthrotomy:  Allows joint inspection and complete joint clearance. Septic hips in young children are drained anteriorly to avoid disrupting the posterior blood supply to the femoral epiphysis. It is critical to do a definitive capsulotomy. Be sure that the joint is aggressively irrigated and that there is no purulent collection left behind. Some have recommended decompression of the femoral neck if there is associated osteomyelitis that has not decompressed itself into the joint

3.     Arthroscopy: All advantages of arthrotomy being minimally invasive

Immobilization of the joint

Aim

To relieve spasm, prevent deformity and instability

Methods

With brace, plaster or traction

Prognosis

Depends on the following factors

-Duration of disease

-Type of organism

-Age of child

-The joint involved

-Intervention

-Associated systemic disorders and immune status

Summary

We recommend high index of suspicion while diagnosing septic arthritis in children and an aggressive treatment approach. Initial investigations include blood cultures, and hematologic markers (WCC, CRP, and ESR) followed by appropriate imaging. Ultrasound should be used to confirm SA and MRI can be used in selected cases. Empirical antibiotics (Amoxycillin Clav combination with amikacin) should be commenced after prompt drainage of joint collections. Further choice of antibiotics will depend on culture report and clinical course. Short antibiotic treatment guided by improvement in clinical parameters and CRP is effective in most cases.

References

Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26:703–708

Buxton RA, Moran M. Septic arthritis of the hip in the infant and young child. Curr Orthop. 2003;17:458–464

Caird MS, Flynn JM, Millman JE, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A propective study. J Bone Joint Surg Am. 2006;88(6):1251-1257.

Jagodzinski, Kanwar, Graham K  Prospective Evaluation of a Shortened Regimen of Treatment for Acute Osteomyelitis and Septic Arthritis in Children Journal of Pediatric Orthopaedics Volume 29(5), July/August 2009, pp 518-525

Jung ST, Rowe SM, Moon ES, et al. Significance of laboratory and radiologic findings for differentiating between septic arthritis and transient synovitis of the hip. J Pediatr Orthop. 2003;23(3):368-372.

Kirkhus E, Flatø B, Riise O, Reiseter T, Smith HJ. Differences in MRI findings between subgroups of recent-onset childhood arthritis.Pediatr Radiol. 2010 Dec 7. [Epub ahead of print]

Kocher MS, Mandiga R, Murphy JM, et al. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am. 2003;85A(6):994-999.

Kocher MS, Mandiga R, Murphy JM, et al. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcomes of septic arthritis of the hip. J Bone Joint Surg Am. 2003;85:994–999

Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86A(8):1629-1635.

Luhmann SJ, Jones A, Shootman M, et al. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg. 2004;86A:956-962.

Lyon RM, Evanich JD. Culture-negative septic arthritis in children. J Pediatr Orthop. 1999;19:655–659

Moumile K, Merckx J, Glorian C, et al. Bacterial aetiology of acute osteoarticular infections in children. Acta Paediatr Int J Paediatr. 2005;94:419–422.

Vinod MB, Matussek NC, Graham HK, et al. Duration of antibiotics in children with osteomyelitis and septic arthritis. J Paediatr Child Health. 2002;38:363–367

Click here to see the presentation

What is Pulled Elbow?

Pulled Elbow or “Nursemaids Elbow” is common in young children between 1 and 4 years of age.It is rare beyond the age of 6 years. It is due to the annular ligament of the radial head becoming stretched and entrapped. There is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent.Sometimes the incident is unobserved or thought to be too trivial to have caused any injury. The child typically allows the arm to hang loosely by their side in a pronated position. They are usually undistressed unless the arm is moved.

Clinical Features

• The parents come with complaint of the child not using the affected limb
• here is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent. Although there may not be history of pull in half the cases
• Inspection: The child keeps the elbow in extension and the forearm in pronation and is distressed only on elbow movement. Usually there is no swelling, deformity or bruising of the elbow or wrist
• Palpation:  tenderness is usually absent
• Movements: marked resistance and pain with supination of the forearm.

