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The brace cannot correct the rotation of the vertebral These platelets oxidized on contact and were thus able to bodies [106] or the lordosis discount voltaren 100mg mastercard. Brace-wearing period: While this investigation calls into question the efficacy of The brace must be worn consistently day and night brace treatment generic 100mg voltaren free shipping, a more recent study showed that a brace until growth is complete (Risser IV) order 100mg voltaren fast delivery. Since the psy- worn for only part of the time is almost just as efficient as chological strain associated with brace treatment is when worn for the whole day discount 50 mg voltaren amex. A significant advantage of considerable generic voltaren 100 mg without prescription, the patient needs good support. Only if the dynamic SpineCor brace is the much better acceptance everyone involved (doctor, parents, physical therapist, by the patients and thus better compliance. The brace must scolioses, however, than for thoracic scolioses, since sur- be worn for 22–23 hours a day, and may be removed gery does not represent a satisfactory alternative for the only for sports activities or during physical therapy. Brace treatment must always be backed up by physical ther- Results of brace treatment apy and exercise since wearing of the brace results in Although brace treatment can halt the progression of the atrophy of the paravertebral muscles, which have less scoliosis it cannot correct the condition in the long term. This atrophy must be countered The initial reduction in curvature is lost again when treat- by swimming, sport and postural exercises. With the Zielke instrumentation, produced by digital methods are also suitable. When the a derotation can be performed while at the same time brace is ready, its effect must be checked radiographically preserving the lordosis. Clinical checks are then arranged every 3 threaded rod that can be rotated by a special derotation months. Kyphosing is avoided by the insertion of al- should be recorded every 6 months (AP only, without the logenic bone grafts in the spaces between the disks. In the 1970’s Luque introduced the rods named for Regular check-ups should continue at this rate until the him (which are anchored without hooks) and the tech- patient is weaned off the brace. The principal advantages of segmental wiring: the correction is produced not just Electrical stimulation via longitudinal but also via transverse forces; a certain In the 1970’s and 1980’s, electrical stimulation raised amount of derotation also occurs, thereby increasing sta- hopes of an alternative to the brace. This technique still has an important role to play in been shown to be ineffective [3, 90]. At the start of the 1980’s an instrumentation system that introduced new elements in the surgical treatment of Surgery can not only halt the progression of scoliosis, scoliosis was developed by Cotrel and Dubousset in France but can (to a certain extent) straighten the curvature. This system allows the curvature to be corrected and essentially maintain the correction after the spinal in three dimensions and provides stable fixation with a fusion has stabilized. Hooks and screws can be fixed to cated in thoracic scolioses from a Cobb angle of 40° bendable rods at any desired point and in any desired po- and, in thoracolumbar or lumbar scolioses, from a Cobb sition. The treatment of thoracic scoliosis in this system is angle of 50° or if decompensation is present. The disad- based on the principle of inserting several hooks (usually vantage of all existing surgical procedures is the need to 4) at certain points on the concave side. The rod is then rotated through 90° in The era of the surgical treatment of scoliosis began with the dorsal direction, i. He described a technique of poste- at one and the same time, the scoliosis is reduced, the rior vertebral fusion, which he subsequently used kyphosis increased and the spine derotated. The correction of the curvature was then applies distraction and secures the hooks in place. Subsequent refinements in the Another rod that exerts a compressive force is inserted on plaster cast technique produced such corrective casts as the convex side (⊡ Fig. A whole In 1962, Harrington reported on the correction of series of instrumentations has since appeared on the mar- scolioses by instrumentation. This primarily involved ket, all of which are based on the principle of Cotrel and a distraction rod that was used on the concave side of the Dubousset and each offering its own particular advantages scoliosis. In 1969, and unaware of the Harrington procedure, Dw- The segmental principle of Luque wiring is further yer in Australia described a correction method for scoliosis perfected in the »Universal Spinal System« [4, 78]. He used screws inserted rod is inserted from the concave side and placed in the from the front into the vertebral bodies on the convex side planned position of kyphosis or lordosis, and hooks and and linked with each other by a cable. The correction was screws are inserted into the laminae or pedicles at various achieved by pulling on the cable to produce compression. The main disadvantage of this method was the kyphosing The advantage of this system over the Cotrel-Dubousset resulting from the resection of the intervertebral disks, technique is the absence of any increase in the rotation of which is highly undesirable in the lumbar area.

