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INFORMATION

This is the Internet site where you will find the explanation to the trauma or orthopaedic problem that worries you. You can find the elucidations of your disease and, easy understandable. Moreover, if it is in your interest, you can go deeper in the topic by a reading of the more specific chapters.

We offer you our experience in orthopaedic problems, especially in: Perthes disease, hip dysplasia, scoliosis, clubfoot, or the knee disorders as chondromalacia or the discoid meniscus. In addition, our group rely on specialists in uncommon diseases and we can help you to contact them.
The used language is simple and understandable for external people to healthcare. Nevertheless, if though you do not understand something, do not hesitate to ask us. You can do it by clicking or come to our medical consultation.

We can study your case, offering the clarification that you need and promoting a treating plan according to the current knowledge in medicine. Our group studies and knows the orthopaedic innovations, promoting conferences and congresses about different pathologies affecting the growth of bones.

WHAT DO WE TREAT?

Perthes disease

Perthes disease is the child’s hip bone necrosis (cell death) with a progressive destruction. From the beginning of necrosis to resume a new revitalization process last several years (2.5-7). X-ray pictures show a damage compression of the sphere that usually shows a femoral head. As it can be compared in two previous pictures, there is a femoral head bone compression (it turns out to be whiter!)
The impact of Perthes is unknown but in our Infant Orthopaedics around 20 cases per year have being diagnosed. The author’s casuistry is based in a review of more than 400 cases of Perthes disease along his professional career and on the study and publication of works on this illness.

Regarding symptomatology, the lameness existence in child must make us think about this pathology. They are children who begin to limp without any justified reason or after a minor trauma. Often they relate pain in inguinal region or in thigh. These symptoms prevail despite the prescribed rest treatment and anti-inflammatory administration. As an exception, the child has not pain and the only noticeable is a slight lameness. The reporting age goes from 4 to 9 years old. Further beyond ages are infrequent.
The disease origin is unknown. However, according to recent studies, it could be a disorder of blood coagulation and particularly a thrombophilia or blood coagulability. This disorder would cause temporary occlusions but not repeated of the small arterioles of the femoral head and subsequently a bone cell death due to the lack of nutrients delivery (Thomas DP and cols, United Kingdom; Hayek S, Israel, our group, Spain). More recent Spanish studies have shown also a greater incidence of Perthes in children from smoking parents, but the latest procedure which is triggering necrosis is unknown.
The diagnosis is based on radiology. Just a simple hip x-ray picture can diagnose the diseases and set the beginning of the treatment. X-ray images in addition to the diagnosis will show us the evolution and final disease –prognosis. It should be noted that the progression time goes from a minimum of 2.5 and a maximum of 7 years, Catterall (London).
The recovery of the head height can be noticed, as well as the shape and architecture.
This case recovered the head spherical shape, as its size, so that it is expected that the joint of this hip has a long survival.
It is a case that hopefully will not require surgery in his adult age, since he will not present an arthrous atrophy.

The treatment should be precocious, during the first or second phase of perthes. That is, at the moment in which the bone is still malleable. In late phases of the disease, the regenerated bone cannot be malleable in the hip acetabulum and thus, its morphology cannot be modified.
Currently the Perthes treatment is based on the “containment method.” The hip is a joint comprising the osteocartilaginous sphere (femoral head) and a semicircle containing it (acetabulum). It is regarded that, whereas the femur ball keeps mobile inside the cup or acetabulum, the head, while necrose, will not loss its spherical shape and therefore it will have a good final result. Stulberg et al. showed that as more spherical is the ending of the femoral head the more years will last this joint in adult age.
Thus, the last purpose of the treatment is to achieve by all means a spherical femoral head and not flat. The old joint discharging methods by bed resting during 1 or 2 years, or the classic discharging splints type Tachdjian have been proven totally ineffective. None of both methods vary the natural disease evolution.

As can be seen, the femoral spherical head shape is been lost, and both head and cup contained are flat. The architecture has not been recovered and it is foreseeable the pain presence and hip rigidity.
This joint disease will be early and this sick individual will need a hip prosthesis at young adult age.
As it is a joint supporting up to 6 times the corporal weight it impaired more easily than the other body joints. Therefore small disorders in shape cause an early joint impairment.
Most of the hip prosthesis that currently are being place in Spain may be due to arthrosis caused by the Perthes disease. An early detection of this disease should be carried out as a rule, to every child who begins to limp without any apparent cause. Just an x-ray picture and the splint of low limbs opening, kept during some months may be sufficient to prevent hip arthrosis. Otherwise, they could be candidate patients to a surgery of prosthesis substitution in young adult age, with the subsequent increase of patient morbidity and a greater healthcare expense for the society.
The disease causal ignorance opens a study field in Children Traumatology. From this point of view, the society should look for the necessary researching ways to clarify its etiology. In this context, a novel scientific study has been published by the Pediatric Orthopedics Journal, JC, Abril et al. (No 6, 2000) of our research team. In it, a Perthes subgroup is described with a really bad clinical progress which makes them different from the classic Perthes, which good results may become the 85%.

Foot pathology
MORE COMMON DEFORMITIES:
FLAT FOOT-PES VALGUS
It is the loss of the inner arc of foot. It must be flexible and painless so, otherwise we should suspect of a base disease.

CLUBFOOT and PONSETI METHOD

Clubfoot is a congenital malformation affecting bones, muscles and foot tendons provoking a curve inwards of down remaining rigid and without being able to recover the normal position. It is the most common pathology in children and it may affect both feet. The more frequent causes are hereditary and environmental. The deformity gives rise the second quarter of foetal life, when the foot is quickly growing and it is detected by ultrasound or in childbirth. For many years the surgery has been the resource to solve the disorder but now there is an option, the Ponseti Method, which is applied in the RUBER INTERNATIONAL CLINIC of Madrid since 1995. Dr.Abril has obtained successful results. A 95% of cases are set right in 8 weeks to later follow the foot corrective care process. The treatment involves firstly a proper manipulation and foot casting, with following casts during the next 6-8 weeks. In most of cases an Aquiles tenotomy is performed under anaesthesia. After taking out casts and three weeks after the tenotomy, the child must wear a splint with two special shoes: straight boots, open up ahead and joined by a bar (Dennis-Brown.) This splint must be used 24 hours a day, except for one hour for personal hygiene, for 6 months. After this period, it will be used overnight until the child has 4 years. Later he must visit the doctor every 6 months until the age of 8 years. It is desirable to start the treatment from childbirth, in the delivery room, to ensure the success; however there are patients who have later begun the Ponseti Method, with 7 years old with worse results. The age is not a restriction to improve the quality of life.

