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	<title>Institute of Paediatric Orthopaedic Disorders (IPOD) &#187; Paediatrician&#8217;s Section</title>
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		<title>Pulled Elbow in Children</title>
		<link>http://ipodindia.org/2009/10/pulled-elbow/</link>
		<comments>http://ipodindia.org/2009/10/pulled-elbow/#comments</comments>
		<pubDate>Wed, 07 Oct 2009 02:03:14 +0000</pubDate>
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				<category><![CDATA[IPOD Focus]]></category>
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		<category><![CDATA[Paediatrician's Section]]></category>
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		<description><![CDATA[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.The treatment is by reduction in flexion and supination]]></description>
			<content:encoded><![CDATA[<h2>What is Pulled Elbow?</h2>
<p><!-- <ecm_dcontent> &#8211;>  					 					  								<!-- <ecm_dcontent> &#8211;>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, su</p>
<p>ch 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.</p>
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/pulled_elbow001.jpg"><img class="size-medium wp-image-285 alignnone" title="pulled_elbow001" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/pulled_elbow001-300x200.jpg" alt="pulled_elbow001" width="243" height="204" /></a></h2>
<h2>Clinical Features</h2>
<ul>
<li>The parents come with complaint of the child not using the affected limb</li>
<li>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</li>
<li>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</li>
<li>Palpation:  tenderness is usually absent</li>
<li>Movements: marked resistance and pain with supination of the forearm.</li>
</ul>
<h3>Diagnosis</h3>
<ul>
<li>Clinically established with a classic history and examination.</li>
<li>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.</li>
<li>Plain radiographs are indicated when a differential diagnosis is suspected:
<ul>
<li>significant tenderness, swelling, bruising or deformity</li>
<li>reduction fails</li>
</ul>
</li>
</ul>
<h2>Treatment</h2>
<p>The treatment consists of reducing the ligament back to its original position</p>
<ol id="intelliTxt">
<li>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.<a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/grasping_elbow_closed1.jpg"><img class="alignnone size-full wp-image-291" title="grasping_elbow_closed" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/grasping_elbow_closed1.jpg" alt="grasping_elbow_closed" width="181" height="146" /></a></li>
<li>You should support the elbow with one of your hands, placing your thumb over the radial head with some gentle pressure. Hold<br />
the child’s hand in your other hand as if you are shaking hands.</li>
<li>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).<br />
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/supination_only.jpg"><img class="size-full wp-image-286 alignnone" title="supination_only" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/supination_only.jpg" alt="supination_only" width="170" height="136" /></a></h2>
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/part_flexion1.jpg"><img class="alignnone size-full wp-image-289" title="part_flexion" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/part_flexion1.jpg" alt="part_flexion" width="169" height="135" /></a></h2>
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/full_flexion.jpg"><img title="full_flexion" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/full_flexion.jpg" alt="full_flexion" width="172" height="137" /></a></h2>
</li>
<li>A click is felt as the ligament moves back into the correct position. You may not always hear this happen.</li>
<li>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.</li>
<li>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.</li>
<li>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</li>
</ol>