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Decision-making before embarking on the use of bracing is dependent on the magnitude of the curvature 100 mg voltaren free shipping, the magnitude of clinical deformity voltaren 50mg line, the location of the curve and the degree of skeletal Figure 5 voltaren 100mg on line. The examination position and clinical findings of scoliosis and maturation discount 50 mg voltaren otc. The clinical findings of a spinal curvature are readily detected in a very brief examination (Figure 5 cheap 100mg voltaren with amex. Those findings most commonly noted are asymmetry of the height of the shoulder, as reflected by the trapezial slope, asymmetry of the inferior and medial border of the scapula when standing erect, asymmetry of the lumbar creases, prominent rib bulge on 90 degree forward bending, or a prominent lumbar muscular bulge. Furthermore, when standing erect a plumb line dropped from the seventh cervical spinous process should rest completely within the gluteal crease. Curves secondary to limb length inequality will generally show no evidence of spinal rotation or vertebral deformation. The diagnosis is easily established, and after assessing the magnitude of the curvature, a determination will be required as to the need for any further specialty care. The condition results in a “roundback” or “humpback” deformity, is best visualized from the side on lateral bending, is seen equally in males and females, and generally is found in patients between 12 and 16 years of age. Commonly there is a hereditary pattern to its presentation but the exact mode of transmission is unknown. The vast majority of cases of Scheuermann’s disease are located in Figure 5. Lateral radiograph demonstrating “wedging” and characteristic the thoracic spine region, with roughly vertebral changes seen in Scheuermann’s disease. At least half of the patients so affected will present with back pain as a significant part of their symptomatology. Although the exact etiology is continuously debated, it is clear that there is a disorder of growth of the ring epiphyses of the thoracic and lumbar vertebrae. The vertebrae end plates are often “irregular” and “frayed,” particularly anteriorly, and distortion is evident in the subchondral bone adjacent to the “limbic” (ring) epiphysis (Figure 5. This disproportionate reduction in anterior to posterior vertebral height likely reflects asymmetrical compression. The sequela of this physeal abnormality is an architectural alteration in the shape of the vertebra, progressing from a rectangular shape to more of a “trapezoidal” or “wedge” shape. If this disorder affects the thoracic spine, the deformity produced is one of kyphosis or kyphoscoliosis. If the deformity affects the lumbar spine there will commonly be straightening of the lumbar spine or a localized lumbar kyphosis. A substantial number of patients with Scheuermann’s disease have an associated spondylolysis. The pain related by the patient may be mechanical in nature and associated with activities or may occur at rest, occasionally Adolescence and puberty 82 occurring at night, and may be more characteristic of an inflammatory type of pain. Standard conservative regimens (heat, rest, massage, and anti-inflammatory medication) usually will ameliorate the symptoms, although occasionally disparaging symptoms may necessitate spinal orthotics. By the conclusion of skeletal maturation, the pain has almost always subsided, leaving whatever degree of spinal deformity remaining. The primary disorder to be differentiated by physicians will be “postural” kyphosis. Children and adolescents presenting with “postural” kyphosis will have a “flexible” spine and can change their degree of kyphosis (deformity) simply by positioning. Prone lateral radiographs will show a distinct reduction in the degree of kyphosis. Patients with Scheuermann’s disease will maintain their thoracic deformity, whether standing radiographs or supine or prone radiographs are taken. Furthermore, “postural” kyphosis is not accompanied by anatomic changes within the vertebrae. In the thoracic region, normal degrees of kyphosis have been estimated to measure as high as 50 degrees without anatomic vertebral wedging. Patients with greater than 50 degrees of kyphosis associated with characteristic signs of vertebral “wedging” and irregularities of the growth plate demonstrate findings compatible with Scheuermann’s disease. Magnetic resonance imaging (MRI) may be necessary in cases with accompanying neurologic defects. The natural history of Scheuermann’s disease is for slow progression to occur during the adolescent growing years, and to stabilize when skeletal maturation approaches. Pulmonary compromise rarely occurs in patients with less than 60 degrees of curvature.

