Lower Extremities In Children Research Articles

Relation of selective voluntary motor control of the lower extremity and extensor strength of the knee joint in children with spastic diplegia.

[Purpose] The aim of this study was to investigate differences in selective voluntary motor control of the lower extremities by objective assessment and determine the relationship between selective voluntary motor control and knee extensor strength in children with spastic diplegia. [Subjects and Methods] Forty individuals who had spastic cerebral palsy, with Gross Motor Function Classification System levels ranging from I to III, were assessed using the Selective Control Assessment of the Lower Extremity and by testing the maximum knee extensor strength. The unaffected side was defined as the lower limb with the higher score, and the affected side was defined as the lower limb with the lower score. [Results] The Selective Control Assessment of the Lower Extremity score on the affected side had a lower average than that on the unaffected side. The scores showed a significant inverse correlation with the maximum knee extensor strength. [Conclusion] There was bilateral difference in the selective voluntary motor control of the lower extremities in children with spastic diplegia, and the selective voluntary motor control of the lower extremity was related to maximum knee extensor strength.

The functional muscle–bone unit in patients with osteogenesis imperfecta type I

ContextOsteogenesis imperfecta (OI) type I is a heritable bone fragility disorder that is caused by mutations affecting collagen type I. We recently showed that patients with OI type I frequently have muscle weakness. As muscle force and bone mass are usually closely related, we hypothesized that muscle weakness in OI type I could contribute to increase bone mass deficit in the lower extremities. ObjectiveTo assess the muscle–bone relationship in the lower extremities of children and adolescents with OI type I. SettingThe study was carried out in the outpatients department of a pediatric orthopedic hospital.Patients and other participantsThirty children and adolescents with OI type I (20 females; mean age [SD]: 11.2years [3.9]) were compared with 30 healthy age- and sex-matched controls (mean age [SD]: 11.1years [4.5]). Main outcome measuresTibia bone mineral content (BMC; mg/mm) was measured by peripheral quantitative computed tomography to estimate bone strength at the 4% and 14% sites. Lower extremity peak force (kN) was measured by mechanography using the multiple two-legged hopping test. ResultsCompared with age- and sex-matched controls, patients with OI type I had 17% lower peak force (1.3kN vs. 1.7kN; p=0.002) as well as a 22% lower BMC (128mg/mm vs. 165mg/mm; p<0.001). Stepwise regression analysis showed that muscle force and tibia length were positively related to bone strength (r2=0.90, p<0.001) whereas there was no effect of the disease status (OI vs. control). ConclusionsThese results suggest that the muscle–bone relationship is similar between children and adolescents with OI type I and healthy age and sex-matched controls. It also suggests that muscle weakness may contribute to decreased bone strength in individuals with OI type I.

Construct validity and reliability of the Selective Control Assessment of the Lower Extremity in children with cerebral palsy.

Assessing impaired selective voluntary movement control in children with cerebral palsy (CP) has gained increasing interest. We investigated construct validity and intra- and interrater reliability of the Selective Control Assessment of the Lower Extremity (SCALE). Thirty-nine children (21 males, 18 females) with spastic CP, mean age 12 years 6 months [range 6y 11mo-19y 9mo], Gross Motor Function Classification System (GMFCS) levels I to IV, participated. Differences in SCALE scores were determined on joint levels and between patients categorized according to their limb distribution and GMFCS levels. SCALE scores were correlated with the Fugl-Meyer Assessment, Manual Muscle Test, and Modified Ashworth Scale. To determine reliability, the SCALE was applied once and recorded on video. SCALE scores differed significantly between the less and more affected leg (p<0.001) and between most leg joints. Total SCALE scores differed significantly between GMFCS levels I and II. Correlations with Fugl-Meyer Assessment, Manual Muscle Test, and Modified Ashworth Scale were 0.88, 0.88, and -0.55 respectively. Intraclass correlation coefficients were all above 0.9, with the minimal detectable change below 2 points. The SCALE appears to be a valid and reliable tool to assess selective voluntary movement control of the legs in children with spastic CP.