<h2>Recurrant Pulled Elbow</h2>
<p>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</p>
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		<title>FAQs on Ponseti treatment for clubfoot</title>
		<link>http://ipodindia.org/2009/08/faqs-on-ponseti-treatment-for-clubfoot/</link>
		<comments>http://ipodindia.org/2009/08/faqs-on-ponseti-treatment-for-clubfoot/#comments</comments>
		<pubDate>Mon, 31 Aug 2009 01:37:47 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Club foot]]></category>
		<category><![CDATA[Featured]]></category>
		<category><![CDATA[Orthopaedician's Section]]></category>
		<category><![CDATA[Paediatrician's Section]]></category>
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		<category><![CDATA[Post graduate Corner]]></category>

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		<description><![CDATA[what is new in the treatment of clubfoot Answered in frequently asked questions mode with answers from recent literature]]></description>
			<content:encoded><![CDATA[<h2><em>Answered by the evidence from the literature</em></h2>
<p><strong>-Taral Nagda</strong></p>
<p><strong>-Rajeev Niravane</strong></p>
<p>Institute of Paediatric Orthopaedic Disorders</p>
<p><a href="http://www.ipodindia.org/">www.ipodindia.org</a></p>
<p>taralnagda@gmail.com</p>
<h3>Who should do Ponseti treatment?</h3>
<p>v      <strong>J Bone Joint Surg Am. 2009 May;91(5):1101-8.<br />
Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot.<br />
Janicki JA, Narayanan UG, Harvey BJ, Roy A, Weir S, Wright JG.</strong></p>
<ul>
<li>The introduction of the physiotherapist-supervised clubfoot clinic has been effective without compromising the quality of care of children with clubfoot deformity.</li>
</ul>
<p>v      <strong>Ann R Coll Surg Engl. 2007 Jul;89(5):510-2.Ponseti treatment in the management of clubfoot deformity &#8211; a continuing role for paediatric orthopaedic services in secondary care centres.Docker CE, Lewthwaite S, Kiely NT.</strong></p>
<ul>
<li>Similar results between tertiary Ped ortho dept and physiotherpy dept</li>
</ul>
<p>v      <strong>J Bone Joint Surg Br. 2006 Aug;88(8):1085-9.<br />
Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity.<br />
Shack N, Eastwood DM.</strong></p>
<ul>
<li>Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme</li>
</ul>
<h3>Can neglected CTEV be treated with Ponseti method?</h3>
<p>v      <strong>J Pediatr Orthop B. 2009 Mar;18(2):76-8.Results of treatment of idiopathic clubfoot in older infants using the Ponseti method: a preliminary report.</strong></p>
<p><strong>Hegazy M, Nasef NM, Abdel-Ghani H.</strong></p>
<p>The use of thePonseti method in older-aged infants with idiopathic congenital clubfoot seems to</p>
<p>be an effective method of treatment, obviating the need for extensive surgery.</p>
<p>v      <strong>J Bone Joint Surg Br. 2007 Mar;89(3):378-81.<br />
Correction of neglected idiopathic club foot by the Ponseti method.<br />
LourenÃ§o AF, Morcuende JA. Brazil</strong><strong></strong></p>
<p>Only 5/24 needed surgery</p>
<ul>
<li>Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.</li>
</ul>
<p>v      <strong>Clin Orthop Relat Res. 2006 Mar;444:224-8.<br />
Ponseti management of clubfoot in older infants.<br />
</strong><strong>Bor N, Herzenberg JE, Frick SL. Israel</strong></p>
<p>older infants with clubfoot can be treated successfullywithout extensive surgery. Our results in older infants are similar to theresults of a previous study we conducted with younger infants</p>
<p>3 % rate of surgery in children less than 3 years</p>
<p>v      <strong>Arch Orthop Trauma Surg. 2006 Jan;126(1):15-21. Epub 2005 Nov 10.<br />
Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complexdeformities.<br />
GÃ¶ksan SB Turkey</strong></p>
<ul>
<li>Our results show that the Ponseti technique is reproducible and effective in children at least up to 12months of age</li>
<li>Only 3 % need extensive PMR</li>
</ul>
<h3>Ponseti method in post PMR cases??</h3>