HOLLOW FOOT

They are foot with an increase of the inner longitudinal arch. It may be painful, especially the most developed. There is a treatment in case of pain and it is recommended the use of insoles before the surgical correction. Most part of them is due to neurological disorders that, we, the doctors, must discard.

ADDUCT FOOT

They are feet “placing” the fingers inwards. Often are flexible and affect to children between 2 and 5 years old. They are fixed by foot manipulation. If this continues, we must treat them by appropriate shoes with straight mould. The prognosis is excellent.

BUNION OR HALLUX VAGUS

It is the first toe inwards deformity, with pain in the inflamed swelling of the bursa when rubbing the shoe. There are two types, the teenager one and the degenerative.

KNEE

Knee diseases occur commonly during childhood and particularly during adolescence. The symptoms are pain and swollenness. It may represent a several series of diseases requiring very different therapies. At this age it is necessary to bear in mind the presence of the cartilage growth, manifest in the bone at childhood, and which can be affected by very aggressive treatments.
The more common knee diseases of child and adolescence are:

  • Chondromalacia patella
    Chronic pain
    Cartilaginous lesion ramollissement
  • Osteochondrosis dissecans
    Pain and efflux
    Bone and cartilage lesion
  • Broken or discoidal meniscus
    Pain with mobility disorder
    Meniscus tissue lesion
  • Osgood-Schlatter disease
    Pain and prominentia after sport
    Appophyseal injury
  • Jumper disease (Sinding-Larsen)
    Located pain of kneecap tip
    Appophyseal injury
  • Benign/malign bone tumors
    Variation of symptoms
    Tumor cell lesion
  • Baker cyst
    Back of the knee tumor
    Cystic joint injury
  • Kneecap dislocation
    Knee failure
    Kneecap loss position
  • Valgum and varus genu
    Painless deformity
    Loss of normal leg axe

For a correct knee function is required:
• a correct anatomical shape, both for femur and tibia, but, in particular kneecap.
• a good stabilization by muscular ligaments and tendons.
If this forces balance is altered by repeated traumas or huge sport needs we could face the above mentioned disorders.
The change in knee alignment can cause:
Kneecap instability: It is produced by anatomical variations that lead to a deficient performance of this pulley. There is a high impact, reaching a 50% of 100.000 children under 10 years old. Many patients do not ask to the specialist until they do not present a strong pain clinical setting.
The knee is the pulley that works by the pulling strength of thigh, when it is contracting on having stretched the knee. Small changes in the kneecap shape or its stabilizers cause disorders in its correct performance. When the knee is bended from the 30º, the kneecap is fitted in the femoral channel performing as a train wheel does to not be derailed. Normally it is a coherent joint and when the pulley has the enough deep to accommodate the keel of the kneecap, it does not get out and does not hurt. If children have a flat kneecap and a slightly deeply femoral cavity a derailment of both bones is produced and subsequently pain. These anatomical disorders may be observed in most of children with chronic knee pain.
Knee is one of the joints that more painful problems cause during the growing period. A right examination may be enough to diagnose the cause.
When a child or adolescent presents a kneecap pathology a series of anatomical disorders must be looked up:
• Flat femoral troclea: it means a cavity or flat path where the kneecap may easily move out.
• Kneecap with small keel: the way in which the keel favours its movement by the femoral troclea. This patients presents a flat kneecap implying lateral kneecap gets out of its way.
• Genu valgum: it is a morphology in x of legs what forces the kneecap to keep extreme pressure in its external side. This type of contact causes a chronic pain. Such deformity is measured with the Q angle.
• Femoral torsion: it is the shape of the femur axis. Usually these patients present a previous torsion of the femoral neck; therefore the kneecap would be pushed outside. Typically these children have knees pointing inwards when they are standing with the hips or legs in neutral position, i.e. looking onwards.
• Tibial torsion: it is usually external, therefore the kneecap tendon insertion is in a very lateral position, what produces the hypertension syndrome and secondarily a deep pain while walking.
Treatment:
• Resting and anti-inflammatories administration
• Rehabilitation.
• Ozonoterapia en forma de infiltraciones.
• Arthroscopic surgery

• Child lameness

Diagnosis Strategy

• Clinical examination: the child shows functional powerlessness more marked while walking, he improves resting. The lower limb is in external abduction-rotation and flexion: “anti-analgesic position”. The lameness is caused by the time reduction of the affected limb support. Sometimes lameness does not exist but located pain in groin region. The pain often is referred to knee.
• Interview: it is difficult as they are very young children. They must be questioned about the pain characteristics, times of appearance, lasting, repetition and intensity. Other affected joints or ankylosing spondylitis or chronic polyarthritis must be looked.
• Examination: a bilateral examination is necessary to be done, comparing both hips. Initially with the child standing up and then in supine position:
a. Mobility: we will look at the largeness of movements: flexion, separation, adduction, extension and rotations. For a better examination of internal rotation movements it is practical to place the patient in supine ventral.
b. Muscular atrophies.
c. General examination: the clinical examination is completed by searching: general state disorders: fever, ganglionic nodules and splenics. Examination of the rest of joints. In palpation we will look for painful points doing it systematically, and always finishing in the painful area.

Differential Diagnoses

The clinical setting of child’s painful hip conceals a big number of etiologies with different prognosis. This diagnostic difficulty is greater as pain is the first disease manifestation.
Some of these settings require a precocious diagnosis to avoid serious complications (iatrogenic pathology: confusion between rheumatoid arthritis and an infectious one). The base-treatment must not be performed without a certainty diagnosis.