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Polydactyly and syndactyly Polydactyly (duplication of fingers or toes) is a common abnormality and is usually inherited as an autosomal dominant characteristic (Fig cheap 50 mg voltaren with visa. Both polydactyly and syndactyly can involve bone or soft tissue and both may require surgery in later childhood for cosmetic purposes order voltaren 100 mg online. The spine Back pain in children is uncommon5 and because of the potential for spinal disease to result in considerable disability buy voltaren 100 mg without prescription, accurate assessment and diagnosis of all spinal complaints is essential and MRI voltaren 50 mg online, in the majority of cases order 100 mg voltaren otc, is the imaging modality of choice14. Discitis 15 Discitis is an infrequent problem of the paediatric thoracolumbar spine that results from bacterial infection of the intervertebral disc spreading to the verte- bral endplates of the adjacent vertebrae over a period of several weeks12. Clini- cal symptoms are dependent upon patient age and include fever and vomiting in the younger child, while in adolescents back pain is the most common presentation. Plain film radiography of the spine will demonstrate a reduced Orthopaedics 181 Fig. Kyphosis and lordosis Paediatric kyphosis and lordosis are uncommon when compared to scoliosis. A possible cause of increased kyphosis and reduced lumbar lordosis during early adolescence is Scheuermann’s disease which results in the anterior compression of the vertebral body. Plain film radiographic examination should include an antero-posterior and a lateral projection. However, it is essential that the arms are not raised above the level of the lower costal margin as this will con- siderably alter the normal spinal curvature and invalidate the diagnostic accu- racy of the examination16. Scoliosis Scoliosis is defined as the lateral curvature of the spine although a sagittal or transverse component to the curve may also be present. The majority of child- 17 hood scoliosis cases are idiopathic in nature (i. Despite technological advancements, plain film radiog- raphy is still the examination of choice to provide the initial diagnosis and evaluate the degree of the curve. However, MRI also has a significant role to play, particularly in the assessment of intraspinal anomalies and pre-surgical planning18. Plain film radiographic examination of the spine for scoliosis should be per- formed with the patient erect, and a single antero-posterior or postero-anterior projection of the whole spine is sufficient for diagnosis and observational mon- 16 itoring of curves less than 20°. However, as patients with progressive scoliosis may have regular imaging to assess the progression of the curve, it is important that the radiation dose is minimised and to facilitate this, the postero-anterior projection is preferred as it will reduce the dose to the sensitive anterior organs. The adoption of a high kilovoltage technique will also reduce patient dose whilst facilitating the visualisation of the whole spine. The lower border of the cassette should be positioned at the level of the anterior superior iliac spines and collimation opened to include the whole of the spine and the iliac crests. Skeletal maturity is achieved when the iliac crest apophyses reach the posterior superior iliac spines and therefore these 7 should be included on all assessment radiographs. Where radiographs of non- ambulatory patients are requested then these should be undertaken with the spine in its normal functional position (i. Infection Infection of the musculoskeletal system can cause severe disability if not detected and treated at an early stage and all imaging modalities may have a role to play (Box 8. The clinical history provided by the patient or their family can provide impor- tant clues to infection, and signs of systemic illness, localised swelling, erythema, reduction in limb movement or unusual limb position are all suggestive of an infective process. Osteomyelitis Osteomyelitis commonly occurs as a result of haematogenous spread (via the blood) and may be acute, subacute or chronic in presentation. It is typically seen 184 Paediatric Radiography Box 8. Plain film radiography Preliminary examination to exclude trauma or other pathologies Ultrasound Useful in the detection of joint effusions and fluid collections in the soft tissues and sub-periosteal regions May guide aspiration or drainage of fluid collections or effusions Scintigraphy Has a high sensitivity rate and is useful in the identification of multifocal infection Magnetic resonance imaging (MRI) High sensitivity Can accurately assess soft tissues and bones to evaluate the local extent of musculoskeletal infections Computed tomography (CT) Can detect osseous or soft tissue abnormalities, particularly gas in the soft tissues in the metaphyseal region of long bones as a result of the slow movement of blood through the sinusoidal vessels which allows bacteria to adhere to the vas- cular membranes. Clinical symptoms of osteomyelitis include localised pain and swelling and a recent history of systemic illness (e. Radi- ographic findings depend upon the age of the patient and the time of infection onset. However, plain films are not sensitive to early osteomyelitic changes and although they may be requested to exclude other causes of the patient’s symp- toms, scintigraphy is the initial imaging investigation of choice in cases of sus- pected skeletal infection7 (Fig. Septic arthritis Septic arthritis is the inflammation of a joint as a result of infection. The infec- tion may enter the joint directly (traumatic or surgical infection), or indirectly from an adjacent osteomyelitic infection or by haematogenous spread.