<p>v      <strong>Clin Orthop Relat Res. 2009 May;467(5):1298-305. Epub 2009 Feb 4.<br />
Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study.<br />
Nogueira MP, Ey Batlle AM, Alves CG.</strong></p>
<ul>
<li>initial and final Pirani scores and range of motion of the ankle and subtalar joint. Plantigrade and fully corrected feet were obtained in 71 feet (86%); 11 feet obtained partial correction; one patient failed treatment and underwent another posteromedial release. Recurrences occurred in ninepatients (12 feet or 14%)</li>
</ul>
<h3>Does FAB give rise to femur/ knee/ tibial tortional deformities ?</h3>
<p>v      <strong>J Pediatr Orthop. 2007 Sep;27(6):712-6.<br />
Foot abduction brace in the Ponseti method for idiopathic clubfoot deformity: torsional deformities and compliance.<br />
Boehm S, Sinclair M.</strong></p>
<ul>
<li>Application of the foot abduction brace did not result in pathological changes of femoral anteversion or tibial torsion</li>
</ul>
<h3>Can Ponseti method avoid surgery?</h3>
<p>v      <strong>Clin Orthop Relat Res. 2009 Apr 7.<br />
Comparison of Ponseti versus Surgical Treatment for Idiopathic Clubfoot: A Short-term Preliminary Report.<br />
Zwick EB, Kraus T, Maizen C, Steinwender G, Linhart WE.</strong></p>
<ul>
<li>a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol</li>
</ul>
<p>v      <strong>Clin Orthop Relat Res. 2009 May;467(5):1271-7. Epub 2009 Jan 14.<br />
Ponseti method: does age at the beginning of treatment make a difference?<br />
</strong><strong>Alves C, Escalda C, Fernandes P, Tavares D, Neves MC.</strong></p>
<ul>
<li>according to their age at the  beginning of treatment; Group I was younger than 6 months and Group II was &gt; 6 months.</li>
<li>The rate of the Ponseti method in avoiding extensive surgery was 100% in Groups I and II;</li>
<li>relapses occurred in 8% of the feet in older children</li>
</ul>
<p>v      <strong>J Pediatr Orthop B. 2007 Sep;16(5):317-21.<br />
</strong><strong>Comparative results of the conservative treatment in clubfoot by two different protocols.<br />
</strong><strong>Cosma D, Vasilescu D, Vasilescu D, Valeanu M.</strong></p>
<ul>
<li>The Ponseti method decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.  5 % need surgery</li>
</ul>
<p>v      <strong>Z Orthop Ihre Grenzgeb. 2006 Sep-Oct;144(5):497-501.<br />
Treatment of congenital clubfoot with the Ponseti method<br />
Eberhardt O, Schelling K, Parsch K, Wirth T.</strong></p>
<ul>
<li>With the Ponseti methodthe need for extensive corrective surgery is greatly reduced. (2/41)</li>
</ul>
<p>v      <strong>Pediatrics. 2004 Feb;113(2):376-80.<br />
Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.<br />
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV</strong></p>
<ul>
<li>11 % relapse</li>
<li>3 % extensive surgery rate</li>
</ul>
<h3>What are the factors affecting relapse?</h3>
<p>v      <strong>J Child Orthop. 2009 Jun 3.<br />
Improved bracing compliance in children with clubfeet using a dynamic orthosis.<br />
Garg S, Porter K.</strong></p>
<ul>
<li>Non-compliance with foot abduction bracing in children with clubfeet treated with the Ponseti method is the leading risk factor for deformity recurrence.</li>
<li>A dynamic foot abduction orthosis is believed to result in improved compliance, fewer skin complications, and fewer recurrences</li>
</ul>
<p>v      <strong>J Bone Joint Surg Am. 2007 Mar;89(3):487-93.<br />
Early clubfoot recurrence after use of the Ponseti method in a New Zealand population.<br />
Haft GF, Walker CG, Crawford HA.</strong></p>
<ul>
<li>Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformitytreated with the Ponseti method.</li>
<li> When the parents comply with the bracingprotocol, the Ponseti method is very effective at maintaining a correction,although minor recurrences are still common.</li>
<li>When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected</li>
</ul>
<p>v      <strong>Iowa Orthop J. 2007;27:82<br />