Dystrophic Pathology

Enfermedad de Perthes
Proximal femoral epiphysiolysis coxa vara
Age: 3-9 years
Age: 10-15 years

Inflamatories Diseases

Transitory acute synovitis
Chronic youthful arthritis
It is the most frequent cause
Rare disorder

INFECTIOUS DISEASES
Acute bacterial arthritis
Other infections: Tuberculosis, salmonellosis, measles, hepatitis.
Requires urgent treatment
Very unusual

-Tumoral pathology:
Benign tumors: Osteoid osteoma, chondroblastoma, eosinophilic granuloma
Malignant tumors:

TRAUMA PATHOLOGY
Fractures
Trauma background

DIVERSE AFFECTATIONS
Laminar coxitis or chondrolysis
Osteochondrosis dissecans
Synovial chondromatosis
intraarticular hemorrhages in hemophiliacs
Villonodular synovitis
Malignant haemopathies
adolescents
Secondary to Perthes
Chronic pain
haemophilia
Risk of chronic injuries

Some of the above described entities deserve only a chapter to be developed. Consequently we are going to highlight the three more frequent causes of lameness in children:
Transitory acute synovitis
It is the more common cause of lameness in children. They are children between 2-6 years (younger than in Perthes case). Pain is presented acute in half of patients and in the other half is of insidious appearance. It is frequent to find a precedent of rhinopharyngitis one or two weeks before (to a 70% according to Spok).
There are no differences regarding the side but rarely are bilateral. Males turn out to be double affected than females.
• The clinic examination shows a restriction in mobility arches with muscle spasm. The child rarely seems to be ill and usually is afebrile.
• Blood analysis shows normalcy.
• Joint ultrasound confirms the existence of liquid inside.
• The joint puncture is not indicated if this pathology is suspected, but if it would be performed a clear liquid would be found and its culture would be negative.
Many authors believe that the transitory synovitis is the previous step of every ostheochondritis or Perthes (3-10% of frequency).
The transitory synovitis diagnosis must be based in:
• Positive criteria: clinically compatible and ultrasound with joint efflux.
• Exclusion criteria: altered radiology.
It is necessary to inform to parents about the frequent recurrence of the clinical setting, but, consequently, is not a prognosis worsening!!! It may be repeated various times in a year or once after several years!!!

The treatment lies in resting in the most comfortable position which usually is a slight hip flexion (pillow under the knee). Most patients improve notably after 24-48 hours what is a support to diagnosis. Afterwards the child can resume its daily activities but gradually. If he would take back the complete support of weight before the recovery there is a greater risk of pain recurrence.

Chronic arthritis (Still’s disease)
It is a not infectious inflammatory disease of one or various joints affecting young people around the age of 16. The symptoms lengthiness is 3 months approximately. There is often a familiar hereditary character.
Initially, diagnosis is complex, since the joint pain is the first illness indicator. When the rest of symptoms arise few weeks or months after, it may be diagnosed with more certainty. The other symptoms involve joints affectation or even other organs harming as liver, spleen, nodes, eyes, skin…
The other joints that may be affected are knees, fingers and feet.
Radiographically no disorders are noticeable up to later periods.
• Diagnosis is based in a blood substance identification named rheumatoid factor, but this is only in a 30% of cases. This encouraging percentage increases with the disease development, even in years.
• The joint fluid puncture shows few cells (less than 3.000 cells by mm3) but with the presence of more than the 5% of ragocytes concentration.
• The synovial biopsy is performable under arthroscopy, showing chronic inflammatory infiltrated. It is easier to diagnosis in the affecting ways of many devices or organism systems, which go along with fever, skin spots, liver or spleen size increase, muscular pains, etc…
Acute bacterial arthritis

Today rather infrequent, for hygiene and antibiotic general usage before any symptom of fever. The relevance of symptoms lies in the quick evolution of complications development (cartilage necrosis and irreparable bone injury).
They are frequently feverish children and with a bad general health, with much pain in the affected joint and with immobility of the concerned limb (very restricted mobility).
The more habitually involved germ as the infection source is the aureus staphylococcus. This bacterium has many tendencies to colonize articulations as it has specific fastening in its wall that joint it to the articular cartilage, from they do not unfasten and easily multiply. This germ is present in our skin where it cannot simply get through it. However, it can reach the blood and be spread within the body through small injuries or grazes, by the gums after a vigorous toothbrushing or even by the finger hangnails.

Diagnosis
• BIOLOGICAL diagnosis
o Leucocytes increase in blood and gain of the speed as well as the rest of inflammatory parameters.
o Ultrasound supports the presence of liquid in the articular cavity.
o The articular puncture identifies the germ and the most suitable antibiotic is chosen.
• X-ray diagnosis may show:
o Precocious signs: Increase of the articular space by a development of its fluids. There are x-ray signs relying on the soft parts, but they are difficult to rendering: Loss of sharpness of muscular planes, greater edema of the subcutaneous tissue.
o late signs: We should not wait to find them as they reveal irreversible joint injuries: Periosteal reaction, geodes, articular clamping.

Treatment
• It must be precocious preparing the irreversible articular destruction. Arthrotomy or surgical joint cleaning: It is the definitive infection healing and, at the same time, a sample for cultivation is taken.
• Effective antibiotherapy during not less than a month and until the symptomatology remission. Firmly fix the joint by traction or casting for a period.
!!! Prognosis is always adverse when there is a belated treatment!!!

Fractures

Bone fracture repair
A broken bone implies the quick start of repairing by biological mechanisms; most of the times give back the bone disruption. The beginning of the haematoma creation is the focus that later is going to be transformed into a bone after 3-4 weeks. The bone immobility accelerates the healing and therefore, is absolutely essential bandaging type casts.
Occasionally surgical procedures are inevitable to realign and stabilize broken bones with plaques, screws, nails or wires. Hardly ever can be required bony grafts, facilitating the fracture healing and speeding such a process.
The surgical repairing is advised for complex fractures, which cannot be realigned (correct) by external methods, not surgical. Since the misalignment of the articular surfaces may benefit the arthrosis benefit, this is valid, mostly in fractures that involve joints.
Bone fractures in children show an unusualness of an active growing physis. In some cases physeal traumas are produced affecting its normal growth, arousing evolving deforming aftermaths, sometimes terrible for the limb function. Disorders in longitudinally growth (affected limb shortening) and axial may be produced, generating lateral imbalances. These disturbances are the axis of “crooked limbs.” They later require surgical corrections.
Accordingly, fractures in children require an extremely carefulness, specifically for long bones fractures manipulation, avoiding also the iatrogenic lesions subsequent to broken bone manipulation.

Hip dysplasia

DISORDERS IN DEVELOPMENT OF CHILD HIP: LUXATION AND DYSPLASIA.
The hip joint is formed by the femur head (spherical ball) and the acetabulum, which is the part of the pelvis that is articulated by it (semi-spherical cup covering it). When this intimate relation between both bones is lost, the ride starts a gradual degeneration that finishes with the arthrosis evolvement in adult age. Problems, luxation and dysplasia are relatively frequent in new-born’s hip or in his early years. Its treatment is rather simple. It brings favourable results when it is early detected.
What is hip dysplasia?
Dysplasia (from Greek dys, means bad, and plássein, shape) it is a term referring the presence of a wide spectrum of abnormalities in the hip formation. These abnormalities are already present from birth and go from very mild, only noticeable by ultrasound, to more serious as complete luxation, that is the exit of the femoral heat from the acetabulum cup.