Muscle Function of Lower Extremities in Children with Lumbar Spina Bifida: Impact on Functional Status

Muscle Function of Lower Extremities in Children with Lumbar Spina Bifida: Impact on Functional Status

The movement patterns used to rise from a supine position by children with developmental delay and age-related differences in these.

The purposes of this study were to determine (1) movement patterns and strategies of children with mild to moderate developmental delay (DD) used to rise up and how they differ from those used by age-matched children with typical development (TD), (2) whether the movement patterns differ with age in children with DD, and (3) to determine the developmental sequences for the UE, AX and LE in children with DD and whether they are different from those used by children with TD. Sixty six children with TD and 31 children with DD aged two to six years were recruited. Peabody Developmental Motor Scale II (PDMS-2) was used to determine the motor performance level. The participants were recorded during rising for at least five repetitions. Two trained pediatric physical therapists viewed each video recording and classified the movement patterns of the upper extremities (UE), trunk/axial (AX) and lower extremities (LE) regions using descriptive categories developed by previous researchers. The DD and TD groups were further divided into four subgroups each using a one-year interval. The percentage of occurrence of the each UE, AX and LE movement was determined and compared across subgroups, and between each age-matched pair of TD and DD groups. The results demonstrated that the participants in the TD group clearly followed the proposed developmental sequence and the children with DD followed the developmental sequences but with different maturation speeds and greater variability, especially at the age of three to five years. The most common movement patterns used by the children in each of the DD subgroups were at least one developmental categorical pattern behind those used by the age-matched children with TD before five years old, except for the LE region. In the DD group, the movement patterns had moderate to high correlation with the child's motor performance level, indicating that the children with better motor performances used more developmentally advanced patterns in comparison with those with lower scores. However, besides motor maturity, numerous other intrinsic/extrinsic factors may affect the child's performance of this task. The information obtained in this study would assist therapists when working with the children with DD, so that they can provide individualized treatment rather than guiding all such children toward a single, mature pattern.

Percutaneous plating of distal tibial fractures in children and adolescents

Fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents. Although most can be treated nonoperatively, with satisfactory long-term results, some fractures require surgical stabilization. The increasing experience in adults with minimally invasive plate osteosynthesis for the treatment of complex fractures of the lower extremity has supported the treatment of selected distal tibia fractures in older children and adolescents. This article details the surgical technique for plating of the distal tibia using the percutaneous approach and assesses the results and complications in a pediatric series. We retrospectively reviewed 11 consecutive patients with open physes who had undergone percutaneous plating of a distal tibial fracture between January 2008 and January 2012. All patients were monitored clinically and radiographically until fracture union. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment, were recorded. Eleven patients (11 tibial fractures) were treated with minimally invasive plate osteosynthesis. The average follow-up period was 22 months (range, 12-48 months). Fractures healed with an average time to union of 9.4 weeks (range, 8-16 weeks). There were no cases of delayed union or nonunion. No clinically evident neurovascular complications were observed. One patient had a superficial infection, treated successfully by oral antibiotics. There were no cases of rotational deformity or leg-length discrepancy at the final follow-up. Because of its biologic advantages and stable fixation that allows early mobilization, percutaneous plating seems a reasonable treatment option for selected distal tibial fractures in children and adolescents. Level IV therapeutic study - Case series.

Stability of Serial Range-of-Motion Measurements of the Lower Extremities in Children With Cerebral Palsy: Can We Do Better?