</strong><strong>Neuromuscular disease as the cause of late clubfoot relapses: report of 4 cases.<br />
Lovell ME, Morcuende JA.</strong></p>
<ul>
<li>Late relapses in patients with idiopathic clubfoot may represent the onset of a previously undiagnosed neuromuscular disease, and should be thoroughly evaluated.</li>
</ul>
<p>v      <strong>J Pediatr Orthop. 2005 Mar-Apr;25(2):225-8.Use of the foot abduction orthosis following Ponseti casts: is it essential?<br />
</strong><strong>Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB</strong></p>
<ul>
<li>The feet of patients compliant with FAOuse remained better corrected than the feet of those patients who were not compliant</li>
</ul>
<p>v      <strong>J Bone Joint Surg Am. 2004 Jan;86-A(1):22-7.<br />
Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet.<br />
Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA.</strong></p>
<ul>
<li>Noncompliance and the educational level of the parents(high-school education or less) are significant risk factors for the recurrenceof clubfoot deformity after correction with the Ponseti method. The identification of patients who are at risk for recurrence may allow intervention to improve the compliance of the parents with regard to the use of orthotics,and, as a result, improve outcome</li>
</ul>
<h3>How does one treat a replapse?</h3>
<p>v      <strong>Instr Course Lect. 2006;55:625-9.<br />
Treatment of a recurrent clubfoot deformity after initial correction with the Ponseti technique.<br />
Dietz FR.Department of Orthopaedics, University of Iowa, Iowa City, Iowa, USA.</strong></p>
<ul>
<li>The indication for anterior tibial tendon transfer is the presence of dynamic supination during gait. After tendon transfer, bracing is no longer required because the eversion force of the transferred tendon maintainsthe correction</li>
</ul>
<h3>Is Ponseti method applicable to clubfoot with MMC?</h3>
<p>v      <strong>J Bone Joint Surg Am. 2009 Jun;91(6):1350-9.<br />
Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele.<br />
Gerlach DJ, Gurnett CA, Limpaphayom N, Alaee F, Zhang Z, Porter K, Kirchhofer M,<br />
Smyth MD, Dobbs MB.</strong></p>
<ul>
<li>Initial correction was achieved in twenty-seven clubfeet (96.4)</li>
<li>Relapse of deformity was detected in 68% of the feet in the myelomeningocele group, compared with 26% of the feet in the idiopathic group (p = 0.001).</li>
<li>Relapses were treated successfully without the need for extensive soft-tissue</li>
</ul>
<p>v      <strong>Journal of Pediatric Orthopaedics. 29(4):393-397, June 2009.<br />
Treatment of Neuromuscular and Syndrome-Associated (Nonidiopathic) Clubfeet Using the Ponseti Method<br />
Joseph A. Janicki, MD,* Unni G. Narayanan, MBBS, MSc, FRCSC,Þ Barbara Harvey, BHScPT,</strong></p>
<ul>
<li>Ponseti method is worth applying to nonidiopathic clubfeet in an attempt to avoid surgical release.</li>
<li>Nonidiopathic clubfeet required significantly more casts (6.4 vs 4.8) to achieve initial correction and had a higher recurrence rate (44% vs 13%).</li>
</ul>
<h3>Is it necessary to change protocol in complex clubfoot ?</h3>
<p><strong>Clin Orthop Relat Res. 2006 Oct;451:171-6.<br />
Treatment of the complex idiopathic clubfoot<br />
Ponseti IV</strong></p>
<ul>
<li>Modifying      the treatment protocol for complex clubfeetsuccessfully corrected the      deformity without the need for extensive correctivesurgery</li>
</ul>
]]></content:encoded>
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		<title>Trigger thumb/ trigger fingers in children</title>
		<link>http://ipodindia.org/2009/08/trigger-thumb-trigger-fingers-in-children/</link>
		<comments>http://ipodindia.org/2009/08/trigger-thumb-trigger-fingers-in-children/#comments</comments>
		<pubDate>Thu, 27 Aug 2009 13:27:51 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Featured]]></category>
		<category><![CDATA[Orthopaedician's Section]]></category>
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		<category><![CDATA[Post graduate Corner]]></category>

