Tendon In Children Research Articles

Clinical experience of using loop threads for tendon suturing of injured tendons of finger flexors in children's hands

BACKGROUND: Despite a significant progress in hand surgery, to date, the number of unsatisfactory functional outcomes in patients with injured flexor tendons of fingers still remains high, which underlines the importance and significance of the problem of flexor tendon repair in children. CLINICAL CASE DESCRIPTION: The authors present a series of clinical cases with the application of loop threads for suturing tendons in children with tendon injuries in deep finger flexors at different anatomical sites. They share their experience in using loop threads for tendon suturing in zones II, III, IV, V including tendon end reinsertion in zone I again with a loop thread. The primary task of surgical treatment of children with injured tendons of finger flexors is their restoration. In order to prevent secondary tendon ruptures, finger contractures, infectious complications and scarring of the tendon with surrounding tissues, it is recommended to use optimal suture material and surgical sutures that meets the basic requirements for tendon suturing . Specific pediatric anatomy must be taken into consideration as well. As the authors' clinical experience shows, a new approach to the restoration of injured finger flexor tendons with loop threads allows to avoid complications in 98% of cases. CONCLUSION: The implementation of loop tendon suturing into pediatric practice in combination with appropriate rehabilitation and motivation for the rehabilitation of a child and his/her parents opens up new prospects for the successful treatment of children with injured tendons of deep flexors of hand fingers.

Long-Term Results of Extensor Indicis Transposition Following Rupture of the Extensor Pollicis Longus Tendon after Paediatric Forearm Fracture

A rare but typical perioperative complication in the surgical treatment of pediatric forearm fractures is injury to the extensor pollicis longus (EPL) tendon. This article presents the long-term results after reconstruction of the EPL tendon with transposition of the extensor indicis (EI) tendon in children and adolescents after surgically treated forearm fracture. Over a period of 15 years, 22 children up to the age of 16 were treated with EI transposition analogous to adult care. In a follow-up examination, the range of motion of the finger and thumb joints, retropulsion of the thumb and index finger, abduction and opposition were examined. In addition, hand span and strength in the gross, key, and point grasp were measured. Subjective complaints were questioned and the DASH score was assessed. Rupture of the EPL tendon is a rare complication, accounting for 1% of all surgically treated paediatric forearm fractures. 15 patients with an average age of 10.9 years could be followed up for an average of 66.5 months after transposition of the EI tendon. Significant differences were found in reduced mobility of the metacarpophalangeal joint of the thumb, isolated extensor strength of the index finger, a reduced span between the thumb and index finger in palmar abduction, and reduced strength in the pointed grip. Subjectively, the differences between the sides were not noticed by the patients and their parents in everyday life. Transposition of the EI tendon for reconstruction of a ruptured EPL tendon as a rare complication after paediatric forearm fracture does lead to a measurable and significant reduction in index finger mobility on the affected side in the long term, but without subjective limitations of the children.

Does harvesting of the semitendinosus tendon really spare the gracilis in pediatric anterior cruciate ligament reconstruction?

Purpose:The use of isolated semitendinosus tendon for Anterior Cruciate Ligament Reconstruction bears several advantages and is popular worldwide. It assumes that the gracilis tendon is spared. The aim of the study was to measure the surface area of the gracilis tendon in children who had undergone arthroscopic reconstruction of the anterior cruciate ligament using a semitendinosus tendon graft. Our hypothesis was that the gracilis tendon may be unintentionally and iatrogenically sectioned due to the anatomical proximity and the small size of the patients.Methods:Fifty patients who had undergone a magnetic resonance imaging preoperatively and postoperatively at 1 year from the surgery and who had been operated between January 2017 and March 2019 were included in this prospective series. The surface area of the gracilis tendon was measured on fat-saturated T2-weighted axial views at the widest point of the medial epicondyle of the femur. Age, sex, body weight, and height were documented.Results:One hundred magnetic resonance imaging of 50 knees were reviewed, from 34 boys (68%) and 16 girls (32%). The mean age was 14.5 years (10–18). The gracilis was visualized in all cases at 1 year postoperatively. The average tendinous surface area of the gracilis before the surgical procedure was 7.13 mm2 versus 8.73 mm2 at 1 year, representing an increase of 1.6 mm2 (p = 0.0003).Conclusions:This study demonstrated that harvesting of the semitendinosus for the purpose of Anterior Cruciate Ligament Reconstruction was a safe technique that preserves the gracilis.Level of evidence:III.

