0
Specialty Update   |    
What's New in Pediatric Orthopaedics
Mininder S. Kocher, MD, MPH1; Daniel J. Sucato, MD2
1 Department of Orthopaedic Surgery, Children's Hospital, 30 Longwood Avenue, Boston, MA 02115. E-mail address: mininder.kocher@childrens.harvard.edu
2 Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219
View Disclosures and Other Information
Note: The authors thank the POSNA Board of Directors for their review of this manuscript.
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Jun 01;88(6):1412-1421. doi: 10.2106/JBJS.F.00442
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
The purpose of this specialty update is to serve as a primary source and review for the general orthopaedic surgeon who wishes to stay up-to-date in pediatric orthopaedics. The topics that have been selected have value for the practicing orthopaedist as well as for the pediatric orthopaedic specialist. The material is not intended to represent the only, or necessarily the best, method or procedure appropriate for the medical situations discussed.
Sources for this article were presentations at meetings of the Pediatric Orthopaedic Society of North America (POSNA) (Ottawa, Ontario, Canada, May 13, 14, and 15, 2005), the American Academy of Orthopaedic Surgeons (AAOS) (Washington, DC, February 23 through 27, 2005), the Scoliosis Research Society (SRS) (Miami, Florida, October 27 through 30, 2005), and the American Academy of Pediatrics (AAP) (Washington, DC, October 8 through 11, 2005), and selected references. Orthopaedic surgeons, residents, and fellows are encouraged to attend educational programs on topics in pediatric orthopaedics presented at the AAOS conferences and courses, Specialty Day at the AAOS annual meeting, and the POSNA annual meeting. Upcoming educational events are listed at the end of this update.

Shoulder

Brachial Plexus Birth Palsy

The timing of early microsurgical intervention in brachial plexus birth palsy is controversial. Waters and Brauer created an economic model to compare the costs of microsurgical treatment at three months compared with the costs of the surgery at six months in patients with brachial plexus birth palsy who had absent biceps function at three months. For surgery at three months to be as cost-effective as surgery at six months, with the assumption that 40% of patients will have a spontaneous return of biceps function between three and six months, the success rate of early surgery would have to be nine times higher than that of surgery at six months. If there is an 80% return of biceps function between three and six months, then early surgery could not be more cost-effective. This model supports waiting for six months before performing microsurgery in most cases.
Kambhampati et al. prospectively studied 183 cases of posterior subluxation or dislocation of the shoulder associated with brachial plexus birth palsy. After performing shortening of the coracoid, elongation of the subscapularis, and correction of humeral retroversion, the authors found, on the average, improvement in the Mallet score from 9.4 to 13.0 points, an increase in lateral rotation of 58°, and an increase in forearm supination of 51°. They also found that the extent of secondary deformity and the result after treatment were determined by the severity of the nerve injury and the duration of the dislocation. Waters and Bae reviewed the results of derotational humeral osteotomy in forty-three children with brachial plexus birth palsy and found a mean 68° improvement in external rotation and a mean improvement in the Mallet score from 13 to 19 points.

Forearm and Hand

James and Bagley performed a multicenter outcomes study of 499 children with unilateral congenital below-the-elbow deficiency; 339 wore a prosthesis, and 160 did not. Using function and quality-of-life instruments, the authors found that use of a prosthesis did not improve function or health-related quality of life, calling into question the standard practice of prosthetic fitting for infants and encouraging prosthetic use by children with unilateral congenital below-the-elbow deficiency. Lerman et al. studied the impact of forearm length on the functional ability, with or without the use of a prosthesis, of 499 children with unilateral congenital below-the-elbow deficiency. They found that, overall, patients with a shorter forearm functioned similarly to patients with a longer forearm in the majority of specific tasks; however, patients with a longer forearm performed several specific tasks better. Use of a prosthesis improved the performance of three specific tasks (twisting a lid off of a drink bottle, threading a string of beads, and using a ruler and pencil to draw a straight line) by patients with a shorter forearm more than it improved the performance by patients with a longer forearm.

Hip

Legg-Calvé-Perthes Disease

The prognosis of Legg-Calvé-Perthes disease is considered to be better for patients with an earlier onset. Dimeglio and Canavese studied 166 patients, at skeletal maturity, who had had the onset of Legg-Calvé-Perthes disease before they were six years of age. All patients with a more benign form of the disease (Catterall type 1 or 2) had a good result according to Stulberg's classification. Of the patients with more severe disease (Catterall type 3 or 4), 67% had a good result; 22%, a fair result; and 10%, a poor result. There were no significant differences between the results of surgical treatment and those of nonsurgical treatment in the patients with severe disease.

Developmental Dysplasia of the Hip

Thonse and Johnson performed a study of 2742 babies who had been referred for screening for developmental dysplasia of the hip with clinical examination and ultrasound. Of the 233 hips with abnormal findings on the ultrasound examination, 106 (45%) were found to be normal on clinical examination. Of the 1862 clinically normal hips, 106 (6%) had abnormal findings on the ultrasound study. Furthermore, the authors thought that a clinical examination could not be performed on 841 babies who could not relax. Because of the concern of missing a diagnosis of developmental dysplasia of the hip in patients who have normal findings on clinical examination and of being unable to examine some babies who are tense, the authors suggested that ultrasonography is useful for all referred babies.
The Bernese periacetabular osteotomy has become an established procedure for the correction of acetabular dysplasia in older adolescents and young adults. Clohisy et al. reported the early results of this osteotomy in sixteen hips in thirteen patients after 4.2 years of follow-up1. There was a mean improvement of 44.6° in the lateral center-edge angle, 51.0° in the anterior center-edge angle, and 25.9° in the acetabular roof obliquity. The average Harris hip score improved from 73.4 points preoperatively to 91.3 points at the time of the latest follow-up. Millis et al. presented the results in their large series of 154 periacetabular osteotomies at a minimum of five years postoperatively. Failure was based on pain scores or conversion to a total hip replacement. Multivariate analysis identified three predictors of failure: a labral tear, older age, and joint incongruity. These findings suggest that the intermediate-term results of a periacetabular osteotomy are best if the procedure is performed on congruous hips prior to the development of a labral tear or arthrosis.