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		<description><![CDATA[Trigger thumb and fingers are common hand conditions in children. The present article provides current thought process and management guidelines for clinicians  ]]></description>
			<content:encoded><![CDATA[<h2><span style="color: #999999;"><strong>What is congenital trigger Thumb/Finger?</strong></span></h2>
<p>Trigger thumb represents an abnormality of the flexor pollicis longus and its tendon sheath at the Al pulley. There is a palpable mass (Notta nodule), representing the flexor pollicis longus constriction at the Al pulley.</p>
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/DSC09015.JPG"><img class="alignnone size-medium wp-image-245" title="Nodule " src="http://ipodindia.org/wp-content/themes/tma/images/uploads/DSC09015-300x224.jpg" alt="Nodule " width="248" height="186" /></a><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/trigger-thumb-clinical.wmv"></a></h2>
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/DSC09016.JPG"><img class="alignnone size-full wp-image-246" title="Clinical presentation" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/DSC09016.JPG" alt="Clinical presentation" width="251" height="244" /></a></h2>
<p><strong> </strong></p>
<h2><span style="color: #999999;"><strong>Is it always congenital?</strong></span></h2>
<p>In the past,trigger thumbs were defined as congenital. However, this</p>
<p>condition is acquired in the first</p>
<p>2 years of life, as indicated</p>
<p>by prospective screening of neonates who failed to yield any</p>
<p>trigger thumbs.</p>
<h2><span style="color: #999999;"><strong>What causes CTT/CTF?</strong></span></h2>
<p>The cause appears to be a size mismatch between the flexor pollicis longus and the Al pulley that leads to progressive constriction. Unlike adult trigger digits, there does not appear to be an inflammatory component.</p>
<h2><span style="color: #999999;"><strong>Can it be hereditary or associated with syndromes?</strong></span></h2>
<p>There is no familialinheritance pattern.30% of the cases are bilateral. Isolated trigger thumbs have no associated syndromes. However,trigger digits are seen with neurologic syndromes (trisomy18) and mucopol</p>
<p>ysaccharidoses.</p>
<h2><span style="color: #999999;"><strong>When and how does a child with TT/TF present?</strong></span></h2>
<p>Trigger thumb patients present at ages ranging from infancy to school age. Often, the diagnosis is missed until local trauma brings attention to the thumb. In the emergency setting the flexed interphalangeal joint can be mistaken for an interphalangeal joint dislocation.Radiographs are misleading because of limited phalangeal ossification. A palpable nodule at the Al pulley is diagnostic.If the trigger is long-standing, compensatory hyperextension</p>
<p>of the MCP joint develops to effectively bring the thumb out of the palm. In addition, there may develop mild radial deviation of the interphalangeal joint secondary to eccentric flexor pull.</p>
<h2><span style="color: #999999;"><strong>How is C</strong></span><span style="color: #999999;"><strong>TT/CTF treated?</strong></span></h2>
<p>In infants younger than 9 months of age, Dinham and Meggit found that 30% of trigger thumbs may resolve spontaneously. In infants older than 1 year of age, less than 10% of trigger thumbs resolved spontaneously. Ger et al.found lack of resolution with observation for 3 years in their patients. There is limited evidence that splinting will be of benefit, and often it is not well tolerated. Surgical release of the constricting Al pulley and flexor tendon sheath is the treatment of choice.</p>
<h2><span style="color: #999999;"><strong>What are the indications for surgery</strong></span></h2>
<p>This is indicated in infants without spontaneous resolution by 1 year of age, and in any toddler or older child presenting with a locked trigger thumb.</p>