Serial joint range-of-motion (ROM) measurements are an important component of assessments for children with cerebral palsy. Most research has studied ROM stability using group data. Examination of longitudinal intraindividual measures may provide more clinically relevant information about measurement variability. The aim of this study was to examine the stability of intraindividual longitudinal measurements of hip abduction (ABD), popliteal angle (POP), and ankle dorsiflexion (ADF) ROM measures of children with cerebral palsy. Secondary data analyses were performed. The stability patterns of individual serial measurements of ABD, POP, and ADF from 85 children (mean age=3.8 years, SD=1.4) collected at baseline (T1), 3 months (T2), 6 months (T3), and 9 months (T4) were examined using T1 as the anchor and bandwidths of ±15 degrees (ABD and POP) and ±10 degrees (ADF) as acceptable variability. Frequencies of stability categories (0°-5°, 5.1°-10°, 10.1°-15°, and >15°) were calculated. Patterns of stability across the 4 time periods also were examined. Group means (T1-T4) were compared using repeated-measures analysis of variance. No significant differences in group means were found except for ABD. Stability patterns revealed that 43.3% to 69.5% of joint measurements were stable with T1 measurements across all 3 subsequent measurements. Stability category frequencies showed that many measurements (ABD=17%, POP=29.9%, and ADF=37.1%) went outside the variability bandwidths even though 39% or more of joint measurements had a change of 5 degrees or less over time. Measurement error and true measurement variability cannot be disentangled. The results cannot be extrapolated to other joint ROMs. Individual ROM serial measurement exhibits more variability than group data. Range-of-motion data must be interpreted with caution clinically and efforts made to ensure standardization of data collection methods.

Management of diaphysealtibial fracture in pediatrics by elastic stable intramedullary nails

Objectives The objectives of this study were to investigate the safety and the efficacy of elastic stable intramedullary nailing in the treatment of pediatric tibial shaft fractures. Background Use of the intramedullary nailing technique in the treatment of one of the common injuries involving the lower extremities in children and adolescents. Patients and methods A prospective study of 20 children with tibial shaft fracture, who had been admitted to the Menoufia University Hospital and the Nasr City Medical Insurance Hospital between March 2012 and June 2013; all patients had diaphysealtibial fracture. The average age of the patients in this series was 11.3 years (range 5-15 years), and the mean follow-up was 8.1 months (range 6-15 months). Patient charts and radiographs were reviewed prospectively. Outcomes were classified as excellent, satisfactory, or poor according to Flynn's classification for flexible nail fixation; functional assessment and radiological assessment using the Radiographic Union Scale of the Tibial Fracture scoring system was carried out in the 4th and the 12th weeks. Results All patients achieved full weight bearing at a mean of 9.7 weeks (range 8-16 weeks). The results were excellent in 15 (75%) patients and satisfactory in five (25%) patients; two cases showed 5-10΀ of angular malalignment, and the other three cases were complicated with nail-end protrusion and a limb-length discrepancy of 2 cm of less. No patient was with poor result. Conclusion On the basis of these results, elastic stable intramedullary nailing with titanium elastic nails is an effective surgical technique that allows rapid healing of tibial shaft fractures with an acceptable rate of complications.

PReS-FINAL-2097: Evaluation of gait in children with juvenile idiopathic arthritis

with oligoarticular arthritis, and 3 patients psoriatic arthritis subtype. The mean of walking speed, step length, double step length and cadence were 0.51 m/s, 0.49 ± 0.07 m, 0.99 ± 0.14 m and 101 ± 25.33 steps/min respectively. The most noticeable changes in range of motion was increase of hip internal rotation(76.7%) and knee flexion(80%). Also, genu valgus incidence was 40%, genu varum was 20% and pes valgus was 36.7%. Conclusion Gait is a parameter that should be considered in children with JIA. This study reported that the time-distance variables of children with JIA were decreased according to healthy peers in the literature. In the same time, we observed some gait deviations during the stance phase in lower extremity in children with JIA. These deviations are moderate or severe increase of hip adduction, hip internal rotation and knee flexion. Also we found genu valgus and pes valgus in static posture. We have identified these problems may relate to response to pain, avoidance harm to joints and some structural changes in joints.