Slipped Capital Femoral Epiphysis

Vitale et al. used the Kids' Inpatient Databases from 1997 and 2000 and United States Census Bureau data to study the epidemiology of slipped capital femoral epiphysis. The overall incidence of slipped capital femoral epiphysis was 10.75 per 100,000 children. It was more prevalent in males (12.52 per 100,000) than females (7.71 per 100,000) and more prevalent in black children (18.63 per 100,000) and Hispanic children (11.85 per 100,000) than in white children (5.38 per 100,000). The age at presentation was older in males (12.4 years) than in females (11.2 years). Furthermore, the incidence of slipped capital femoral epiphysis varied by geographic region in the United States (highest in the south) and household income. This study suggests that the rate of slipped capital femoral epiphysis is somewhat higher than previously reported and that the age of onset is becoming younger.
Hormonal disorders may predispose children to the development of slipped capital femoral epiphysis. Papavasiliou et al. performed a comprehensive endocrinological work-up for fourteen patients with slipped capital femoral epiphysis. Fourteen of 168 hormonal determinations revealed abnormal values, including those for luteinizing hormone, parathyroid hormone, follicle stimulating hormone, and testosterone, although no cases of true endocrinopathy were found. The authors suggested that a temporary hormonal disorder during the early years of adolescence, and not necessarily a true endocrinopathy, may play a role in the development of slipped capital femoral epiphysis.
The risk of a contralateral slipped capital femoral epiphysis is estimated to be 25% to 40%, and some surgeons routinely perform prophylactic contralateral pinning at the time of pinning of a unilateral slipped capital femoral epiphysis. Stratification of the risk of contralateral slipped capital femoral epiphysis would identify patients who are at greatest risk for a contralateral slip and may be candidates for prophylactic pinning. In a study of 260 patients followed through maturity, Karol et al. found that the modified Oxford bone age was a useful predictor of a contralateral slipped capital femoral epiphysis.

Knee

Anterior Cruciate Ligament Injury

One of us (M.S.K.) and colleagues reviewed the results of a physeal-sparing combined extra-articular and intra-articular reconstruction of the anterior cruciate ligament with use of the iliotibial band in forty-four prepubescent children (mean age, 10.3 years)2. They found a low revision rate (4.5%), excellent function, and no cases of growth disturbance. They advocated a physeal-sparing approach in these young children.

Osteochondritis Dissecans

Czarnecki et al. reviewed the results of fixation, with various techniques and implants, in twenty-six knees with unstable juvenile osteochondritis dissecans. The overall healing rate was 85% (twenty-two of twenty-six). There was no significant difference in the healing rate according to the location of the lesion, fixation method, or grade of the lesion. In fact, all six completely detached lesions healed. The authors emphasized the importance of attempting to fix unstable juvenile lesions in lieu of using chondral resurfacing techniques given the relatively high healing rate that they found.

Blount Disease

Many studies have suggested that weight plays a role in infantile Blount disease. Scott et al. studied ninety-eight extremities with physiologic bowing and twenty-six extremities with infantile Blount disease. They found that a tibial metaphyseal diaphyseal angle of = 14° or an angle of = 10° associated with a body mass index of >1.8 was highly predictive of infantile Blount disease (sensitivity, 88%; specificity, 94%).
The efficacy of staple hemiepiphysiodesis for the treatment of late-onset tibia vara was studied by Park et al.3. Thirty-three extremities in twenty-six patients were treated with lateral stapling of the proximal part of the tibia. Additional distal femoral lateral stapling was performed in fourteen patients. At the time of follow-up, twenty extremities were in normal alignment, four were in mild varus, seven were in moderate varus, and two were in valgus. The authors recommended this procedure for patients with mild-to-moderate deformity who are younger and have sufficient growth remaining.

Leg

Refracture and deformity can occur after osteosynthesis of a congenital pseudarthrosis of the tibia. Cho et al. observed refracture following twenty-two of forty-three successful osteosynthesis procedures, at an average of 19.4 months after union. Refracture was more common in younger children, those without a distal tibiofibular synostosis, and those with a thinner tibial diaphysis. In a group of seventeen patients treated with a successful osteosynthesis, Inan found deformity in all but two patients, with a mean of 11.4° of tibial valgus, 19.4° of procurvatum, and 22.2° of ankle valgus.
Children with fibular deficiency may be managed with amputation or limb reconstruction. There are scant data comparing health-related quality of life and function between these two treatments. Walker et al. used multiple outcome instruments to compare thirty-two patients treated with an amputation and twenty-five patients treated with limb lengthening and found no difference between the results with regard to almost all quality-of-life measures. Compared with controls, both groups of patients were functioning with an average or above-average health-related quality of life.

Foot and Ankle

Clubfoot

The Ponseti technique of serial manipulations and casts has become the standard management of congenital clubfoot, resulting in much lower rates of major surgery. Dietz et al. reviewed Ponseti's personal experience with the treatment of 541 feet from 1948 to 1991. The rate of relapse and the need for surgery were higher before the use of hyperabduction in the last cast and in patients who were noncompliant with bracing. Cummings et al. investigated the utility of botulinum toxin injections to the gastrocnemius muscle as an adjunct to the Ponseti method in a randomized clinical trial of thirty-two clubfeet. The injection had no significant effect on deformity correction.

Cavovarus Foot

Bilateral cavovarus foot deformity may be idiopathic or associated with an underlying hereditary neuropathy, particularly Charcot-Marie-Tooth disease. In a review of 148 patients who presented with bilateral cavovarus foot deformity, Guille et al. found that 118 (80%) had Charcot-Marie-Tooth disease as demonstrated by further neurological work-up. Thus, clinicians should have a strong suspicion for this disease in a patient who presents with bilateral cavovarus foot deformity.