Why is caused this disease?
There is not any cause to origin this abnormality but there is a series of risk factors, which oblige to be watchful to discover high likely children to develop this disorder.
Which are the risks factors to develop dysplasia?
1. Family history: Heredity is an important factor. Those children whose parents or relatives had it have a higher risk; for example, grandparents submitted to hip prosthesis surgeries.
2. Pregnancy background*. Dysplasia is more frequent in first-borns, in low weight at birth, multiple pregnancies, breech births, or if his mother presented a decreasing of amniotic fluid during pregnancy.
3. Feminine sex: Dysplasia is more usual in women regarding men in a 6-1 rate.
4. Related malformations: It is habitual finding hips with dysplasia in children with other disorders: As clubfoot, metatarsus adductus, stiff neck, or limb malformations.
* All these factors have in common the space restriction in which foetus may move inside the uterus, interfering in his hip’s normal development. Birth by caesarean is not by itself a risking factor for the disease development.
Any child with risking factors or with an abnormal physical examination must be submitted to confirming diagnosis tests to discard a hip dysplasia!!!
How is the dysplasia detected?
There are several methods to detect dysplasia and they are used in according to the patient’s age, in particular regarding the x-ray examinations. The most useful and effective measure to be early diagnosed is to execute a clinical test to all newborn of hips, looking for clinical signs as reduction of the normal hips opening, or the comparative difference in low limbs skinfolds or the patient’s limb shortening. Altogether, the children orthopaedal traumatologist or paediatrics tries to do some soft manipulation to determine if the child’s hip is steady; that is to say, if he keeps his position in the acetabulum cup, or if it is luxated and cannot be placed in the normal anatomical position.
Child detailed follow-up with variations in the exploration!!!
Those patients with repeated disorders are compelled to be submitted to x-raying explorations to check the existence of this problem and settle its severity.
The hip dysplasia detecting programs advise to perform, in addition to the newborn initial evaluation, periodic joint examinations to every child under one year old.
Which are the tests more used to confirm the diagnosis?
A hip ultrasound for a child under three months and a pelvis x-ray to children over this age. Performed x-rays before the third month of life have less utility because these children, around an 80% of the joint, is made up by cartilage, thus, it is not visible with x-ray. Once the diagnosis is done, clinical and x-ray controls must be done to settle the treatment response.
When the dysplasia treatment should begin?
As earlier it is started, greater will be the possibilities of a positive response and a complete recovery!

How is the dysplasia treated?
The treatment relates to the moment of luxation detection and its degree. Generally, children with dysplasia are initially treated with orthopaedic devices or even cast to support hip in a fixed open position and hip flexion. Children with severe dysplasias or non-responding to the treatment may require at any moment surgeries to correct this defect, restoring the femoral head to its right position.

What are the types of devices for treating dysplasia?
Albeit there is a wide range of devices for the dysplasia treatment, the most used are the Pavlik harness and the Frejka splint. The first one is device made up of fastened belts to a type of strip surrounding the baby thorax, and it is used to guide patents about the appropriate position and adjust it to reach the desired position.
How many hours a day must them be used?
Depending on the dysplasia severity and the patient’s age, and it must be customized to each child according to the infant traumatologist criteria. Likewise, he will evaluate the moment of removing it. Overall it will be used 23 hours a day to be diminished gradually when its withdrawal is contemplated. It can be removed just one hour a day; it will match the moment for baby bath, if the harness or splints are permanently used. If the child starts walking and he does not tolerate the device, it can be turn out to night use if the patient’s evolution allow it.

Which cares does need the devices?
The main parents ‘duty is: to follow strictly the infant traumatologist’s indications regarding schedules and form of laying the device, to be watchful of the compression areas, skin reddening or grazes and to attend accurately to all the checkouts.

How often the patients must be controlled?
The controls frequency is variable, and it mainly depends on the patient’s age and its case severity. At the beginning, it may be required even weekly controls to children with severe dysplasias or complete luxation, doing then assessments every three or four months; at the age of two years old, the evaluations are more dispersed.

How long may last the treatment?
In general, the treatment lasting is difficult to forecast, but it largely rests on the problem severity and the collaboration degree of parents regarding his advises. Children with hip dysplasia or luxation diagnosis must follow periodic controls until almost the end of growth or even after if it is considered necessary due to the presence of some persistent alteration.

In which moment is surgery needed?

Children with hip luxation or who cannot reduce the joint with the initial treatment, that is, to put it in the correct position, may require early surgeries (from six to eight months old) to execute a reduction under anaesthesia and fixing his hip by casting it. Those patients with persistent dysplasia at the end of their orthopaedic treatment may require surgery to restore the hip after three years.

Do all patients respond equally to the treatment?
This reaction is very uncertain; children with severe dysplasias, who have a hip luxation or those whose parents do not help correctly to the treatment, may show partial improvements and, in this case they may require to be submitted to one or various hip surgeries.

Which consequences does the non-treated dysplasia have?
The result of leaving the treatment or not performing it under the stated is obvious in all those patients who did not receive a proper manipulation and today show a premature hip wear disease, causing them pains and lameness. These people must be submitted sometimes to several surgeries which results are not usually so good as the ones of a child’s early treatment. These patients’ lameness is a consequence of the produced wear in hip (situation called arthrosis), and the final limbs length, which, although in most cases, it is not significant, it may also need treatment.

Which complications may the treatment entail?
The most regular intricacies provoked by hip dysplasia and luxation often are transitory disorders as a slight delay to start walking as the child feels difficult moving himself wearing the devices, or he has skin irritations caused by these devices.

How to prevent hip luxation or dysplasia?
There is no measure in our reach to effectively prevent these disorders development. As exposed, and the severe consequences that altogether implies, the best thing is to have a diagnosis as soon as it is possible.

Malformations

Congenital abnormalities.
The birth of a child with a congenital malformation involves an inevitable anger for all the family and a guilt feeling. Not surprisingly parents look for an explanation to this problem. In view of the frequency of such malformations is really high, the problem may be more serious of the expected. Thus, as clarification we can state that;
• Half of spontaneous miscarriages are due to incompatible chromosomal defects with life.
• A 30% of children mortality is secondary genetic disorder. The big malformations are the second cause of death in children under one years old.
• 5% of newborns present genetic defects.
• A third of the periodic hospitalizations are for genetic reasons.
• Each individual is a carrier of 5 to 8 with genetic defects; therefore each couple has the possibility to conceive genetic anomalies in a 3% of their sons.