Botulinum toxin A treatment of the lower extremities in children with cerebral palsy

In the last 2 decades, BTX-A is increasingly being used in the management of spasticity in children with Cerebral Palsy (CP) and there is no doubt about its effect on range of motion, spasticity reduction and gait pattern in this patient population. However, in daily practice, there is still an ongoing search for the best way to apply BTX-A. Two studies were set up to evaluate how successful an integrated multilevel treatment approach is in children with CP. The first study identifies crucial factors within the treatment strategy which may predict the outcome. The second study evaluates the efficacy of repeated BTX-A injections. Patient selection was based on following criteria: diagnosis of CP, lower limb BTX-A treatment, age at time of treatment <24 years, no combined surgery at the time of BTX-A injections, 3D gait analysis and clinical evaluation pre and 2 months post BTX-A injections. The first study included the last treatment of 577 patients. In the second study, the first and last BTX-A treatment of 222 children were included. The Goal Attainment Scale (GAS) was used to evaluate the functional outcome of each treatment session. In the first study, the mean GAS score of the total group was 51.7 (±7.5). Considering a converted total score of 50 as cut-off score for successful treatment, 67.1% of the treatments were successful. Significantly higher GAS scores were found in mildly involved children compared to more involved children (p<0.0001) and for multilevel injections or injections in the distal muscle groups only compared to injections in the proximal muscles of the lower limb only (p<0.0001). Other crucial factors for a successful outcome were amount of physical therapy per week (p=0.0026), post injection casting (p=0.005) and frequency of using day and night orthoses after injection (p<0.0001). In the second study, the mean GAS score of the total group decreased from 54.8 (±6.8) at the first treatment to 50.7 (±6.9) at the last treatment, indicating that on average, repeated BTX-A treatment is successful. The integrated multilevel BTX-A approach is successful in children with CP. Several factors might help the clinician to select patients that are most likely to benefit from the treatment, to assure the most optimal treatment strategy and to predict the outcome. Each treatment should be carefully planned and goals should be well chosen, because the effectiveness of the BTX-A treatment may decrease with increasing number of treatments in the same patient.

FRI0590-HPR Evaluation of gait in children with juvenile idiopathic arthritis

BackgroundJuvenile idiopathic arthritis (JIA) in children and adolescents is a chronic autoinflammatory affection which might occur in any joint. The disease causes pain that may lead to posture and movement...

Leczenie zakażonych ran oparzeniowych kończyn dolnych w ciężkich oparzeniach u dzieci w aspekcie profilaktyki przykurczów stawów kolanowych – doświadczenia własne

Statyczne szynowanie kończyn stosowane w zapobieganiu przykurczom we wczesnej fazie gojenia jest powszechnie akceptowane, ale jednocześnie budzi kontrowersje. Efektywne leczenie głębokich ran oparzeniowych zapewnia szybka interwencja chirurgiczna: wycięcie martwicy do powięzi i pokrycie ran przeszcz

Primary study on deep venous thrombosis in children after neurosurgery

Objective To study the incidence and related causes of deep venous thrombosis of lower extremities in children after neurosurgery. Methods The children with or without deep venous thrombosis of lower extremities after neurosurgery in our hospital from January 2007 to December 2011 were selected.The clinical data including primary diseases and operation time were collected to be compared to find the related causes of deep vein thrombosis.Results There were 18 children with postoperative deep venous thrombosis.All of them had deep venouscatheter invasive operation.The major primary disease was craniopharyngioma.They all had longer operation time compared with those without thrombosis.Conclusions The causes of deep venous thrombosis in neurosurgical children involve not only deep venous catheter -related but also neurological primary disease and operation time. Key words: Neurosurgery ; Children; Deep venous thrombosis; Craniopharyngioma