Spine

Demographics and Growth Prediction

Vitale et al. analyzed discharge databases from New York and California hospitals to better understand the distribution of spine deformity cases treated by pediatric orthopaedic fellowship-trained surgeons and spine fellowship-trained surgeons4. They found that more scoliosis surgery is being performed by surgeons with pediatric fellowship training than by surgeons with spine fellowship training in New York and that the number of procedures performed by pediatric orthopaedic fellowship programs was four times that performed by spine fellowship programs in California.
A prospective analysis of 324 girls with adolescent idiopathic scoliosis determined that a risk factor for scoliotic curve progression was osteopenia in the femoral neck on the side of the concavity5. Sanders et al. correlated the maturation of the hand phalanges with peak height velocity and found that an uncapped phalangeal epiphysis indicated pre-peak height velocity.

Bracing

A study of 276 patients with adolescent idiopathic scoliosis by Sucato et al. demonstrated that overweight patients have a greater risk of curve progression and less successful results following orthotic treatment than do patients who are not overweight. Moon et al. showed that the success of bracing with a thoracolumbosacral orthosis improved when compliance with brace wear increased and when orthotists were retrained (a success rate of 40% prior to retraining compared with 81% after it). In a study of 365 patients who were treated with a flexible bracing system, Rivard et al. demonstrated that 65% of the curves were corrected, 31% were stabilized, and only 4% worsened.

Etiology of Adolescent Idiopathic Scoliosis

Considerable efforts to determine the genetic etiology of adolescent idiopathic scoliosis continue. Wise et al. reported additional evidence to support a role for the 8q region of chromosome 8, and Miller et al. suggested that various regions on chromosome 17 may be involved in idiopathic scoliosis. Using magnetic resonance imaging, Chu et al. demonstrated that patients with severe scoliosis had a diminished spinal cord length, in relation to the vertebral column length, when compared with patients who did not have scoliosis or who had mild scoliosis. Kouwenhoven et al. reviewed computed tomography images of normal individuals and found that 89% of them had substantial axial plane rotation, which may set the stage for the development of scoliosis.

Congenital Scoliosis

Hedequist et al. reported that the use of allograft during fusion surgery resulted in a low prevalence of pseudarthrosis (2.8%) and infection (0.9%). In a study by Tsirikos and McMaster, rib anomalies were observed in 19.2% of patients with congenital spine deformities and were most commonly seen in patients with congenital scoliosis (especially those with a unilateral failure of vertebral segmentation) and were less commonly seen in patients with congenital kyphoscoliosis or kyphosis6. Smith et al. reported on the costotransversectomy approach for anterior and posterior resection of a hemivertebra or for spinal osteotomy in the treatment of congenital kyphosis in sixteen patients7. On the average, 31° of kyphosis correction was achieved.

Early-Onset Scoliosis and Thoracic Insufficiency

To better understand the normal thoracic dimensions, Emans et al. analyzed the pelvic inlet width on computed tomography scans of healthy patients who were less than twenty-one years of age, and they established gender-specific reference ranges for spine and chest dimensions. Emans et al. also reported their experience with the use of the vertical expandable prosthetic titanium rib (VEPTR) in thirty-one patients who had thoracic insufficiency syndrome associated with fused ribs. Control of the curvature of the thoracic spine with continued growth was noted in thirty patients. The conclusion drawn from this study was that VEPTR is a good technique for the right patient who has chest wall deformity and scoliosis associated with fused ribs but attention to detail, especially with respect to the soft tissues, is important. Campbell, the developer of the VEPTR technique, reported on its use in sixteen patients with progressive thoracic insufficiency. He found a decrease in scoliosis (from 77° to 39°) and an improvement in the space available for the lung, but there was only a modest improvement in the transverse dimension of the chest. In a study of eighteen patients who had undergone thoracic fusion before the age of eight years, Karol et al. found that eight had severe restrictive pulmonary disease that was correlated with the percentage of thoracic levels that were fused, the presence of rib deformity, and the cephalad extent of the fusion.

Pulmonary Function

In a multicenter study, Kishan et al. reported that the minimally invasive thoracoscopic approach for the treatment of thoracic adolescent idiopathic scoliosis resulted in improvement in forced vital capacity, forced expiratory volume in one second, and total lung capacity at two years, whereas the open thoracotomy approach led to decreases in these parameters. Kim et al. found a significant (p = 0.015) decrease in selected pulmonary function values at two years after open thoracotomy but not at two years after use of the thoracoabdominal approach.

Thoracic Pedicle Screws in Scoliosis

The definition of severe scoliosis requiring anterior release may be changing with the use of more powerful pedicle-screw techniques. A comparison of patients in whom curves measuring between 70° and 100° had been treated with either a posterior all-pedicle-screw construct or combined anterior-posterior surgery demonstrated no difference in the amount of thoracic coronal curve correction8. A similar finding was reported in a study in which forty-six patients who had posterior instrumentation alone demonstrated a mean correction of 64% with good outcome scores at two years9. Kim et al. evaluated the positions of thoracic pedicle screws on plain radiographs and computed tomography scans to develop three plain radiographic criteria with which to judge accurate placement of thoracic pedicle screws; these criteria were a harmonious contour of the screws in the axial plane, no crossing of the medial pedicle wall, and no violation of the midline of the vertebral body10. This group also reported decreases in thoracic kyphosis after treatment with thoracic pedicle screws, but there was some increased cephalad junctional kyphosis and loss of lumbar lordosis to maintain global sagittal balance. The superiority of thoracic pedicle screws for correcting spinal deformity was challenged in a study that compared twenty-five patients treated with a sublaminar wire technique with twenty-five patients treated with thoracic pedicle screws and demonstrated no difference in coronal plane correction or fusion length11. A similar conclusion was reached by Vora et al., who found that use of a hook-and-wire construct resulted in better correction of the coronal plane deformity than did pedicle screws when the preoperative flexibility of the curve was considered. In a study of 203 patients selected to be treated with thoracic fusion with thoracic pedicle screws, Suk et al. documented 69% thoracic curve correction, with 66% correction of the segment of the spine not included in the area of instrumentation, and coronal decompensation in 5% of the patients at five years. Kuklo et al. reported that 96% of thoracic screws were placed accurately and demonstrated an overall 68% correction of curves measuring >90° without neurologic injury.