Relation of the Sural Nerve and Medial Neurovascular Bundle With the Achilles Tendon in Children With Cerebral Palsy Treated by Percutaneous Achilles Tendon Lengthening.

One of the most common treatment options for a short Achilles tendon (AT) in cerebral palsy is percutaneous AT lengthening using 3 hemisections. Because of proximity of neurovascular structures around the tendon, iatrogenic injury to them have been a concern about this technique. The sural nerve (SN) is under risk of injury at the site of the lateral incomplete cut, especially if it is done proximally. The medial neurovascular bundle is under injury risk at medial cuts. The aim of the article was to study the anatomical relations of the SN and medial neurovascular bundle to the AT, and define dangerous levels for injury with the help of magnetic resonance imaging (MRI). Patients operated for percutaneous Achilles lengthening were called for MRI investigation of the SN and medial neruvascular bundle integrity and their anatomical relation with the AT. The distance of 5 mm was taken as the threshold for increased risk of injury. Measurements were done on MRI at each cm from the insertion of the tendon on both medial and lateral sides, and at the level of the middle cut. Thirty ankles operated and followed at least 1 year were included to the study. On the medial side, the tibial nerve, and the posterior tibial artery lied more than 5 mm away from the tendon at all levels in all patient. On the lateral side, the first 4 cm were relatively safe for the middle lateral cut, while increased risk of SN damage was detected in more proximal levels. Overall, 6 of 30 ankles had radiographically detectable SN injury. The first 4 cm of the AT on the lateral side was detected to be safe for the middle lateral directed cut, while whole tendon length were found to be safe for the first and the third cuts of the percutaneous Achilles lengthening surgery using 3 hemisections in children with cerebral palsy. Level III.

Muscle architecture and passive lengthening properties of the gastrocnemius medialis and Achilles tendon in children who idiopathically toe-walk.

Children who idiopathically toe‐walk (ITW) habitually operate at greater plantarflexion angles and thus, at shorter muscle‐tendon unit (MTU) lengths than typically developing (TD) children. Therefore, it is often assumed that habitual use of the gastrocnemius muscle in this way will cause remodelling of the muscle‐tendon architecture compared to TD children. However, the gastrocnemius muscle architecture of children who ITW has never been measured. It is essential that we gain a better understanding of these muscle‐tendon properties, to ensure that appropriate clinical interventions can be provided for these children. Five children who ITW (age 8 ± 2 years) and 14 TD children (age 10 ± 2 years) participated in this study. Ultrasound was combined with isokinetic dynamometry and surface electromyography, to measure muscle architecture at common positions and passive lengthening properties of the gastrocnemius muscle and tendon across full range of motion. Regardless of which common condition groups were compared under, both the absolute and normalised to MTU muscle belly and fascicle lengths were always longer, and the Achilles tendon length was always shorter in children who ITW than TD children (p < 0.05; large effect sizes). The passive lengthening properties of the muscle and tendon were not different between groups (p > 0.05); however, passive joint stiffness was greater in children who ITW at maximum dorsiflexion (p = 0.001) and at a joint moment common to all participants (p = 0.029). Consequently, the findings of this pilot study indicate a remodelling of the relative MTU that does not support the concept that children who ITW commonly experience muscle shortening. Therefore, greater consideration of the muscle and tendon properties are required when prescribing clinical interventions that aim to lengthen the MTU, and treatments may be better targeted at the Achilles tendon in children who ITW.