The Lower Extremity in Morquio Syndrome

The modalities and results of surgical intervention in the lower extremity in children with Morquio syndrome type A [mucopolysaccharidosis-IV (MPS-IVA)] have not been well described. The aims of this study are to define the lower extremity deformities, and describe the results of intervention in MPS-IVA patients. Retrospective chart and radiograph review of 23 MPS-IVA patients with a minimum follow-up of >2 years. Patients were divided into no intervention and surgical groups. Demographic data, surgical details, clinical results, and complications were recorded. Standard lower extremity radiographic measurements made on standing radiographs at initial presentation, preoperatively (in surgical group), and at the final follow-up were used to study the deformities and effects of hip, knee, and ankle surgery. Descriptive statistics were performed. There were 11 boys and 12 girls. The average age at presentation was 6.8±3.4 years and at the last visit was 13.5±5 years with a mean follow-up of 6.7±3.7 years. Progressive hip subluxation, genu valgum, and ankle valgus were observed in all patients without intervention. Twenty patients had a total of 159 lower extremity surgical procedures (average, 8 procedures per patient). There were 61 hip, 78 knee, and 20 ankle procedures. Surgery resulted in improvement of the center edge angle, femoral head coverage, lateral distal femoral angle, medial proximal tibial angle, tibiofemoral angle, and lateral distal tibial angle. Mechanical axis of the lower extremities improved after intervention. Six patients (12 hips) had recurrence of hip subluxation after acetabular osteotomies and/or femoral varus derotation osteotomy, and 8 patients (16 knees) had postoperative genu valgum recurrence requiring subsequent intervention. There was no recurrent hip subluxation after shelf acetabuloplasty. Progressive hip subluxation, genu valgum, and ankle valgus were seen and often needed surgery. After shelf acetabuloplasty and varus derotation osteotomy, there was no recurrent hip subluxation. Recurrence after genu valgum correction was common. Level IV, therapeutic case series.

Lateral Supramalleolar Flap for Coverage of Ankle and Foot Defects in Children

The lower part of the leg, the ankle and the foot, is a difficult region to cover especially with exposure of bones or tendons. There are many options for covering soft tissue defect in these areas. The supramalleolar flap is an interesting procedure. The lateral supramalleolar flap was used in 8 cases for the reconstruction of skin defects of the ankle, heel, and foot that compromised the Achilles tendon and the osteoarticular system. Of the 8 patients, 5 were males and 3 were females, with an average age of 6.4 (range 2 to 10) years. The skin defect was secondary to trauma in all cases. The mean follow-up period was 31 (range 19 to 47) months; at the last follow-up visit, the region had been successfully covered in all cases. No necrosis of the flap was reported. The donor site morbidity was minimal. The lateral supramalleolar flap is an interesting surgical technique to salvage the lower extremity in children because this flap has a large skin paddle and a wide rotation arc and is based on a secondary vascular axis.

Three-dimensional measurements of the lower extremity in children and adolescents using a low-dose biplanar X-ray device

To evaluate three-dimensional (3D) measurements of the lower extremity using a biplanar low-dose X-ray device in children and adolescents. Firstly, 3D measurements of eight dried bones were analysed by a biplanar low-dose X-ray device (LDX) using stereoscopic software and compared with 3D computed tomography (CT). Secondly, 47 lower limbs of children and adolescents were studied using LDX two-dimensional (2D) and 3D measurements. Both parts were evaluated for femoral and tibial lengths and mechanical angles, frontal and lateral knee angulations, and the femoral neck-shaft angle. The 3D specimen comparison between LDX and CT measurements showed no significant differences: femoral length (P = 0.069), tibial length (P = 0.059), femoral mechanical angle (P = 0.475), tibial mechanical angle (P = 0.067), frontal knee angulation (P = 0.198), lateral knee angulation (P = 0.646) and femoral neck-shaft angle (P = 0.068). The comparison between LDX 2D and 3D measurements showed significant differences in tibial length (P = 0.003), femoral mechanical angle (P < 0.001) and femoral neck-shaft angle (P = 0.001); other parameters were unremarkable. The 3D LDX system presented reliable measurements compared with 3D CT. Differences between LDX 2D and 3D measurements were noted in the femoral mechanical angle, femoral neck-shaft angle and tibial length. Moderate to good interobserver agreement for the 3D LDX measurements were found. Low radiation dose is essential when assessing potential lower extremity discrepancies. A new biplanar low-dose X-ray device can assess such discrepancies in children/adolescents. This LDX device provides equally reliable 3D measurements as prevalent practice LDX measurements carry good overall interobserver agreement.