Neuromuscular Disorders

Use of modern posterior hybrid constructs for the surgical treatment of scoliosis in patients with Marfan syndrome produces excellent results when the fusion is extended to include the neutral and stable vertebrae, as reported by De Silvestre et al. Milbrandt et al. reviewed a fifty-year experience with treating scoliosis in patients with Down syndrome and reported an 8.7% incidence of scoliosis. Treatment with a brace to prevent curve progression was generally ineffective, and surgical treatment in seven patients was associated with a high complication rate; however, only one reoperation was required. In a long-term prospective follow-up study of eighty-two patients with neuromuscular scoliosis who had undergone surgery, Larsson et al. reported improvements in sitting and activities of daily living. They found that patients who had been operated on at the age of twenty-one years or younger had more improvement than those who had had the surgery later. Parent et al. reported overall excellent results in seventy-two patients with spinal muscular atrophy who had undergone spine fusion; life-threatening pulmonary complications were avoided in all but one patient. Shah et al. used multivariate analysis with logistic regression to demonstrate that intrathecal baclofen therapy did not increase the risk of progressive scoliosis developing in patients with cerebral palsy.

Spondylolisthesis

Gaines reviewed the results of L5 vertebrectomy for the surgical treatment of fixed spondylolisthesis in thirty patients and demonstrated overall patient satisfaction and good sagittal plane alignment; however, twenty-one patients had a transient L5 nerve-root deficit, and two additional deficits were permanent. In a long-term follow-up study comparing patients who had reduction of a high-grade spondylolisthesis with those who had an in situ fusion, Helenius et al. demonstrated better performance in nearly all measured clinical parameters for patients with an in situ fusion.

Back Pain

Auerbach et al. evaluated 873 consecutive children who presented with back pain without any positive findings on physical examination or any causes for concern in their history. They found that a negative hyperextension test and normal radiographic findings had a high predictive value (0.81) for the diagnosis of mechanical back pain. This predictive value was increased to 0.94 when a negative bone scan was added, and the authors suggested that a bone scan rather than a magnetic resonance imaging scan is the test of choice in this setting.

Spinal Cord Monitoring

Raynor et al. analyzed the utility of triggered electromyography when placing lumbar pedicle screws and demonstrated an increasing probability of a breach of the medial pedicle wall with decreasing triggered electromyographic thresholds. One of us (D.J.S.) and colleagues reported that it was more difficult to perform good baseline spinal cord monitoring when a neural axis abnormality such as a syringomyelia was present. This resulted in a higher rate of false-positive results compared with the rate for patients with adolescent idiopathic scoliosis, but the monitoring still identified neurologic injury.

Outcomes and Complications

Heddon et al. reported that 128 patients with adolescent idiopathic scoliosis rated the appearance of their waist and their overall appearance worse than their parents rated them. Richards et al. reported that 13.0% of patients operated on for adolescent idiopathic scoliosis subsequently had at least one reoperation, most commonly because of pain over the posterior implants, pseudarthroses, or infection, and the prevalence was higher after posterior surgery than after anterior surgery.

General

Playground accidents can result in fractures in children. In a study of data from the Canadian Hospitals Injury Reporting and Prevention Program database, Howard et al. identified 1092 children with fractures resulting from playground accidents and found that falls from equipment were much more likely to cause severe fractures than were falls from the child's height (odds ratio, 5.03). These data support further efforts to improve playground equipment design, height, and surfaces.
Urgent débridement and fixation is commonly advocated for open fractures in children. In a retrospective multicenter study of 554 open fractures in 536 consecutive patients who were eighteen years old or younger, Skaggs et al. found no difference in the infection rate between fractures treated within six hours after the injury (twelve of 344) and those treated after six hours (four of 210)12. They advocated early antibiotic treatment with surgical débridement within twenty-four hours after the injury.

Supracondylar Humeral Fractures

The standard management of completely displaced (type-3) supracondylar humeral fractures in children is closed reduction and percutaneous pinning. There is controversy about whether lateral entry pinning or combined medial and lateral entry pinning is the optimal configuration. Lateral entry pinning avoids the potential for iatrogenic ulnar nerve injury associated with the placement of a medial pin, but it may provide less biomechanical stability. One of us (M.S.K.) and colleagues performed a randomized clinical trial comparing lateral entry with combined medial and lateral entry pinning of type-3 supracondylar humeral fractures in fifty-one children. There was no major loss of reduction or iatrogenic ulnar nerve injury in either group. Thus, it was concluded that both techniques are effective and that attention to proper technique is important. Lateral entry pins should engage both the lateral and the central column of the distal part of the humerus. Medial pinning was performed after lateral pinning with the elbow extended beyond 90°; a small medial incision was used to avoid the ulnar nerve.

Lateral Condylar Fractures

The management of cubitus valgus associated with an established nonunion of the lateral condyle in children is difficult. Tien et al. described a technique involving compression fixation of the lateral condylar nonunion and a dome-shaped supracondylar osteotomy of the distal aspect of the humerus through a single posterior incision; the operation resulted in successful union and function in eight children13.

Femoral Shaft Fractures

Flexible intramedullary nailing remains a popular method of fixation of femoral shaft fractures in children. Mehlman et al. performed a study of 101 patients to determine the patient-related characteristics related to complications of this method. They found that angular malunion was more likely in patients who weighed >99 lb (45 kg) and who were more than twelve years of age. Other treatment methods may be preferred for these heavier, older patients.
Flexible intramedullary nails are usually routinely removed. In a study of thirty-five children followed for a mean of three years after flexible nailing and for whom nail removal was not routinely planned, Hoffinger et al. reported that the nail had to be removed from seven patients because of lateral knee pain. However, the remaining children had no symptoms and retained the nail.
Wall et al. compared titanium nails with stainless-steel nails in ninety-two children with a femoral shaft fracture and found no difference in terms of complications, nonunions, or malunions. This suggests that stainless-steel flexible nails are as effective as titanium flexible nails.
Immediate application of a spica cast is the standard treatment for femoral shaft fractures in children who are six years old or younger. However, spica cast treatment has potential drawbacks. Willis et al. compared the results of the use of a spica cast (seventeen patients) with those of flexible nailing (fifteen patients) in a study of children with a femoral shaft fracture who were between the ages of three and six years. They found a faster time to full weight-bearing, full motion, and no limp in the group that had undergone the flexible nailing. In addition, they found that those children missed fewer days of school or daycare and had a lower rate of malunion. Mubarak et al. drew attention to the potential disastrous complication of compartment syndrome with the immediate use of a 90/90 spica cast for seven children. Application of a short leg cast with a large amount of traction followed by completion of the spica cast should be avoided.
The management of femoral shaft fractures in obese children is challenging. Leet et al. studied the results of the treatment of 103 femoral fractures with external fixation or a flexible intramedullary rod in children14. Complication rates after both treatment techniques were higher in the obese and very heavy children.