Management of Wounds with Exposed Bones or Tendons in Children by Vacuum-Assisted Closure Therapy: A Prospective Study.

Background The management of complex soft tissue defects with exposed bones/tendons is always a challenging task for the surgeon and the problem becomes more pronounced when it comes to the management of these wounds in children. Though flap procedures are considered the standard for managing the complex soft tissue defects with exposed bones/tendons yet small blood vessels for anastomosis, long operative period, increased chances of perioperative thrombosis, and difficult perioperative management in children add to the difficulty in performing flap procedures in children. The vacuum-assisted closure (VAC) therapy has emerged as a novel modality for the management of the difficult wounds with added advantages, especially in children. Objective To evaluate the efficacy of VAC in the management of wounds with exposed bones/tendons in children. Patients and Method Forty-six children of complex wounds with exposed bones/tendons were included in the study from July 2016 to June 2018. Results Out of 46 patients, 31 were male; the patients had a mean age of 8.4 years. Road traffic accident was the most common mode of injury (54%), with most of the wounds located over extremities. The mean duration of VAC therapy was 12 days. More than 90% coverage of the exposed structure was seen in 89% of patients. The wounds were definitively managed by split-thickness skin graft in 89% of patients and flap cover in 6.5% of patients. The mean cost of the VAC therapy at our government run hospital was 187 Indian rupees per day. No significant major complications were seen during the treatment. Conclusion VAC therapy is an efficient, safe, and cost-effective modality of treatment for the management of complex wounds in the pediatric population.

Treatment of flexor tendon injuries in children

Injuries to the flexor tendons in children are less common than in adults. The clinical examination and diagnostics require extensive experience. Leaving flexor tendons untreated will result in growth disorders of the affected finger. Therefore, the indications for operative exploration of any type of open injury in achild's hand should be liberally applied. As for adults the primary treatment of flexor tendon injuries as an emergency is rarely indicated. In the recent literature various tendon suture techniques and rehabilitation protocols have been differently assessed. According to the Ulm algorithm flexor tendon injuries in children are treated by a2-strand core stitch technique followed by acontinuous circular suture. Children under 6years of age are postoperatively immobilized for 3weeks with a fist bandage. Children older than 6years are treated like adults with a dynamic aftercare as described by Kleinert for 5weeks. The results are comparable with those of other aftercare protocols.

Step-advanced rectangular flap: A novel technique for the reconstruction of soft-tissue defects overlying the Achilles tendon in children (an observational study).

Soft-tissue defects overlying the Achilles tendon are common complications after bicycle or motorcycle spoke injuries in children and usually require surgical management by various flaps. There is no apparent consensus on the optimal choice of flaps for these injuries. We designed a novel step-advanced rectangular flap to reconstruct small to moderate soft-tissue defects around the Achilles tendon. This study was performed to review our experience and evaluate the clinical effectiveness of the step-advanced rectangular flap.From May, 2014 to September, 2016, 12 consecutive children with soft-tissue defects overlying the Achilles tendon caused by spoke injuries were treated with the step-advanced rectangular flap. The patients’ general information, surgical details, and postoperative complications were recorded. The Mazur evaluation system was used to assess clinical outcomes.All patients were followed up for ≥12 months (range 12–38 months). All flaps survived completely. Superficial infection occurred in 2 patients and healed by second intention after dressing changes; the other patients’ surgical wounds healed by primary intention. The scars around the flaps in 2 patients were remarkable, and all others showed good results in terms of flap color and texture. Ankle function was normal, and satisfactory results were obtained in all cases. According to the Mazur evaluation system, the results were excellent in 9 patients and good in 3, with an excellent and good rate of 100% at 12 months postoperatively.The rectangular advancement flap appears to be a simple and reliable method for small to moderate soft tissue defects overlying the Achilles tendon in children.