Diagnosis

• Clinically established with a classic history and examination.
• X rays are unnecessary if there is a typical history and no visible swelling or deformity. If the child has a pulled elbow the X ray is normal. The child may have normal use of the arm on return from radiology since positioning by the radiographer may solve the problem.
• Plain radiographs are indicated when a differential diagnosis is suspected:
  • significant tenderness, swelling, bruising or deformity
  • reduction fails

Treatment

The treatment consists of reducing the ligament back to its original position

1. Have your child sit in a chair facing you or stand facing you. Ask an older sibling or adult to distract the child as that there is slight temporary pain when you treat a pulled elbow, and it will be easier to slip the ligament back into place if the child is relaxed.
2. You should support the elbow with one of your hands, placing your thumb over the radial head with some gentle pressure. Hold
   the child’s hand in your other hand as if you are shaking hands.
3. Fully supinate the forearm and then fully flex the elbow. A click is usually felt over the radial head either when the elbow is fully supinated or fully flexed. This is known as supination/flexion manoeuvre. Alternatively one can also try full pronation followed by flexion (pronation flexion manoeuvre).
   

   

   

   

4. A click is felt as the ligament moves back into the correct position. You may not always hear this happen.
5. Offer the child a toy to see if he or she will once again use his or her arm.  A good test for successful reduction is whether the child will actively reach for a toy at arms reach. Most children will use the arm normally within 5 minutes of the reduction. There may be residual pain, but overall, the child should feel much better.
6. Failure may be due to not putting the elbow through the complete range of motion. Repeat the reduction if the ligament is still out of place. This process should cure and treat your child’s pulled elbow in a few seconds, and they should be ready to play once again.
7. If the reduction has been delayed for 12 hours or longer the child may not use the arm normally for a longer period of time.  A sling ± backslab can be used for comfort, with review of whether the child will use the arm 24 hours late

Recurrant Pulled Elbow

Recurrances with pulled elbow are common till 3-4 years age. The repeat injuries are treated in the similar manner. Repeated subluxations do not produce long term problems. The problem generally disappears by 5 year age. Very rarely, in child with multiple recurrances the doctor may advice cast for 3 weeks

Updates in the management of pulled elbow

Obscure pathology of pulled elbow: dynamic high-resolution
ultrasound-assisted classificationHossam S. Diab • Manal M. S. Hamed •Yasser Allam

J Child Orthop (2010) 4:539–543

Of the 50 included children, 39 (78%) had intact,yet interposed annular ligament (classified as type I) and 11
(22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50
children had recurrent subluxation and constituted falsenegative cases for the detection of torn ligament and represented
the reoccurrence rate of 6%.

Sobel E, Caselli MA, Velez Z.

New York College of Podiatric Medicine, New York, USA.
Abstract

Sixty idiopathic toe walkers (age range 1 to 15 years) were evaluated to determine the natural history of toe-to-toe gait and the relationship between the range of ankle dorsiflexion and increasing age. The majority of toe walkers had a normal birth weight (average 7.06 pounds), walked on time (average 11.14 months), began toe walking immediately (87%), stood plantigrade (90%), were able to demonstrate a heel-toe gait (88%), and toe walked intermittently (68%). Forty-six percent of all toe walkers were found to have 0 degree or less of passive ankle dorsiflexion. Equinus toe walkers (mean dorsiflexion -5.2 degrees) had significantly less dorsiflexion than the remaining toe walkers (mean dorsiflexion 16.9 degrees; p < 0.01). An average of 12 degrees of dorsiflexion was resent in the 1-to 2-year age group, which gradually diminished to -4 degrees in the 6- to 15-year age group. It appears that there may be a relationship between persistent toe walking and the development of ankle equinus in some children and therefore interventions should be considered to inhibit the toe walking progression.