Ankle Fractures

Screws are frequently used for the management of Tillaux and triplane fractures of the distal part of the tibia in adolescents. Charlton et al. measured total force and peak contact pressures in adult and pediatric cadaveric ankles before and after placement of a single 4.5-mm cannulated screw in the distal tibial epiphysis. They found that screw placement led to significant (p = 0.011) increases in ankle joint contact forces, which normalized after screw removal. They hypothesized that the screw altered the load-bearing properties of the distal part of the tibia, and they recommended screw removal after union of these fractures.

Tumors

Unicameral bone cyst is a common benign bone lesion in children that may lead to pathologic fracture. Yandow et al. reported the results from a multicenter bone cyst randomized clinical trial carried out through the Pediatric Orthopaedic Society of North America (POSNA) clinical trials network. In a group of forty-eight patients who had been followed for two years, there was no significant difference in healing rates between those treated with methylprednisolone injection (22%; five of twenty-three) and those treated with bone-marrow injection (12%; three of twenty-five).
Dormans et al. reviewed their experience with the treatment of fourteen children who had osteoblastoma. The mean age at the time of diagnosis was nine years, and the lesions were most frequently seen in the lower extremities (43%) or the spine (36%). The patients were treated with open incisional biopsy and intralesional curettage, and those with a spinal lesion were also treated with spinal fusion and instrumentation. The local recurrence rate was 28%, and all recurrences were in young children who were less than six years of age.

Cerebral Palsy

Gait analysis studies have shown improvement following multilevel orthopaedic surgery in children with cerebral palsy; however, it is unclear whether these improvements result in changes in function and health-related quality of life. One year after multilevel lower-extremity surgery in a series of twentyfive children with cerebral palsy, Wren et al. found that gait parameters were correlated with function and health-related quality-of-life outcome measures, suggesting that gait analysis has criterion validity in terms of outcomes assessment.
Botulinum toxin is often used as an adjunct to application of serial casts for the management of contractures in children with cerebral palsy. In a randomized clinical trial, Kay et al. compared the results of serial casts alone with those of serial casts as well as botulinum toxin injections in twenty-three children with cerebral palsy and fixed equinus contractures15. On the basis of motion, spasticity, and gait parameters, the authors found that botulinum toxin offered no additional benefit in the management of these patients.
The optimal technique for lengthening of the Achilles tendon in patients with cerebral palsy is controversial. Yen et al. performed a randomized clinical trial of three different procedures (z-lengthening of the Achilles tendon, Vulpius gastrocnemius recession, and percutaneous [Hoke] lengthening of the Achilles tendon) in nineteen patients with spastic diplegia. They found that all three procedures improved functional gait, but z-lengthening of the Achilles tendon was the most effective in terms of maintenance of the initial correction.
Hip flexion contracture is common in children with cerebral palsy who are able to walk. Iliopsoas lengthening, in the context of multilevel lower-extremity surgery, has been proposed to decrease this deformity and improve function. Pirpiris et al. performed a randomized clinical trial comparing iliopsoas lengthening with no lengthening in seventy-nine children with cerebral palsy who were undergoing multilevel surgery. They found that iliopsoas lengthening decreased static hip flexion contractures but did not significantly alter the functional and health-related quality-of-life outcome measures.
Hip subluxation and dislocation are common in spastic cerebral palsy. Presedo et al. studied the results in sixty-five children with cerebral palsy who had undergone open adductor tenotomy and psoas muscle recession or iliopsoas tenotomy at a mean age of 4.4 years16. The mean hip migration index changed from 34% preoperatively to 18% at a mean of 10.8 years postoperatively. Nineteen patients required subsequent osseous reconstructive procedures, and eleven required repeat soft-tissue releases. The migration percentage at one year postoperatively was the best predictor of the final outcome, and patients who had been able to walk preoperatively had a better long-term outcome.

Rickets

The management of angular deformity of the leg in children with X-linked hypophosphatemic rickets is controversial, with osteotomy being the most frequently recommended procedure. In a study of hemiepiphysiodesis in nine patients, Stevens and Novais reported complete correction in four patients, partial correction in two patients, and no correction in three patients who were noncompliant with medical instructions. They recommended hemiepiphysiodesis in younger children (less than ten years old) who were taking appropriate medication and had mild-to-moderate deformity.