The Passive Mechanical Properties of Muscles and Tendons in Children Affected by Osgood-Schlatter Disease

Osgood-Schlatter disease (OSD) is a sports-related disorder involving apophysitis, which affects the tibial tuberosity. The identification of factors related to OSD is important for its prevention and early recovery from the disease. This study aimed to compare the passive mechanical properties of the muscle-tendon unit in children affected by an OSD and healthy children, by using ultrasound real-time tissue elastography. Eighteen legs affected by OSD (OSD group) and 42 healthy legs (control: CON group) were assessed. The elasticity was obtained from the quadriceps muscles and patella tendon (PT) using real-time tissue elastography. The strain ratio (SR; muscle or tendon/reference ratio: strain rate of the muscle or tendon divided by that of the reference material) was calculated as an indicator of the elasticity of the tissue of interest. The SR of the PT in the OSD group was significantly lower than that in the CON group (P<0.05). We found no significant difference between the groups in terms of the SR value of all muscles (P>0.05). The results suggest that a PT with a lower SR may be associated with an OSD and that the passive mechanical properties of the quadriceps muscles have limited association with an OSD. Level IV.

Biomechanical properties of the patellar tendon in children with heritable connective tissue disorders.

Hereditary connective tissue disorders (HCTDs), such as classic Ehlers-Danlos syndrome (cEDS) and Marfan syndrome (MS) share overlapping features like hypermobility and tissue fragility. In clinical practice it remains a challenge to distinguish children and adolescents with HCTD from healthy children. The purpose of this study was to investigate the biomechanical properties of the patellar tendon and joint laxity (Beighton score) in children with HCTDs (n = 7) compared to healthy controls (n = 14). The mechanical properties of the patellar tendon were assessed using simultaneous force and ultrasonographic measurements during isometric ramp contractions. Ultrasonography was also used to measure tendon dimensions. The HCTD children were matched with 2 healthy controls with regard to age, body mass index (BMI), sex and physical activity level. The HCTD children had a greater degree of joint laxity (P < 0.01). Although, the patellar tendon dimensions did not differ significantly between the two groups, the HCTD children showed a tendency toward a larger patellar tendon cross-sectional area (CSA) (35%, P = 0.19). Moreover, stiffness did not differ between the two groups, but secant modulus was 27% lower in children with a HCTD (P = 0.05) at common force and 34% lower at maximum force (P = 0.02). The present study demonstrates for the first time that children with HCTDs have lower material properties (modulus) of their patellar tendon, which may be indicative of general impairment of connective tissue mechanics related to their increased joint laxity.

Effects of Two Plyometric Protocols at Different Surfaces on Mechanical Properties of Achilles Tendon in Children

Objectives: The purpose of this study was to compare the changes in muscle strength and Achilles tendon strain after two plyometric training programs performed on different surfaces in children. Methods: Thirty six children (21 girls, 15 boys) aged 9.30 ± 0.55 years were assigned into a mini-trampoline plyometric group (TPLG), a ground-plyometric group (GPLG) and a control group (CG). The training groups completed a 4-week plyometric intervention (PL) (three-times a week), consisting of hopping exercises performed either on a mini-trampoline (TPLG) or ground (GPLG). Achilles tendon strain, peak ankle plantar flexion torque (PAT), and rate of torque development (RTD) at 3 different angular positions of the ankle (15°, 0° and -15°) were measured before and after training. Results: The main finding of this study was that Achilles tendon strain decreased significantly after plyometric training performed on a mini-trampoline or ground surface ( 25% and 15%, for the TPLG and GPLG, respectively (P < 0.05)). This was accompanied by an increase in maximum ankle MVC torque and an increase in RTD (at 15°, 0° positions) for both experimental groups. Especially, statistically significant increases in PAT (30%) and RTD (14%) (P < 0.05) were found for the TPLG while for the GPLG group the increase was 19 % and 8% for PAT and RTD, respectively (P < 0.05). Conclusions: Both protocols show similar adaptations regardless of the surface of training. Training on elastic surface should be incorporated into exercise programs aiming either to enhance strength performance safely, or to achieve the target goal which is not only the safe performance but also the muscle-tendon system efficiency.