The article concludes that toe walkers where there is equinus deformity need treatment to improve dorsiflexion

2. What are the results of conservative treatment and serial casting?

Acta Paediatr. 2004 Feb;93(2):196-9.
The natural history of idiopathic toe-walking: a long-term follow-up of fourteen conservatively treated children.
Hirsch G, Wagner B.

Department of Paediatric Orthopaedics, Astrid Lindgren’s Children’s Hospital, Karolinska sjukhuset, Stockholm, Sweden. georg.hirsch@ks.se
Abstract

AIM: To determine the long-term results after conservative treatment (physiotherapy, casting, orthoses, or a combination of these) of idiopathic toe-walking (ITW). METHODS: Tiptoe-walking is diagnosed as idiopathic (habitual) if no signs of neurological, orthopaedic, or psychiatric disease are detected. The diagnosis is one of exclusion. Sixteen former patients with ITW, all now at least 13 y old, were asked to participate in a follow-up investigation 7-21 y after being first diagnosed. Two cases were excluded because heel-cord lengthening had been performed later on in other hospitals. The remaining 14 patients completed a questionnaire. Eleven patients consented to a clinical examination, during which they were videotaped and their active and passive ankle-joint dorsiflexion measured. These data were compared with the assessment at the initial evaluation. In one instance, the toe-walking ceased after conservative treatment (plaster cast). In all other cases the toe-walking pattern recurred. RESULTS: At follow-up three patients showed some toe-walking when they were unobtrusively observed. When videotaped, they did not toe-walk, although a distinct heel-strike was missing. The remaining eight patients all walked with a heel-strike. Two patients had slight symptoms possibly related to toe-walking. No fixed contracture was present at the first evaluation, and none was found at follow-up. There was no systematic change in ankle-joint dorsiflexion from initial assessment to follow-up examination. CONCLUSION: Non-surgical treatment of ITW does not have a lasting effect and the long-term results in this study are considered to reflect the natural history, i.e. the toe-walking pattern eventually resolves spontaneously in the majority of children. Surgical treatment of ITW should be reserved for the few cases with a fixed ankle-joint contracture.

The article concludes that toe walkers where there is equinus deformity need treatment to improve dorsiflexion

Acta Orthop Belg.  2006 Dec;72(6):722-30.
Serial casting in the treatment of idiopathic toe-walkers and review of the literature.

Fox A, Deakin S, Pettigrew G, Paton R.

Blackburn Royal Infirmary, Blackburn, United Kingdom. annafox2k@btopenworld.com
Abstract

Idiopathic toe-walking is defined as persistent toe-walking in a normal child in the absence of developmental, neurological or neuromuscular conditions. True idiopathic toe-walking is a rare referral, representing approximately 1:100 new patients seen in the Paediatric Orthopaedic Clinic. A prospective study of idiopathic toe-walking (ITW) was organised between 1999 and 2003. Patients underwent full history, neurological examination and assessment of ankle dorsiflexion, followed by below-knee weight-bearing casting. Forty four developmentally normal children with no delay in walking age were in this study. There was an age range on presentation from 2 years to 14 years 4 months, with median 60.5 months. Sixty eight percent were male. Thirty four percent had a family history of the condition. Following casting, 66% of patients had improved gait on patient and clinician determined outcomes, with the majority of children ceasing to toe-walk. Ankle dorsiflexion significantly improved in those children who were successfully treated (p = 0.001).

The article conclused that in one third of patients the serial casting did not work these are likely to be patients with ankle equinus

3. What is the outcome of surgery for ITW

J Pediatr Orthop.  2006 May-Jun;26(3):336-40.
Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking.

Hemo Y, Macdessi SJ, Pierce RA, Aiona MD, Sussman MD.

Dana Children’s Hospital, Tel Aviv Medical Center, Tel Aviv, Israel.
Abstract

Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantarflexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from -8 to 12 degrees and maximum swing phase dorsiflexion improving from -20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery.