Small hip condition rapidly spiral if it is not diagnosed children have an excellent instinct in relation to pain discount 50mg voltaren free shipping. They spontaneously avoid weight-bearing on a painful extremity until the symptoms have disappeared (in con- An experienced clinician is usually able to complete the trast with adults purchase voltaren 100mg with visa, some of whom like to play the hero while differential diagnosis with a high degree of certainty on others suffer from inertia and do not risk weight-bearing the basis of the child’s general condition alone generic voltaren 100 mg with amex. On moval of the fluid relieves the joint and also the pain 50 mg voltaren, the the other hand – every experienced clinician was once effusion often recurs after aspiration [10 purchase voltaren 50 mg with visa, 21]. The cal parameters suggest an infectious process, the hip drawback of aspiration is the need for a general anes- effusion must be aspirated and the aspirated fluid for- thetic. We therefore aspirate only in those cases involving warded for bacteriological investigation. Under no cir- a distinct restriction of movement and with sonographic cumstances may antibiotics be administered before the evidence of a substantial effusion. One If the aspirated fluid is clear but there are definite randomized study comparing the administration of ibu- clinical signs of infection, the possibility of acute he- profen vs. In our view, the constantly repeated recommenda- If there are no signs of infection but the illness and/or tion to follow-up a case of transient synovitis after 3–6 effusion is protracted, we consider the following differen- months on the grounds that Legg-Calvé-Perthes disease tial diagnoses [1, 2, 5, 8, 16]: could develop from the effusion is not appropriate. Any ▬ juvenile rheumatoid arthritis of the hip, incipient Legg-Calvé-Perthes disease found at this point ▬ leukemia, will have already been present beforehand but had simply ▬ Lyme disease, not been visible or had been overlooked and did not 260 3. Fink AM, Berman L, Edwards D, Jacobson SK (1995) The irritable hip: immediate ultrasound guided aspiration and prevention of hospital admission. Futami T, KasaharaY, Suzuki S, Ushikubo S, Tsuchiya T (1991) Ul- trasonography in Transient Synovitis and Early Perthes’ Disease J Bone Jt Surg 73-B: 635 7. Goertzen M, Schulitz KP, Assheuer J (1991) Die Bedeutung der bildgebenden Verfahren für die Diagnosestellung und Therapie- 3 planung des M. Graf J, Bernd L, Niethard FU, Kaps HP (1991) Die Diagnostik bei der Coxitis fugax, der häufigsten Hüfterkrankung beim Kind. Kallio P, Ryöppy S (1985) Hyperpressure in juvenile hip disease, Acta ortop scand 56: 211 10. Kallio P, Ryöppy S, Kunnamo, I (1986) Transient synovitis and Perthes disease – is there an aetiological connection? Kermond S, Fink M, Graham K, Carlin J, Barnett P (2002) A random- ized clinical trial: should the child with transient synovitis of the hip be treated with nonsteroidal anti-inflammatory drugs? Kesteris U, Wingstrand H, Forsberg L, Egund N (1996) The effect of arthrocentesis in transient synovitis of the hip in the child: a longitudinal sonographic study. Kocher M, Zurakowski D, Kasser J (1999) Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR (2004) Validation of a clinical prediction rule for the differentia- tion between septic arthritis and transient synovitis of the hip in develop from the effusion. J Bone Joint Surg Am 86-A:1629-35 if incipient Legg-Calvé-Perthes disease is involved, is 16. Konermann W, de Pellegrin M (1993) Die Differntialdiagnose des that recurrent episodes of limping can be expected and kindlichen Hüftschmerzes im Sonogramm. Landin LA, Danielsson LG, Wattsgard C (1987) Transient synovitis transient effusion of itself does not trigger Legg-Calvé- of the hip – its incidence, epidemiology and relation to Perthes Perthes disease. Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, the parents do not even bother bringing the patients for Luhmann JD (2004) Differentiation between septic arthritis and a consultation since they treat the condition themselves transient synovitis of the hip in children with clinical prediction algorithms. Robben S, Lequin M, Diepstraten A, den Hollander J, Entius C, same as that for the initial episode. Meradji M (1999) Anterior joint capsule of the normal hip and in children with transient synovitis: US study with anatomic and References histologic correlation. Hüftgelenksentzündung (Coxitis fugax) Z Orthop 130: 529 J Bone Jt Surg Br 77:748 2. Terjesen T, Osthus P (1991) Ultrasonography in serous coxitis Septic arthritis versus transient synovitis of the hip: the value of Tidsskr Nor Laegeforen 111: 2970 screening laboratory tests. Ehrendorfer S, Le Quesne G, Penta M, Smith P, Cundy P (1996) and transient synovitis of the hip. Clin Orthop 385: 118–23 Bilateral synovitis in symptomatic unilateral transient synovitis 23.

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