Real-time ultrasound elastography of the Achilles tendon in patients with cerebral palsy: is there a correlation between strain ratio and biomechanical indicators?

Our aim was to comparatively investigate the strain ratio and thickness of the Achilles tendon in children with cerebral palsy (CP), and to elucidate whether there is a correlation between biomechanical features of the Achilles tendon and strain ratio. A total of 155 participants (72 CP patients and 83 healthy controls) who underwent real-time elastography of both Achilles tendons were studied. A linear transducer (4.8-11.0MHz) was used to obtain the images. Correlation analysis between age, length, and thickness of the Achilles tendon, and strain ratio (SR) was performed by means of Pearson correlation and Spearman's rho tests. Comparison of results obtained from CP patients and controls showed that the length of the Achilles tendon was shorter (p<0.001) and SR was higher (p<0.001) in CP patients. In CP patients, there was a positive correlation between SR and age and between SR and the thickness and length of the Achilles tendon (p<0.001 for all). Furthermore, the length of the tendon and age were positively associated (p<0.001). ROC analysis revealed that the cut-off value for SR was 1.89. The results of the present study demonstrated that real-time elastography can constitute a simple, practical, and noninvasive method for evaluation of the elasticity of the Achilles tendon in children with CP.

Mechanical and material properties of the plantarflexor muscles and Achilles tendon in children with spastic cerebral palsy and typically developing children

BackgroundChildren with spastic cerebral palsy (CP) experience secondary musculoskeletal adaptations, affecting the mechanical and material properties of muscles and tendons.CP-related changes in the spastic muscle are well documented whilst less is known about the tendon. From a clinical perspective, it is important to understand alterations in tendon properties in order to tailor interventions or interpret clinical tests more appropriately. The main purpose of this study was to compare the mechanical and material properties of the Achilles tendon in children with cerebral palsy to those of typically developing children. MethodsUsing a combination of ultrasonography and motion analysis, we determined tendon mechanical properties in ten children with spastic cerebral palsy and ten aged-matched typically developing children. Specifically, we quantified muscle and tendon stiffness, tendon slack length, tendon strain, cross-sectional area, Young׳s Modulus and the strain rate dependence of tendon stiffness. FindingsChildren with CP had a greater muscle to tendon stiffness ratio compared to typically developing children. Despite a smaller tendon cross-sectional area and greater tendon slack length, no group differences were observed in tendon stiffness or Young׳s Modulus. The slope describing the stiffness strain-rate response was steeper in children with cerebral palsy. InterpretationThese results provide us with a more differentiated understanding of the muscle and tendon mechanical properties, which would be relevant for future research and paediatric clinicians.

Ultrasonographic evaluation of Achilles tendon in children with flatfoot: A case-control morphometric study.

The purpose of this study was to investigate whether any relationships exist between the presence of flatfoot and ultrasonographic morphometric findings of Achilles tendon in children. The study included 30 pediatric patients with a mean age of 11.96±2.44 (SD) years (range: 9-16 years) with flexible flatfoot and 29 healthy pediatric controls who were matched for age and served as a control group. Demographic data of both groups such as age, height and weight, and anthropometric measurements including leg length and, length and cross-sectional area of the Achilles tendon on ultrasonography were tabulated. Relationships between the cross-sectional area of Achilles tendon and flatfoot and the other parameters were searched for using backward multiple regression analysis. No associations between flatfoot and length and cross-sectional area of the Achilles tendon, age, height, leg and foot length were found. A negative correlation was found between the cross-sectional area of Achilles tendon and presence of flatfoot (Beta=-4.93, P=0.01) and age (Beta=-1.96, P=0.04). A positive correlation was found between the cross-sectional area of Achilles tendon and shoe size (Beta=2.13, P=0.007). Flatfoot, shoe size, age and weight must be kept in mind as a clue for a thinner Achilles tendon morphometry which can be a risk factor in lower limb pathologies.