The article conclused that surgery in selected cases who do not improve with conservative treatment improves ankle dorsiflexion and way the child walks inclusing the energy efficiency. There may be calf weakness post operatively which corrects in one year time

J Pediatr Orthop.  2001 Nov-Dec;21(6):790-1.
Simplified approach to idiopathic toe-walking.

Kogan M, Smith J.

Primary Children’s Medical Center, Salt Lake City, Utah, USA.
Abstract

Controversy exists as to the treatment of idiopathic toe-walking (ITW). Since 1993, the authors have managed children with ITW using an outpatient percutaneous lengthening of the Achilles tendon, followed by placement of below-knee walking casts for 4 weeks. The authors reviewed 15 children who were treated for ITW with percutaneous Achilles tendon lengthening between 1993 and 1999. Ten of the 15 patients could be contacted for a follow-up survey. None of the parents stated that their child’s toe-walking had recurred. There were no painful scars. All of the children were able to keep up with other children and did not notice any calf weakness. Two children had occasional Achilles tendinitis, which was relieved with antiinflammatory medications. All parents were satisfied with their child’s outcome. The authors believe that percutaneous tendo-Achilles lengthening in ITW greatly simplifies the management of ITW.

Dr Taral V Nagda

Institute of Paediatric Orthopaedic Disorders
 www.ipodindia.org
taralnagda@gmail.com

E plate hemiepiphysiodesis is a modern method to correct the deformities of long bones in a growing child. It works on the principle that controlling the growth on one side of growth plate results in angulation on the opposite side.

In presence of deformity the growth modulation on the convex side/ apical side can result in slow controlled correction of the deformity. The advantages of such a procedure will be

• No need of immobilisation or plaster as the bone is not cut
• Earlier mobilisation and return to activities
• Slow and safe correction
• The growth resumes normally after plate removal hence can be done even at younger age
• Timing of surgery not important as long as atleast 1 year available for corection before the growth stops.
  

Indications

• Correcting angular deformity in a growing child with open physis

Prerequisites

 
• 1 year of growth remaining
• One plane deformity frontal sagital oblique
• Growth potential on opposite side
  

Contraindications

• Closed Physis
• Skeletal Maturity
• Physio logical Deformities

Case Study

8 yr old girl with renal osteodystrophy with genu valgum shows excellent correction in 1 year

Equipments needed

• C ARM
• Radiolucent table
• 1mm and 1.5 mm guide wires
• E plate
• 4.5mm self tapping cannulated screws (15-30mm)
• Stop Drill

Surgical steps

Step 1 : LOCALIZATION OF PHYSIS

• Under image intensifier 1.5 mm guide wire is passed at the center of physis
• Confirmed in both AP & Lat views

Step 2: SKIN INCISION

• About 1.5 cm centered over guide wire
• The incision is deepened till perichomdrium
• E plate is positioned with its central hole sliding over the guide wire over the perichondrium
• The plate should be along the midline of the bone axis on lateral view

Step 3 GUIDE WIRES

• 2 guide wires are passed  through the holes on either sides of the physis
• They  need not be parallel but  care should be taken is not to violate the physis

Step 4 SELF TAPPING CANNULATED SCREWS

• Screw length is measured
• Should not be too short
• Generally 15-30 mm screws are sufficient
• Cortex is drilled
• Self tapping screws are passed

Step 5 Closure and Dressing

The closure is done in layers and compression dressing is applied.

No cast or immobilization is needed

Full weight bearing supported walking and knee mobilization are started the next day

Post op Protocol

• Day care surgery
• No immobilisation
• Immediate mobilisation
• Xrays once in 3 months
• Implant removal once the deformity is corrected

Advantages of E plate over staples

• Flexi bility
• Unconstrained implant
• Load sharing
• One plate per physis
• Fully threaded cannulated screws resist pull-out forces
• Diverging screws function like a hinge to gently guide natural growth
• Easy to remove