Quantification of dynamic EMG patterns during gait in children with cerebral palsy

Our goal was to simplify the representation and interpretation of surface electromyographic (EMG) activity during gait to develop a clinical method for evaluating gait disabilities in children with cerebral palsy (CP). EMG was recorded from four muscles of a lower extremity. Gait cycles were tracked from one force-sensing resistor signal that was recorded synchronously with EMG. The method is based on the comparison of a patient's dynamic EMG envelope shapes and the normative gait-related patterns (norms). Developed norms were based on EMG data obtained in 10 healthy children. Due to newly introduced techniques for time and amplitude normalization, norms were developed regardless of differences in subject age, gender, basic gait parameters and the EMG measurement process. The proposed gait metric quantifies the similarity between a patient's gait-related patterns and norms by a single global value suitable for gait analysis in general, including a detailed analysis using the 10 partial values. The gait metric was experimentally validated with a control group of healthy children and a group of children with CP with different degrees of motor deficits. Gait metric values obtained in children from the control group are high for all muscles, which means that gait-related patterns are close to norms, whereas in children with CP the higher the degree of motor deficit, the lower the gait metric values. The method could be a very useful clinical tool for the recognition and tracking of motor disorders of the lower extremities in children with CP as well as many other neuromotor pathologies.

Surgical epiphysiodesis indications and techniques: update

To present a summary of epiphysiodesis indications and to report most recent advances in the field, along with their clinical relevance. Percutaneous epiphysiodesis using transphyseal screws (PETS) and guided growth using eight plates represent the most recent techniques used for hemiepiphysiodesis. PETS and guided growth have yielded very good results and low rates of complications and are the current standard for the management of angular deformities of the lower extremities in children. Permanent percutaneous epiphysiodesis remains the preferred method for the treatment of limb length discrepancies.

THE STATE OF COMPENSATION OF CARBOHYDRATE EXCHANGE AND HAEMODYNAMICS RATES OF THE LOWER EXTREMITIES IN CHILDREN OF DIFFERENT AGE WITH I TYPE DIABETES MELLITUS ON INPATIENT STAGE OF REHABILITATION TREATMENT

The article is dedicated to the study of the state of carbohydrate exchange compensation and haemodynamics rates of lower extremities in children of two age groups (6–13 and 14–17 years old) with type I diabetes mellitus after the inpatient treatment. It is found out that 14–17 years old children have a higher risk of getting complications of this disease according to the indicators of glycated hemoglobin. Complex treatment with the usage of magnitolazerotherapy, magnetic therapy and vortical baths directed to the lower extremities can improve the state of their haemodynamics in children of both age groups, especially in junior group.

An Unusual Presentation of Spitz Lesion on an Adolescent’s Foot

The authors present a case of spitzoid nevus of the left fourth toe in a 16-year-old boy, which was confirmed by biopsy to be a Spitz nevus. In a young individual, we feel that it is important to maintain a high index of suspicion for an atypical lesion that displays unusual physical findings. Spitz nevus is an infrequent, acquired melanocytic nevus composed of epithelial and spindle melanocytes that is difficult to differentiate from a melanoma. Presently, there are no immunohistochemical markers or molecular biologic techniques that can be used to make a completely certain diagnosis of Spitz nevus versus melanoma. Spitz tumors are most commonly located on the lower extremities in children. Treatment of the lesion is typically carried out by means of excision.