Etiology

The origin of congenital malformations is varied and several, being in more than half the cases of unknown cause. It may be multifactorial in a 25%, chromosomal in 10%, monogenic in an 8% and only in a 7% the cause could be environmental (medicines, infections, environmental poisons, etc.)
Genetic diseases transmission may be produced in three ways: Chromosomic abnormalities, monogenetic disorders and complex disorder resulting of the multiple genes integration and environmental factors.
• Chromosomal disorders happen in a 1% of newborns alive and are responsible of half of the spontaneous miscarriages occurring in the first half of pregnancy.
• Monogenetic disorders occurring in approximately a 2% of population. There are three big categories: Dominants, recessives and connected to chromosomes X.
o Dominant: At least a father affected. In each pregnancy have a 50% of chances to transmit the defects to his descendants. If affectation is of both parents, their descendants have a probability of a 75% to be affected.
o Recessive: Both parents are carriers but not ill. The option to have an ill descendant is of a 25%.
o Connected to the chromosome X: A man only has a chromosome X and woman has two. So, man will be ill and the woman will be carrier but not ill.
• Multifactorial disorders: Incidence between a 2% and 4% of population. It is difficult or almost impossible to determine the risk of contracting a multifactorial disease, when there is a descendant affected it is calculated that the possibility of affection to another descendant is a 5%.
The number of secondary malformations to exogenous noxae (drugs, medicines, alcohol, tobacco…) or teratogenic is minimum and thus many theories have been proposed to clarify this malformations origin:
• The polygenic origin is based on the idea that a malformation depends on several genetic places. This hypothesis has several factors in its favour but, on the contrary it would not explain why the different frequency of malformations in identical twins.
• The multifactorial hypothesis suggests several alternatives, in particular the genetic disease as interaction of intrinsic and extrinsic factors.
• The environmental synergy implies that various not teratogenic factors by themselves may provoke a malformation in certain circumstances.
• The evolution noise: Assumes that the malformation origin would be in a series of spontaneous and intrinsic mistakes would be as spontaneous mutations. If this explanation was certain it would imply that the incidence of malformations never could be reduced to zero.

Teratogenesis mechanisms

All the malformations specialists apparently agree that there is an exhibition threshold in below this the teratogenic effects do not appear, they are distinguished of mutation in this, and the carcinogenesis that are phenomena that, the simple contact implies risk.
The embryopathies generally come about the first two months of life, that is where most of the structures usually are formed, and it is a time in which the mother is not typically fully watchful on his pregnancy.

Etymologiae

There are some terms used to talk about congenital malformations, and frequently they are used in an exchanging way, but its meaning is different:
• Malformation: Word coming from the Latin root “bad formation”, that is, bad built structure.
• Deformation:
A structure formed correctly but loses its normal shape. It appears at the end of the fetal life.
• Dysplasia: A tissue produced in a wrong organ, not matched to the structure where it lives.
• Congenital: Referring to all the conditions already present in birth independently of its cause.
• Syndrome: Word derived from Greek and means coincidence. A group of symptoms concurring in the same disease.
• Genetic: Also called hereditary. Familiar: It means the condition affecting various members of a family.

Congenital malformations study

These researches are hard for diverse reasons; firstly, the unawareness of the real malformations occurrence and what is usually interpreted as an incidence increase or decrease is just environmental noticed health service factors. Secondly, due to the difficulty on establishing a causal connection between cause and malformation. Cost and arduousness to perform those studies are added to the previous difficulties, since for proving a hypothesis it is necessary a pretty extensive patient’s sample.

How acting before a malformation?
• First contact to a paediatrics or children traumatologist who will give you a genetic advice for the future and a treatment planning of the possible child’s deformities.
• Moreover functional and aesthetic aftermaths that may affect the child should be foreseen.
• And, at last, treating deformities and its effects, if these are already produced.

Cerebral palsy

Cerebral palsy name means a lesion affecting muscles control and it is caused by a cerebral damage. It means that, due to a brain lesion, muscles cannot be normally used. Children who have cerebral palsy (CP) are unable to walk, talk, eat or play as most of children.
It is important to discern that the CP is not a disease, but a lesion suffered by the brain and of which it will not be recovered.
• It is not contagious.
• It does not need to worsen.
• There is no cure, they will have it for life.

How is a cerebral palsy diagnosed?
Physicians diagnose cerebral palsy by testing the motor development of the child and carefully studying his medical history. These children will have a slowly development, an abnormal muscle tone or a rare posture. We also observe tendon reflexes (the ones we are searching with the hammer!!) and the earlier development of neck, hand, trunk and legs movements.
Reflexes are body movements automatically made in response of a certain stimulus. For instance: a newborn is held on his back, and we bend him as his legs must remain over his head; automatically the baby will extend his arms in a gesture, called Moro reflex but, in cerebral palsy cases, this instinctive reflex may be retained for an unusual period of time. This is just one of the several reflex tests to be done.

Doctors also look up the dominant hand (or preferred), the trend to more frequent use of right or left. If the doctor lifts an object before and next to the child, the child who has a dominant hand will use his favourite hand to reach the object, even though this one is closer to the opposite hand to the object. Children often do not show preference for any hand during his 12 first months of life. Nonetheless, especially children with spastic hemiplegia may sooner develop this preference, since the hand in the affected side is much more useful.

The next step in cerebral palsy diagnosis is to recognize further disorders that could give rise to movement disturbances. The essential for doctors is to determine whether the child situation is not worsening. While CP symptoms may get more noticeable, the underlying problems do not worsen over time. In the event that a child is continuously losing motor capabilities, the problem obviously may appear from another disorder (genetic disorders, musculars, metabolism disorders, or nervous system tumors included.) In some other cases, the child history, and special diagnosis tests may help to confirm the diagnosis.