<h2><span style="color: #999999;"><strong>What are the steps of the surgery?</strong></span></h2>
<ol>
<li>Anaesthesia general with local block</li>
<li>Incision: Transversely in the digital crease to lessen scarring.</li>
<li>Deeper dissection: Perpendicular to incision. Care must be taken to avoid iatrogenic injury to the superficial digital neurovascular bundles. A1 pulley is releasd.</li>
<li>It is usually not necessary to excise a portion of this pulley nor to shave the nodule, which will disappear after the release.The oblique pulley needs to be preserved to prevent<br />
<h2><a href="http://ipodindia.org/wp-content/themes/tma/images/uploads/intraop.JPG"><img class="size-full wp-image-248 alignright" title="intraop" src="http://ipodindia.org/wp-content/themes/tma/images/uploads/intraop.JPG" alt="intraop" width="235" height="235" /></a></h2>
<p>flexor tendon bowstringing.</li>
<li>The thumb is extended fully to be certain that the release is complete.</li>
<li>On ly the skin is closed</li>
<li>The thumb is placed in a light (child-proof) dressing for 1 week and then removed to allow return to the usual activities. No further treatment is required. The chance of recurrance are very few</li>
</ol>
<h2><span style="color: #999999;"><strong>How is trigger finger different from rigger thumb?</strong></span></h2>
<ol>
<li>Trigger digits are more often multiple, and can be associated with central nervous system disorders and syndromes (trisomy 18, mucopolysaccharidoses).</li>
<li>The pathology appears to predominate at the decussation of the flexor tendons under the A2 pulley, and not at the Al pulley alone.</li>
<li>Th e tri ggering appears to occur as the flexor digitorum profundus passes through the chiasm of the flexor digitorum superficialis.</li>
<li>Surgic al recurrence is high in pediatric trigger digits. This may be because Al pulley release alone is not sufficient to solve the problem. Further opening of the chiasm or resection of a slip of the flexor digitorum superficialis is often necessary to prevent recurrence</li>
</ol>
<h2><span style="color: #999999;"><strong>Related Articles</strong></span></h2>
<h3><span style="color: #999999;"><strong>The Natural History of Pediatric Trigger Thumb</strong></span></h3>
<p><strong>Goo Hyun Baek, MD, Ji Hyeung Kim, MD, Moon Sang Chung, MD, Seung Baik Kang, MD, Young Ho Lee, MD and Hyun Sik Gong, MD </strong></p>
<p>Department of Orthopedic Surgery, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea. E-mail address for G.H. Baek: <a href="mailto:ghbaek@snu.ac.kr">ghbaek@snu.ac.kr</a></p>
<p>Investigation performed at the Department of Orthopedic Surgery,<sup> </sup>Seoul National University College of Medicine, Seoul, South<sup> </sup>Korea<sup> </sup></p>
<p><strong>Background:</strong> <strong>Pediatric</strong> <strong>trigger</strong> <strong>thumb</strong> is a condition of flexion<sup> </sup>deformity of the interphalangeal joint in children. Although<sup> </sup>the surgical outcome is satisfactory, the indications for nonoperative<sup> </sup>treatment for this condition are not clear. The aim of the present<sup> </sup>study was to determine the rate of resolution of untreated <strong>pediatric</strong><sup> </sup><strong>trigger</strong> <strong>thumb</strong>.<sup> </sup></p>
<p><strong>Methods:</strong> Data on seventy-one <strong>thumb</strong>s in fifty-three children<sup> </sup>were collected prospectively. The dates of the first visits<sup> </sup>ranged from April 1994 to March 2004. Patients were diagnosed<sup> </sup>with <strong>pediatric</strong> <strong>trigger</strong> <strong>thumb</strong> during initial outpatient department<sup> </sup>visits. During the present study, no treatment such as passive<sup> </sup>stretching or splinting was applied. The amount of flexion deformity<sup> </sup>at the <strong>thumb</strong> interphalangeal joint was measured at every six-month<sup> </sup>follow-up visit, and the duration of follow-up was at least<sup> </sup>two years after diagnosis. The end point of follow-up was when<sup> </sup>the deformity caused pain or secondary deformity or prevented<sup> </sup>normal use of the hand. The median duration of follow-up was<sup> </sup>forty-eight months.<sup> </sup></p>