The results of adductor magnus tenodesis in adolescents with recurrent patellar dislocation.

Recurrent dislocation of the patella is a common orthopaedic problem which occurs in about 44% of cases after first-time dislocation. In most cases of first-time patellar dislocation, the medial patellofemoral ligament (MPFL) becomes damaged. Between 2010 and 2012, 33 children and adolescents (39 knees) with recurrent patellar dislocation were treated with MPFL reconstruction using the adductor magnus tendon. The aim of our study is to assess the effectiveness of this surgical procedure. The outcomes were evaluated functionally (Lysholm knee scale, the Kujala Anterior Knee Pain Scale, and isokinetic examination) and radiographically (Caton index, sulcus angle, congruence angle, and patellofemoral angle). Four patients demonstrated redislocation with MPFL graft failure, despite the fact that patellar tracking was found to be normal before the injury, and the patients had not reported any symptoms. Statistically significant improvements in Lysholm and Kujala scales, in patellofemoral and congruence angle, were seen (P < 0.001). A statistically significant improvement in the peak torque of the quadriceps muscle and flexor was observed for 60°/sec and 180°/sec angular velocities (P = 0.01). Our results confirm the efficacy of MPFL reconstruction using the adductor magnus tendon in children and adolescents with recurrent patellar dislocation.

Compartmental pressure after percutaneous tenotomy of the Achilles tendon in children with infantile cerebral palsy

Our objective was to study the pressure of the posterior superficial compartment of legs of children with spastic cerebral palsy and equinus deformity before and after a percutaneous tenotomy of the Achilles tendon. We studied compartmental pressure in 28 percutaneous tenotomies of the Achilles tendon (18 patients). All patients suffered cerebral palsy: 19 were tetraplegics (67.9%) (Ashworth Grade 4, Gross Motor Function Classification System (GMFCS) Level IV), and 9 were hemiplegics (32.1%) (Ashworth Grade 3, GMFCS Level III). Exclusions were previous surgery and those who had previously been treated with botulinum toxin. An auto-calibration monitor (measurement error ±1 mmHg) was used to calculate the pressure of the posterior superficial compartment of the leg. The ankle equinus was measured using a goniometer (measurement error ±2°). The systolic and diastolic arterial pressures and the weight were measured simultaneously. Descriptives, Wilcoxon test, and Kruskal-Wallis test were performed. The mean total age was 9.1 years, the mean total weight was 27.7 kg, and the mean systolic and diastolic pressures were 96.4 and 43.6 mmHg, respectively. The compartmental pressure was 11.3 mmHg pre-tenotomy and decreased by 30.1% post-tenotomy to 7.9 mmHg. Compartmental pressure pre-tenotomy was 10.2 mmHg in hemiplegics and 11.8 mmHg in tetraplegics and was reduced to 2.3 and 10.5 mmHg post-tenotomy in hemiplegics and tetraplegics, respectively. The pressure was significantly reduced in post-tenotomy hemiplegics (p = 0.001). Compartmental pressure was independent of weight, systolic/diastolic pressure, both pre- and post-tenotomy. Compartmental pressure decreased significantly in spastic boys after percutaneous tenotomy of the Achilles tendon. Compartmental pressure was higher in tetraplegic than in hemiplegic boys.

The prevalence of bifid iliopsoas tendon on MRI in children.

ObjectiveThe variation in the anatomy of the iliopsoas tendon is important information for orthopaedic surgeons operating around the hip. The aim of this study was to identify the prevalence of bifid iliopsoas tendons in children on magnetic resonance imaging (MRI).MethodsMRI hip and pelvis images of 50 sequential children aged 7–15 years were retrieved from our radiology database at the Evelina London Children’s Hospital from 2007 to 2013. Included were 37 children with imaging of both hips and 13 children with imaging of one hip only. Therefore, our study was based on a total of 87 hips.ResultsAt least 1 bifid tendon was noted in 13 children (26 %). Five children from a total of 37 (14 %) with both hips adequately imaged had bilateral bifid tendons. Among all 87 adequately imaged hips, 18 (21 %) were found to have two discrete distal iliopsoas tendons.ConclusionsBifid iliopsoas tendon is noted anecdotally by surgeons but was only reported in scattered case reports and a few anatomical studies until very recently. Our finding is that a bifid iliopsoas tendon with two distinct tendinous components at the level of the hip joint is quite common. This has clinical significance, particularly in children’s orthopaedic surgery when an adequate iliopsoas release is important.