The doctor could require specialized test to know more about the CP potential cause. One of these tests may be a computerized axial tomography, CAT, an advanced imaging technique used x-rays and a computer to create a brain anatomical picture and its structures. A CAT may reveal brain areas poorly developed, abnormal cysts (frequently full of fluids) in brain, or other physical disorders. With the TAC provided report, the doctors can be better informed and long-term enlighten who the affected child will be.
The Magnetic Resonance; MRI is an imaging technique relatively new which is becoming more popular than others in order to identify brain disorders. This technique uses the magnetic field and radio waves, which are better than x-rays. MRI offers optimum structures pictures or of abnormal areas close to the bone.
There is a third test showing the brain tissues problems, the ultrasound (echography). It is a technique that makes bouncing sound waves in brain and uses patterns generated by the echo to form a picture or sonogram of its structures. Ultrasound may be used in children before his skull bones have been closed and hardened. In contrast to be less precise than CAT and MRI, these techniques may detect cysts and brain structures, it is cheaper and it does not require patient’s immobilization during a long period of time.
To sum up, other problems jointly to the cerebral palsy can be sought, including convulsions, intellectual impairment and vision and ear disorders. When doctor suspects of convulsions problem (epilepsy) he may require an electroencephalogram (EEG). Small electrodes are used in an EEG placed in the head to record the natural electricity circulation inside the brain. These records may help the physicians to see the electric brain activity patterns which may involve convulsive crisis.
Intelligence tests are frequently used to determine if the child with cerebral palsy is mentally qualified. Anyhow sometimes, child intelligence may not be valued for his motor, sensitive or speech problems because the cerebral palsy makes difficult to perform these tests.
The specialist may forward the patient to an ophthalmologist for being examined if a vision disorder is presumed; the same is applied to hearing, an otolaryngologist visit may be required.
It is highly significant to perform an early diagnose to identify all the possible symptoms. Many of these annoyances can be ameliorated with specific treatments.
How CP is contracted?
CP is caused by an earlier brain injury during or a short time after birth. In many cases, nobody certainly knows the cause of cerebral lesion or what to do to prevent it.
Occasionally the child’s brain lesion occurs while the baby is still in the mother’s womb (before birth). The lesion can be brought about an infection or an accident in which the mother is injured. If the mother has a medical problem as high blood pressure or diabetes, this one can be transferred to the child. During childbirth, problems as lack of oxygen or a complex delivery may cause damage in the child brain. The complications after delivery appear when the child is preterm born, and his body is not still ready to live outside the mother’s uterus. Even children born on the due term may develop infections or brain effusions that may origin the damage because the brain is still being developed even after birth.
The most significant is to remember that CP is not contagious from a person to another, and that there is not further later progression. It is only caused by a brain lesion near the birth date.

CP types
Children with CP have damaged the area of their brain controlling the muscular tone. Their muscular tone will be too much or too many developed or a mix of both depending on the brain-damaged area and on the size of the lesion. The muscular tone is what allows to our body to adapt particular positions like sitting with the head upward looking at the teacher in class. Changes in the muscular tone allow us to move.
Try this: Double your arm to lead your hand touching your nose. To do this, you must shorten or increase the muscular tone in the frontal upper side of your arm (biceps) while lengthen or diminishing the tone of the posterior upper arm (triceps). For moving your arm gently without shocks and without striking your nose, the muscles tone used to perform the movements must be changed in the way and precise moment – one is stretching while the other is relaxing.
Children with CP are not able to gently change their muscular tone and on time, so their movement may be shocking or clumsy.

-Spastic cerebral palsy.

The term spastic is to describe this type of cerebral palsy, if the muscular tone is too high or strong. Children with spastic CP have disorganized movements and stiff because their muscles are too tight. Often they take too much time in moving from one position to another or leaving something from their hands. This is the most common CP type. Approximately half of the CP patients have a spastic CP.

-Ataxic Cerebral Palsy.
Ataxia is loss of coordination in their movements and low muscular tone. Children with ataxic CP seem rather unsteady and shaking. They have many trembles like elder people ones, especially when they are trying to do something as turning a page or cutting with scissors. They also often have little balance and may be really unstable when walking. As a consequence of these trembling movements and the coordination problems of their muscles, the children with ataxic CP are neither good in writing nor in artistic works.

-Athetoid cerebral palsy.
The term athetoid is used to describe the type of cerebral palsy when the muscular tone is mixed – sometimes too tight and other ones too lax. Children with athetoid CP have problems being stood, in a correct position for walking or sitting, and commonly they do many uncontrolled movements on the face, arms and the upper part of their body (randomly, involuntary movements). Their movements are generally large. For some children with athetoid CP, doing something manual (as scratching their nose or reach a cup) involves a big effort and concentration. They are incapable of holding things (as a toothbrush, a fork or a pencil) due to their mixed tone and their problems to maintain a position. Around a fourth part of people with CP have an athetoid CP.

-Mixed cerebral palsy
When the muscular tone is too low in some muscles and too much high in others we talk of mixed cerebral palsy. Around a fourth part of people with cerebral palsy have a mixed CP.

Children with CP in addition to the different types of muscular tone, may have different parts of their body affected by the CP. It is also due to the damaged part of their brain and the size of the lesion.

-Quadriplegia (tetraplegia): Quadriplegia means that the child presents CP in both arms and legs. Children with quadriplegia have problems to move all their parts of the body, face and trunk as well as limbs, and they may require a wheelchair to transport him. Due to these problems for controlling the face and upper part of the body muscles, they also may have speaking and eating disorders.
Hemiplegia: It means that the CP only affect to one side of the child’s body. Thus, right hand and leg or left hand and right leg are affected. The remaining parts of the body have a correct activity. Many children with hemiplegia are capable to walk and run, however they have a clumsy appearance or limp.

-Diplegia: Many children suffer CP only in their legs which are much more severe than in their arms. This is called diplegia. As you likely may suppose, the difficulty for children with diplegia is their legs use, then, they may have serious troubles for walking and running. They are perfectly capable to stand up and have a good usage of their arms and hands as their upper body is not affected. You may wonder how someone can suffer CP in their arms but not in their legs. It happens sometimes but rarely.

Therapies for cerebral palsy.
Children with CP must follow different types of therapies to help them to ameliorate their functionality for walking, speaking and using their hands. Some children follow the therapy at school and other ones in special educational centres. Therapists are specialized professionals trained to help people to learning better to find easy ways to do things. As a couch helps a football team to improve their play, therapists train people helping them to learn and practice new abilities.

Physical therapy.
Physiotherapists help children to find the skills to move or improve their balance. They must help children with CP to learn how to walk, to use their wheelchairs, be standing, or to go upstairs or downstairs safely. Children must learn also other amusing physical skills as running, kicking and throwing the ball, or learning to ride or mount in bicycle.
Speech therapy and language. Speech therapist must work with children in the different types of communication. Types of communication mean: Speaking, using sign language or helping to communicate (communication) Children capable of talking, can work with their speech therapist to make their language clearer (easy to understand), or increasing their vocabulary by introducing new words, learning to use sentences, or improving their learning. The children who are not capable to talk due to their difficulty to control the necessary muscles for the speech must use the sign language or some type of alternative or augmentative communication. A type of augmentative communication might be a book or a poster with drawings that shows the things wished by the person, or a board with the alphabet which the individual can use to construct his message. There are also computers used as a communication help, and even can talk instead the person!