<p><strong>Results:</strong> Of the seventy-one <strong>trigger</strong> <strong>thumb</strong>s, forty-five (63%)<sup> </sup>resolved spontaneously. The median time from the initial visit<sup> </sup>to resolution was forty-eight months. There was no significant<sup> </sup>difference in the pattern of resolution between patients with<sup> </sup>unilateral and bilateral <strong>trigger</strong> <strong>thumb</strong>. Although resolution<sup> </sup>was not observed in the remaining twenty-six <strong>thumb</strong>s, flexion<sup> </sup>deformities improved in twenty-two <strong>thumb</strong>s. For the first two<sup> </sup>years after the initial visit, the mean flexion deformity significantly<sup> </sup>decreased over the one-year intervals (p &lt; 0.05).<sup> </sup></p>
<p><strong>Conclusions:</strong> <strong>Pediatric</strong> <strong>trigger</strong> <strong>thumb</strong> can be expected to resolve<sup> </sup>without treatment in &gt;60% of patients. Moreover, the flexion<sup> </sup>deformity can be expected to show an improving pattern in patients<sup> </sup>who do not have resolution. This information may help both parents<sup> </sup>and surgeons to make decisions regarding the treatment of <strong>pediatric</strong><sup> </sup><strong>trigger</strong> <strong>thumb</strong>.</p>
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		<title>What is Osteogenesis Imperfecta</title>
		<link>http://ipodindia.org/2009/06/what-is-osteogenesis-imperfecta/</link>
		<comments>http://ipodindia.org/2009/06/what-is-osteogenesis-imperfecta/#comments</comments>
		<pubDate>Tue, 30 Jun 2009 03:05:13 +0000</pubDate>
		<dc:creator>admin</dc:creator>
				<category><![CDATA[Featured]]></category>
		<category><![CDATA[Osteogenesis Imperfecta]]></category>
		<category><![CDATA[Paediatrician's Section]]></category>

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		<description><![CDATA[What is Osteogenesis Imperfecta?
Osteogenesis imperfecta (OI) is a genetic disorder characterized by fragile bones that break easily. It is also known as “brittle bone disease.” A person is born with this disorder and is affected throughout his or her life time.
What causes OI
OI is caused by an error called a mutation on a gene that [...]]]></description>
			<content:encoded><![CDATA[<h3><strong>What is Osteogenesis Imperfecta?</strong></h3>
<p>Osteogenesis imperfecta (OI) is a genetic disorder characterized by fragile bones that break easily. It is also known as “brittle bone disease.” A person is born with this disorder and is affected throughout his or her life time.</p>
<h3>What causes OI</h3>
<p>OI is caused by an error called a mutation on a gene that affects the body’s production of the collagen found in bones, and other tissues. It is not caused by too little calcium or poor nutrition.</p>
<p>Genetics</p>
<p>* The majority of cases are caused by a dominant mutation to type 1 collagen (COL1A1 or COL1A2) genes<br />
* Other types are caused by mutations of the cartilage-associated protein (CRTAP) gene or the LEPRE1 gene. This type of mutation is inherited in a recessive manner.<br />
* OI occurs with equal frequency among males and females and among all racial and ethnic groups.<br />
* Approximately 35% of children with OI are born into a family with no family history of OI. Most often this is due to a new mutation to a gene and not by anything the parents did before or during pregnancy</p>
<h3>What are the types of OI</h3>
<p>OI is variable with 8 different types described in medical literature.The types range in severity from a lethal form to a milder form with few visible symptoms. The specific medical problems a person will encounter will depend on the degree of severity.A person with mild OI may experience a few fractures while those with the severe forms may have hundreds in a lifetime.</p>