Real time evaluation of monolateral clubfoot with sonoelastography

This study was undertaken to assess the feasibility of real-time elastosonography (RTE) of Achilles tendon in the clinical evaluation of a cohort of children affected by unilateral clubfoot, not surgically treated. Twenty patients affected by unilateral clubfoot were evaluated. The study group consisted of 8 males and 12 females (mean age, 16 ± 7.3 months), all treated with the Ponseti method. Children were divided into two groups according to age: group 1 aged 0-18 months, and group 2 aged 18-60 months. Any further systemic pathological conditions were considered exclusion criteria. For each subject, RTE examination of the Achilles tendons was performed bilaterally, and then regions of interest (ROIs) were positioned. In children aged 0-18 months, the mean value ROI 1/mean value ROI 2 ratio was 2.0 ± 0.18 and it showed a statistically significant difference if compared to the same ratio from healthy tendons, 2.5 ± 0.17 (p < 0.05). In group 2 (children aged 18-60 months) the mean ROI 1/mean value ROI 2 ratio value was 1.8 ± 0.27, compared to a 2.04 ± 0.21 (p < 0.05) ratio in healthy tendons. RTE is a feasible, reliable and easily performed technique that allows an accurate study of the mechanical properties of Achilles tendon in children with clubfoot.

Passive muscle properties are altered in children with cerebral palsy before the age of 3 years and are difficult to distinguish clinically from spasticity

Clinical determination of spasticity is confounded by the difficulty in distinguishing reflex from passive contributions to muscle stiffness. There is, therefore, a risk that children with cerebral palsy (CP) receive antispasticity treatment unnecessarily. To investigate this, we aimed to determine the contribution of reflex mechanisms to changes in the passive elastic properties of muscles and tendons in children with CP. Biomechanical and electrophysiological measures were used to determine the relative contribution of reflex and passive mechanisms to ankle muscle stiffness in 35 children with spastic CP (21 males, 14 females; mean age 9 y, SD 3 y 4 mo; range 3-15 y) and 28 control children without CP (19 males, nine females; mean age 8 y 11 mo, SD 2 y 10 mo; range 3-15 y). Twenty-seven children were diagnosed as having spastic hemiplegia, six with spastic diplegia, and two with spastic tetraplegia. According to the Gross Motor Function Classification System, 31 children were classified in level I, two in level II, and two in level III. Only seven children with spastic CP showed reflex stiffness outside the range of the control children. In contrast, 20 children with spastic CP showed abnormal passive muscle stiffness (p<0.001). No correlation between increased reflex or increased passive muscle stiffness and age was observed within the age range studied. These data suggest that increased reflex-mediated muscle stiffness is difficult to distinguish clinically from changes in passive muscle stiffness and that signs of changes in muscle properties are already present from the age of 3 years in children with CP. This emphasizes the importance of accurately distinguishing different contributions to muscle stiffness to avoid unnecessary antispasticity treatment.

Isolated rupture of the subscapularis tendon in children

We report the case of an 11-year-old, male, competitive hockey player with a complete rupture of the subscapularis insertion but no avulsion fracture of the lesser tuberosity. Ultrasound and MRI were performed before surgical repair with suture anchors. The boy regained a normal range of movement after 4 weeks of immobilization and 2 months of rehabilitation. This unique case (with the absence of lesser tuberosity avulsion) is compared with the 16 other cases of paediatric subscapularis avulsion fracture reported in the literature.