Occupational therapy
Occupational therapists often work with children the best way to use their arms, hands and upper body. They teach children the ideal way to write, to draw, to cut with scissors, to brush their teeth, to dress and to eat by themselves or to control their wheelchair. The occupational therapies also help children to find the easier way for doing a task.

Play therapy.
These therapists help children with CP to enjoy themselves. They work with them in sport or leisure activities. By this leisure therapy, children may learn ballet dancing, swimming or riding a horse. Moreover they can work in arts or horticulture (taking care of plants) or any other hobby in which they are interested.

Other problems related to CP:
Further to their muscles controlling problems, children with CP may also face other complications. Most of them are led to the same cerebral lesion that caused CP.

Speaking and eating
The language problem suffered by most of the children with CP is called dysarthria. It means the difficulty for them to control and coordinate the necessary muscles for speaking.
Their words may be slow and whispering, and their faces may seem rather funny when they make efforts for speaking. Some children’s voices may also sound different. If too much air would arrive through their nostrils while they speak, their voice would be hypernasal. If too few air arrives their voice would sound hyponasal, as when you are cooled and cannot breathe by the nose. If you meet someone with CP having language problems, try to understand their words, and do not feel culpable to tell him that you do not understand any word. Most of the people are ready to repeat it again, or to find a different way of communication, maybe writing or indicating, instead of pretending that you are understanding him, when it is not true.
Many of the muscles used to speak are also used for eating. Some children with CP may not be capable of biting and chewing some type of food. They also have problems sipping with a cane or licking an ice cream.

Learning problems
A fourth to half part of children with CP also has some type of learning problem. It can be a difficulty of learning that causes problems with one or two subjects assimilating very well the rest or a more severe problem that make them learn much slowly.

Epilepsy
Approximately half of the CP patients have crisis. This means that in some occasion an abnormal activity arises in their brains interrupting their current activity. Often, the brain abnormal activity happens in the same location where they have the injury causing CP. The brain is continuously sending messages to the body for breathing, moving, supporting the heart beating. A crisis is a series of abnormal messages sent simultaneously. Some people show it with convulsions when they have a crisis. Crisis usually last from few seconds to some minutes. Many children take an special medication to reduce the number of crisis. In any case, you should know that these crises also happen to people without CP.

Incontinence
A common problem is incontinence, it is caused by a lack of control in muscles which are keeping sphincters closed. The incontinence may also appear under the form of “wetting the bed” (also known as enuresis), Lack of urine control during physical activities (or stress incontinence), or by slowly urine loss through sphincters. Some medical treatments for incontinence may be special exercises, medicines administration or surgical implants to replace or to help the muscles. There is also specially designed underwear for these problems.

Risk factors
According to some researches, there are certain factors considered “risked” and which are increasing the possibility that a child is diagnosed with CP
• Breech birth. Many babies with CP seem to present firstly feet instead the head at the beginning of the childbirth.
• Complicated childbirth. Baby’s vascular or respiratory problems during childbirth may sometimes be the first symptom of cerebral injury or a deficient brain development. Such complications may be the origin of a permanent cerebral lesion.
• Nervous system malformations. Children with physical defects at birth (including insufficient spine formation, groin hernia, o abnormally small jaw – increase CP risks.
• Low Apgar score. Apgar (named by the anaesthetist Virginia Apgar) informs about the new born situation through a test score. To determine the Apgar score, the physicians periodically check the baby’s heart, breathing, muscular tone, reflexes and feet colour during the first minutes after birth. All these items are rated by points; the highest score is the best baby’s condition. A low result after 10-20 minutes after childbirth is frequently considered as an important signal of potential problems.
Newborns with low weight and premature birth. The CP risk is higher among babies’ weight underneath 2500 g. at birth and children born under the 37 weeks of pregnancy.
• Pregnancy.
• Multiple pregnancy. Twins, triplets and other multiple pregnancies are joined to the CP high risk.
• Nervous system malformations. Some babies born with CP have visible signs of nervous system malformations, such as an abnormally small head, this suggest that some problem occurred during the child nervous system when he was in his mother’s womb.
• Mother’s blood loss or severe proteinuria at pregnancy final stage. Loss of vaginal blood during the ninth month of pregnancy and proteins excess in the urine, are annexed to a high risk of have a child with CP.
• Mother’s hyperthyroidism, intellectual impairment or convulsions. Mothers with some of these symptoms must be aware of higher possibilities to have a child affected by CP.
• Newborn convulsions. A child with convulsive crisis presents a high risk of a CP diagnosis.

How is a cerebral palsy diagnosed?
Physicians diagnose cerebral palsy by testing children’s functional development and carefully studying their medical history. In addition of looking for symptoms as: Slow development, abnormal muscular tone or rare posture. The child’s reflexes and the early development of the dominant hand are also tested.

Reflexes are body movements automatically made in response of a certain stimulus. For instance, a newborn is held on his back, and we bend him as his legs must remain over his head; automatically the baby will extend his arms in a gesture, called Moro reflex but, in cerebral palsy cases, this instinctive reflex may be retained for an unusual period of time. This is just one of the several reflex tests to be done.
Doctors also look up the dominant hand (or preferred), the trend to more frequent use of right or left. If the doctor lifts an object before and next to the child, the child who has a dominant hand will use his favourite hand to reach the object, even though this one is closer to the opposite hand to the object. Children often do not show preference for any hand during his 12 first months of life. Nonetheless, especially children with spastic hemiplegia may sooner develop this preference, since the hand in the affected side is much more useful.

The next step in cerebral palsy diagnosis is to recognize further disorders that could give rise to movement disturbances. The essential for doctors is to determine whether the child situation is not worsening. While CP symptoms may get more noticeable, the underlying problems do not worsen over time. In the event that a child is continuously losing motor capabilities, the problem obviously may appear from another disorder (genetic disorders, musculars, metabolism disorders, or nervous system tumors included.) In some other cases, the child history, and special diagnosis tests may help to confirm the diagnosis.

The doctor could require specialized test to know more about the CP potential cause. One of these test may be a computerized axial tomography, CAT, an advanced imaging technique used x-rays and a computer to recreate a brain anatomical picture and its structures. A CAT may reveal brain areas poorly developed, abnormal cysts (frequently full of fluids) in brain, or other physical disorders. With the TAC provided report, the doctors can be better informed and long-term enlighten who the affected child will be.
The Magnetic Resonance; MRI is an imaging technique relatively new which is becoming more popular than others in order to identify brain disorders. This technique uses the magnetic field and radio waves, which are better than x-rays. MRI offers optimum structures pictures or of abnormal areas close to the bone.