<h3>How does one diagnose OI?</h3>
<p>Diagnosis for OI is primarily based on signs seen in a doctor’s examination. When there is uncertainty about the diagnosis, it is best to consult a physician who is familiar with OI. Genetic testing is available to confirm a diagnosis of OI through collagen or gene analysis—a skin sample or a blood sample are used to study the amount of Type I collagen or to do a DNA analysis.</p>
<h3>What are the Health issues frequently seen in children and adults with  OI ?</h3>
<ul>
<li>Short stature</li>
<li>Weak tissues, fragile skin, muscle weakness, and loose joints</li>
<li>Bleeding, easy bruising, frequent nosebleeds and in a small number of people heavy bleeding from injuries</li>
<li>Hearing loss may begin in childhood and affects approximately 50% of adults</li>
<li>Breathing problems, higher incidence of asthma plus risk for other lung problems</li>
<li>Curvature of the spine</li>
</ul>
<p><a href="http://www.oif.org/site/PageServer?pagename=AOI_Types">Types of OI</a></p>
<h3>What is the treatment for osteogenesis imperfecta</h3>
<p>The team:</p>
<p>Doctors who see children and adults with OI include primary care physicians, orthopedists, endocrinologists, geneticists and physiatrists (rehabilitation specialists). Other specialists such as a neurologist may be needed.</p>
<p>The goals:</p>
<ul>
<li>At this time, there is no cure.</li>
<li>Treatments focuses on minimizing fractures,  maximizing mobility, maximizing independent function and general health</li>
<li>Treatments include
<ul>
<li>Physical therapy and safe exercise including swimming</li>
<li>Casts, splints or wraps for broken bones</li>
<li>Braces to support legs, ankles, knees and wrists as needed</li>
<li>Orthopedic surgery, often including implanting rods to support the long bones in arms or legs</li>
<li>Medications to strengthen bones</li>
<li>Mobility aids such as canes, walkers, or wheelchairs and other equipment or aids for independence may be needed to compensate for weakness or short stature.</li>
</ul>
</li>
</ul>
<ul>
<li>Treatment to improve bone strength</li>
</ul>
<ul style="padding-left: 90px;">
<li>Medications</li>
<li>Bisphosphonates (pamidronate/ alendronate/zoledronic acid)</li>
<li>Growth Hormone</li>
<li>Increased vitamin D intake</li>
<li>Physical activity</li>
<li>Potential for gene therapy</li>
</ul>
<p style="padding-left: 150px;">
<h3>What is the prognosis for children and adult with OI?</h3>
<p style="padding-left: 30px;">The prognosis for a person with OI varies greatly depending on the number and severity of symptoms.</p>
<ul>
<li>Life expectancy is not affected in people with mild or moderate symptoms.</li>
<li>Life expectancy may be shortened for those with more severe symptoms.</li>
<li>The most severe forms result in death at birth or during infancy.</li>
</ul>
<p>Respiratory failure is the most frequent cause of death for people with OI, followed by accidental trauma.Despite the challenges of managing OI, most adults and children who have OI lead productive and successful lives. They attend school, develop friendships and other relationships, have careers, raise families, participate in sports and other recreational activities and are active members of their communities.</p>
<h3>Managing OI</h3>
<ul>
<li>Techniques for safe handling, protective positioning and safe movement are taught to parents</li>
<li>Infancy, early childhood and the pre-teen years are often challenging</li>
<li>Growth and hormonal changes can affect the frequency of fractures</li>
<li>Children and youth learn which activities to avoid and how to practice energy conservation</li>
<li>The number of fractures usually decreases in adulthood</li>
<li>Following a healthy lifestyle including not smoking, and maintaining a healthy weight is beneficial</li>
</ul>
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