Osteogenesis Imperfecta

The relationship between bone mineral density and the risk of fracture in patients with osteogenesis imperfecta has not been established. Huang et al. correlated low spine bone mineral density to an increased rate of fractures and surgery in twenty patients with osteogenesis imperfecta.
Improving bone mineral density is a primary goal of the medical management of these patients. Guarniero et al. randomized fifty-five patients with osteogenesis imperfecta into three groups—no medication, treatment with pamidronate, and treatment with alendronate—and measured bone mineral density initially and at one year. Pamidronate, the newer bisphosphonate, resulted in the greatest improvement in bone mineral density (19.7%).
While treatment of osteogenesis imperfecta has been directed at improving bone mineral density, the effect of such an improvement on functional outcome has not been elucidated. Huang et al. correlated bone mineral density to functional outcome, as measured with the Pediatric Outcomes Data Collection Instrument, in twenty-four consecutive children with osteogenesis imperfecta. They found a significant (p = 0.025) positive relationship between bone mineral density and physical function, including upper-extremity function, transfers, sports, and global function.
Linden et al. performed a controlled intervention study of the effect of exercise, for three years, on bone mineral density in healthy children. Seventy-six boys and forty-eight girls who performed forty minutes of physical activity every school day were compared with ninety-nine age and sexmatched children who performed the standard physical activity regimen for sixty to ninety minutes per week. At three years after the start of the intervention, the boys had greater spine bone mineral density and the girls had greater spine, total body, femoral neck, and leg bone mineral density than did the controls. This suggests that increased time spent in physical activity during childhood can result in lasting improvements in bone mineral density, which may help avoid the development of osteoporosis.
Bone density decreases in children who cannot walk. Snyder et al. found increased calcaneal bone mineral density in twelve nonambulatory children who had been treated with a program that involved standing for two hours per day, five days per week; however, the improvements diminished with noncompliance with the program.
The Heuter-Volkmann principle of physeal growth states that longitudinal growth is retarded by increased compressive forces. Ballock et al. investigated the basic science of this principle in growth-plate chondrocytes loaded in a static compression chamber. They found that compression of growth-plate chondrocytes inhibited differentiation into hypertrophic cells by suppressing the expression and activity of bone morphogenetic proteins in the growth plate.
Hahn et al. compared the results of femoral and tibial lengthening by means of the Ilizarov technique (twenty-eight cases) and those of the use of an elongating intramedullary nail (twenty-three cases) in young adults. Following treatment with the Ilizarov technique, there were seventeen excellent, eight good, and three fair results. Following use of the elongating intramedullary nail, there were nineteen excellent and four good results. The authors concluded that the elongating nail was effective and had advantages in terms of maintaining the range of motion, avoiding pin-track infection, and improving patient convenience.
In a prospective study of fifty-three children who had undergone aspiration because of an irritable hip, Caird et al. found that fever, an elevated C-reactive protein level, an elevated erythrocyte sedimentation rate, non-weight-bearing, and an elevated serum white blood-cell count were predictors of septic arthritis17. The probability of septic arthritis was estimated to be 98% when five predictors were present, 93% when four predictors were present, and 83% when three predictors were present.
The recent emergence of community-acquired methicillin-resistant Staphylococcus aureus as a cause of bone and joint infections in children is alarming. Over a four-year period from 2000 through 2003 at the Campbell Clinic in Memphis, Tennessee, Warner et al. found that twenty-seven (26%) of 104 cases of acute hematogenous osteomyelitis or septic arthritis involved methicillin-resistant Staphylococcus aureus, with 41% of the cases in the last year of the study involving that organism. Methicillin-resistant Staphylococcus aureus infections were much more difficult to treat, with higher rates of subperiosteal abscesses, multiple surgical procedures, longer hospital stays, and prolonged periods for which blood cultures tested positive. The emergence of musculoskeletal infections with methicillin-resistant Staphylococcus aureus in children has major implications in terms of management: (1) initial antibiotic management may need to be changed to clindamycin or vancomycin if the local prevalence of methicillin-resistant Staphylococcus aureus is relatively high, (2) aspiration of the bone or joint is imperative prior to the initiation of treatment to identify methicillin-resistant Staphylococcus aureus, and (3) patients with infection due to methicillin-resistant Staphylococcus aureus likely need multiple surgical procedures and prolonged intravenous antibiotics.
 
Anchor for JumpAnchor for Jump
+Fig. 1AAOS and POSNA public service announcement promoting pediatric orthopaedics.

Awards

At the 2005 POSNA annual meeting, the Distinguished Achievement Award was given to Dr. Robert Hensinger, the Arthur H. Huene Memorial Award for excellence and promise was given to Dr. Paul Sponseller, the Angela S.M. Kuo Young Investigator Memorial Award for recognition of an outstanding young investigator and to promote a long-term research career was given to Dr. Jeffrey Shilt, and the St. Giles Young Investigator Award for educational or research endeavors was given to Dr. James McCarthy.
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles published previously in this journal or cited already in this Update, six level-I articles were identified that were relevant to pediatric orthopaedics. A list of those titles is appended to this review after the standard bibliography. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.
American Academy of Pediatrics: Section on Orthopaedics October 7 through 10, 2006 Atlanta, Georgia.
Third International POSNA/AAOS Pediatric Orthopaedic Symposium November 29 through December 3, 2006 Orlando, Florida.
POSNA Specialty Day Meeting February 17, 2007 San Diego, California.
POSNA One Day Course: Upper Extremity May 22, 2007 Hollywood, Florida.
POSNA Annual Meeting May 23 through 26, 2007 Hollywood, Florida. Information at www.posna.org.
Lanou AJ, Berkow SE, Barnard ND. Calcium, dairy products, and bone health in children and young adults: a reevaluation of the evidence. Pediatrics. 2005;115:736-43.
These authors performed a quantitative synthesis of the literature regarding dairy products and total dietary calcium and bone integrity in children and young adults to assess whether there is evidence to support the current recommended calcium intake levels and the suggestion that dairy products are better for promoting bone integrity than other calcium-containing food sources or supplements. The authors concluded that, in clinical, longitudinal, retrospective, and cross-sectional studies, neither increased consumption of dairy products specifically nor total dietary calcium consumption has shown even a modestly consistent benefit for bone health in children or young adults. Thus, there is scant evidence to support nutrition guidelines focused specifically on increasing milk or other dairy product intake for promoting bone health in children and adolescents.
West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle fractures of the distal radius are safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J Pediatr Orthop. 2005;25:322-5.
Thirty-nine children with a buckle fracture of the distal part of the radius were randomized to be treated with a plaster cast for four weeks or with a soft bandage. There were no adverse events or skin problems in either group. The soft bandage was removed by 83% of the patients in the first week and by 100% by the second week. Care was simpler when the bandage was used. The authors suggested that use of a conventional cast for buckle fractures may be overtreatment and that a soft bandage may be appropriate.
Keppler P, Salem K, Schwarting B, Kinzl L. The effectiveness of physiotherapy after operative treatment of supracondylar humeral fractures in children. J Pediatr Orthop. 2005;25:314-6.
Forty-three children treated with open reduction and pinning of a supracondylar humeral fracture were randomized to receive physical therapy or no therapy after pin removal at four weeks. At twelve and eighteen weeks post-operatively, the range of motion was greater in the physical therapy group, but there was no difference in the range of motion at one year. The results of this study are not generalizable to patients treated with closed reduction and percutaneous pinning, as that method was not studied. Closed reduction and pinning is the most common method of treatment for these fractures, and physical therapy is usually not utilized after the pins and cast are removed at three to four weeks. The results of this study suggest that physical therapy may not be necessary after open reduction and pinning of supracondylar humeral fractures. However, physical therapy may be of some benefit for patients who had the limb immobilized for longer than four weeks or for older patients.
Florentino-Pineda I, Thompson GH, Poe-Kochert C, Huang RP, Haber LL, Blakemore LC. The effect of Amicar on perioperative blood loss in idiopathic scoliosis: the results of a prospective, randomized double-blind study. Spine. 2004;29:233-8.
Thirty-six patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion with instrumentation and autogenous iliac crest bone graft were randomized to receive Amicar (aminocaproic acid) or saline solution. Amicar inhibits activation of plasminogen to plasmin. Patients in the Amicar group demonstrated a significant decrease in the perioperative estimated blood-volume loss (41% compared with 47% in the control group) and the need for autologous blood transfusion (1.0 compared with 1.7 autologous units given). The decrease in blood loss was predominantly in the postoperative suction drainage. The patients who took Amicar had no intraoperative or postoperative thromboembolic complications. The results of this study support the use of Amicar to decrease blood loss and the need for transfusion after posterior spinal surgery in patients with adolescent idiopathic scoliosis.
Caulton JM, Ward KA, Alsop CW, Dunn G, Adams JE, Mughal MZ. A randomized controlled trial of standing programme on bone mineral density in non-ambulant children with cerebral palsy. Arch Dis Child. 2004;89:131-5.
Twenty-six nonambulatory patients with cerebral palsy were randomized to be treated with a program that involved increased standing, compared with baseline, in an upright or semiprone standing frame for nine months or were randomized to a control group, and bone mineral density was measured with quantitative computerized tomography. After the treatment period, the median standing duration was 80.5% and 140.6% of baseline in the control and intervention groups, respectively. There was a significant (p = 0.040) (6%) increase in vertebral bone mineral density in the intervention group. There was no significant increase in proximal tibial bone mineral density. The results of this study suggest that increasing the time that nonambulatory patients with cerebral palsy stand may increase bone density, which may reduce fracture risk.
Piza G, Caja VL, Gonzalez-Viejo MA, Navarro A. Hydroxyapatite-coated external-fixation pins. The effect on pin loosening and pin-track infection in leg lengthening for short stature. J Bone Joint Surg Br. 2004;86:892-7.
Twenty-three patients underwent a total of twenty-eight bilateral lower-extremity lengthening procedures with external fixators, and a total of 322 pins, because of short stature. The patients were randomized, by side, to be treated with either hydroxyapatite-coated pins or non-hydroxyapatite-coated pins. The mean implantation time was 530 days, and the mean lengthening achieved was 78% of the initial bone length. The mean extraction torque was 7611.6 Nmm/deg for the hydroxyapatite-coated pins and 85.4 Nmm/deg for the non-hydroxyapatite-coated pins. The rate of loosening was lower for the hydroxyapatite-coated pins (4% compared with 80%). There was no significant difference in the prevalence of pin-track infections. The results of this study support the use of hydroxyapatite-coated pins during limblengthening with external fixation.
Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J Bone Joint Surg Am. 2005;87: 254-9.87254  2005  [PubMed][CrossRef]
 
Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005;87: 2371-9.872371  2005  [CrossRef]
 
Park SS, Gordon JE, Luhmann SJ, Dobbs MB, Schoenecker PL. Outcome of hemiepiphyseal stapling for late-onset tibia vara. J Bone Joint Surg Am. 2005;87: 2259-66.872259  2005  [PubMed][CrossRef]
 
Vitale MA, Heyworth BE, Skaggs DL, Roye DP Jr, Lipton CB, Vitale MG. Comparison of the volume of scoliosis surgery between spine and pediatric orthopaedic fellowship-trained surgeons in New York and California. J Bone Joint Surg Am. 2005;87: 2687-92.872687  2005  [PubMed][CrossRef]
 
Hung VW, Qin L, Cheung CS, Lam TP, Ng BK, Tse YK, Guo X, Lee KM, Cheng JC. Osteopenia: a new prognostic factor of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2005;87: 2709-16.872709  2005  [CrossRef]
 
Tsirikos AI, McMaster MJ. Congenital anomalies of the ribs and chest wall associated with congenital deformities of the spine. J Bone Joint Surg Am. 2005;87: 2523-36.872523  2005  [PubMed][CrossRef]
 
Smith JT, Gollogly S, Dunn HK. Simultaneous anterior-posterior approach through a costotransversectomy for the treatment of congenital kyphosis and acquired kyphoscoliotic deformities. J Bone Joint Surg Am. 2005;87: 2281-9.872281  2005  [PubMed][CrossRef]
 
Luhmann SJ, Lenke LG, Kim YJ, Bridwell KH, Schootman M. Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary? Spine. 2005;30: 2061-7.302061  2005  [PubMed][CrossRef]
 
Burton DC, Sama AA, Asher MA, Burke SW, Boachie-Adjei O, Huang RC, Green DW, Rawlins BA. The treatment of large (>70 degrees) thoracic idiopathic scoliosis curves with posterior instrumentation and arthrodesis: when is anterior release indicated? Spine. 2005;30: 1979-84.301979  2005  [PubMed][CrossRef]
 
Kim YJ, Lenke LG, Cheh G, Riew KD. Evaluation of pedicle screw placement in the deformed spine using intraoperative plain radiographs: a comparison with computerized tomography. Spine. 2005;30: 2084-8.302084  2005  [PubMed][CrossRef]
 
Cheng I, Kim Y, Gupta MC, Bridwell KH, Hurford RK, Lee SS, Theerajunyaporn T, Lenke LG. Apical sublaminar wires versus pedicle screws—which provides better results for surgical correction of adolescent idiopathic scoliosis? Spine. 2005;30: 2104-12.302104  2005  [PubMed][CrossRef]
 
Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg Am. 2005;87: 8-12.878  2005  [CrossRef]
 
Tien YC, Chen JC, Fu YC, Chih TT, Hunag PJ, Wang GJ. Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. J Bone Joint Surg Am. 2005;87: 1456-63.871456  2005  [CrossRef]
 
Leet AI, Pichard CP, Ain MC. Surgical treatment of femoral fractures in obese children: does excessive body weight increase the rate of complications? J Bone Joint Surg Am. 2005;87: 2609-13.872609  2005  [PubMed][CrossRef]
 
Kay RM, Rethlefsen SA, Fern-Buneo A, Wren TA, Skaggs DL. Botulinum toxin as an adjunct to serial casting treatment in children with cerebral palsy. J Bone Joint Surg Am. 2004;86: 2377-84.862377  2004  [PubMed]
 
Presedo A, Oh CW, Dabney KW, Miller F. Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. J Bone Joint Surg Am. 2005;87: 832-41.87832  2005  [PubMed][CrossRef]
 
Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006;88: 1251-7.881251  2006  [CrossRef]
 

Submit a comment

Anchor for JumpAnchor for Jump
+Fig. 1AAOS and POSNA public service announcement promoting pediatric orthopaedics.

References

Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J Bone Joint Surg Am. 2005;87: 254-9.87254  2005  [PubMed][CrossRef]
 
Kocher MS, Garg S, Micheli LJ. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005;87: 2371-9.872371  2005  [CrossRef]
 
Park SS, Gordon JE, Luhmann SJ, Dobbs MB, Schoenecker PL. Outcome of hemiepiphyseal stapling for late-onset tibia vara. J Bone Joint Surg Am. 2005;87: 2259-66.872259  2005  [PubMed][CrossRef]
 
Vitale MA, Heyworth BE, Skaggs DL, Roye DP Jr, Lipton CB, Vitale MG. Comparison of the volume of scoliosis surgery between spine and pediatric orthopaedic fellowship-trained surgeons in New York and California. J Bone Joint Surg Am. 2005;87: 2687-92.872687  2005  [PubMed][CrossRef]
 
Hung VW, Qin L, Cheung CS, Lam TP, Ng BK, Tse YK, Guo X, Lee KM, Cheng JC. Osteopenia: a new prognostic factor of curve progression in adolescent idiopathic scoliosis. J Bone Joint Surg Am. 2005;87: 2709-16.872709  2005  [CrossRef]
 
Tsirikos AI, McMaster MJ. Congenital anomalies of the ribs and chest wall associated with congenital deformities of the spine. J Bone Joint Surg Am. 2005;87: 2523-36.872523  2005  [PubMed][CrossRef]
 
Smith JT, Gollogly S, Dunn HK. Simultaneous anterior-posterior approach through a costotransversectomy for the treatment of congenital kyphosis and acquired kyphoscoliotic deformities. J Bone Joint Surg Am. 2005;87: 2281-9.872281  2005  [PubMed][CrossRef]
 
Luhmann SJ, Lenke LG, Kim YJ, Bridwell KH, Schootman M. Thoracic adolescent idiopathic scoliosis curves between 70 degrees and 100 degrees: is anterior release necessary? Spine. 2005;30: 2061-7.302061  2005  [PubMed][CrossRef]
 
Burton DC, Sama AA, Asher MA, Burke SW, Boachie-Adjei O, Huang RC, Green DW, Rawlins BA. The treatment of large (>70 degrees) thoracic idiopathic scoliosis curves with posterior instrumentation and arthrodesis: when is anterior release indicated? Spine. 2005;30: 1979-84.301979  2005  [PubMed][CrossRef]
 
Kim YJ, Lenke LG, Cheh G, Riew KD. Evaluation of pedicle screw placement in the deformed spine using intraoperative plain radiographs: a comparison with computerized tomography. Spine. 2005;30: 2084-8.302084  2005  [PubMed][CrossRef]
 
Cheng I, Kim Y, Gupta MC, Bridwell KH, Hurford RK, Lee SS, Theerajunyaporn T, Lenke LG. Apical sublaminar wires versus pedicle screws—which provides better results for surgical correction of adolescent idiopathic scoliosis? Spine. 2005;30: 2104-12.302104  2005  [PubMed][CrossRef]
 
Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg Am. 2005;87: 8-12.878  2005  [CrossRef]
 
Tien YC, Chen JC, Fu YC, Chih TT, Hunag PJ, Wang GJ. Supracondylar dome osteotomy for cubitus valgus deformity associated with a lateral condylar nonunion in children. J Bone Joint Surg Am. 2005;87: 1456-63.871456  2005  [CrossRef]
 
Leet AI, Pichard CP, Ain MC. Surgical treatment of femoral fractures in obese children: does excessive body weight increase the rate of complications? J Bone Joint Surg Am. 2005;87: 2609-13.872609  2005  [PubMed][CrossRef]
 
Kay RM, Rethlefsen SA, Fern-Buneo A, Wren TA, Skaggs DL. Botulinum toxin as an adjunct to serial casting treatment in children with cerebral palsy. J Bone Joint Surg Am. 2004;86: 2377-84.862377  2004  [PubMed]
 
Presedo A, Oh CW, Dabney KW, Miller F. Soft-tissue releases to treat spastic hip subluxation in children with cerebral palsy. J Bone Joint Surg Am. 2005;87: 832-41.87832  2005  [PubMed][CrossRef]
 
Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006;88: 1251-7.881251  2006  [CrossRef]
 
Accreditation Statement
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Topic Collections
Related Audio and Videos
Clinical Trials
Readers of This Also Read...
JBJS Jobs
02/28/2014
District of Columbia (DC) - Children's National Medical Center
12/04/2013
New York - Icahn School of Medicine at Mount Sinai
04/02/2014
W. Virginia - Charleston Area Medical Center
12/31/2013
S. Carolina - Department of Orthopaedic Surgery Medical Univerity of South Carlonina