There is a third test showing the brain tissues problems, the ultrasound (echography). A technique that makes bouncing sound waves in brain and uses patterns generated by the echo to form a picture or sonogram of its structures. Ultrasound may be used in children before his skull bones have been closed and hardened. In contrast to be less precise than CAT and MRI, this techniques may detect cysts and brain structures, it is cheaper and it does not require patient’s immobilization during a long period of time.

To sum up, other problems jointly to the cerebral palsy can be sought, including convulsions, intellectual impairment and vision and hearing disorders. When doctor suspects of convulsions problem (epilepsy) he may require an electroencephalogram (EEG). Small electrodes are used in a EEG placed in the head to record the natural electricity circulation inside the brain. These records may help the physicians to see the electric brain activity patterns which may involve convulsive crisis.

Intelligence tests are frequently used to determine if the child with cerebral palsy is mentally qualified. Anyhow, sometimes, child intelligence may not be valued for his motor, sensitive or speech problems because the cerebral palsy makes him difficult to perform these tests.
The specialist may forward the patient to an ophthalmologist for being examined if a vision disorder is presumed; the same is applied to hearing, an otolaryngologist visit may be required.

It is highly significant to perform an early diagnose to identify all the possible symptoms. Many of these annoyances can be ameliorated with specific treatments.

Dystonia

Dystonia causes involuntary long-lasting contractions of one or more muscular groups, causing torsions, trembles and abnormal postures. These movements may reach the whole body or only an aisled area. It is an abnormal muscular tone status (as for excess or lack). There are many dystonies, some of them are defined as specific syndromes:

Dystonic syndromes:
• Dystonic torsion: Formerly named muscles deforming dystonia, it is rare, it can be hereditary, usually begins in childhood and it turns progressively worse.
• Spasmodic torticollis: It is the most common focal dystonies. In torticollis, muscles which are controlling the head position are affected causing a head torsion to one to another side. Sometimes head can be inclined towards behind or ahead.
• Blespharospasm: It is the second more common dystonia. It is the involuntary eyelids closing. Even completely closing.
Dystonia treatments: they are varied, an specialized neurologist will be the best guide. Treatments can be medicine-based or surgical. Botulinum toxin injections are very effective for focal dystonies, it is very useful when dystonia affects to a limited group of muscles. The treatment needs to be repeated each three or four months and it must be performed by very experienced doctors in this area. Botulinum toxin.
Botulinum toxin is a complicated protein molecule and very sensible. Compared to its weight, it has the maximum toxicity of all the natural or artificial substances.
From when is known the botulinum toxin?
The botulinum toxin effects regarding the food poisoning were already known in the Ancient Roman Empire. Many big efforts were done to prevent botulism epidemics by the hygienic ruling in the Middle Age. At the end of the last century the botulism connexion, its corresponding bacteria and the botulinum toxin were finally explained. Through experiments with animals and a molecular biologic study, it was known who it works and which the effects of botulinum toxin are.

How does it work toxic botulin?
The involuntary movements are generated on electrical impulses in different parts of the brain, cerebellum and spinal cord. These impulses are sent to the peripheral nerves. At the end of the peripheral nerves is stocked in a chemical substance called acetylcholine. When an electric impulse reaches this point, the acetylcholine is activated and provokes the muscle to origin its contraction. When the botulinum toxin is injected in the right muscle a reaction is produced and the botulinum toxin blocks the acetylcholine. To take the most advantage of the therapy through botulinum toxin, it is necessary to identify which are the hyperactive muscles causing the clinical symptomatology and decide the suitable dosage to normalize the activity. The procedure is sure since the used amount in therapy is negligible, and the botulinum toxin remains long time in the point where it was injected, and it does not contact sensitive organs like liver, kidney or heart.

Which are the side effects?
There are no permanent effects. It may happen a temporary loss of muscle control near the infected area, normally without interfering its functions. The botulinum toxin must be injected in the hyperactive muscle, usually from one to three injections by muscle. The syringe is too small, thus, the pain should be insignificant (this, obviously changes according the tolerance of the patient).

When is evident the therapy effect?
The effect is generally evident after three days, usually between five or ten days; the maximum effect reaches from ten days to three weeks after, depending on the person. The effect last normally from two to four months, it will be decreasing gradually during some weeks after. After six months the benefits disappear completely.

Which are the necessary tests to decide if the therapy through botulinum toxin should be used?
It depends on the professional but, in general a full analysis of all the patient’s symptoms and also should be performed an electromyogram. The electromyogram shows which are the muscles with hyperactivity and in which degree.

How does it work botulinum toxin?
A drug solution is injected in the affected muscles using a disposable syringe with a thin needle. If several muscles are affected, several injections will be needed. It seems that, as a preventive measure, pregnant women must not be treated, although there are no indications regarding excluded patients. When a patient is taking anticoagulants, the botulinum toxin must be used with special caution. Certainly, the doctor must decide. It is important to tell him which the medicaments are being taken at present. Certain antibiotics or other nerve pulses interfering medicines may increase its effect.

What can cause fails in the therapy?
A fail may be due to various reasons. Some patients may develop antibodies voiding the botulinum toxin effect or some treatments may fail due to an incorrect dosage or an incorrect injection in the muscles.
Botulin, of course, improves the symptoms. It reduces pain and the movement is significantly better. The treatment can greatly improve the quality of life.

Additional treatments
Must be used exclusively the treatment by botulinum toxin? Very rarely. The patient must be informed of which the additional treatments are.
A psychological treatment must be followed? Dystonia is a neurologic disorder, not psychic; however, most of the dystonias are chronic, a psychological treatment can be proposed. A support team can be also very positive.

Physiotherapy is recommended? In some cases, as a cervical dystonia, axial and general dystonias, exercises are beneficial. Patients must consult with doctors and with professionals the best advantageous exercises.

May alternative medicine help? Unluckily, there are not records about the big success through the various alternative medicine perspectives. Anyhow, in some cases, there are improvements with alternative medicine.
MULTIPLE FIBROTOMIES by a method of Ulcibat. Our team has starting to perform the technique of fibrotomies in the children palsy. The percutaneous technique involves elongations and muscular contractures releases by small muscular and fascias sections. It is performed in OT under strict asepsis and general anaesthesia. The patient must rest during some weeks after the muscles section.

Thus, muscular disorders in children with cerebral palsy may be treated and also patients who suffer similar symptoms to the ones of CP. The main origin of contractures is the muscular hypertonia subordinate to a problem of the first neurone and may be formed in any functional segment of the body.
There are contractures:
• Of soft tissues (muscular contractures).
• Of joints (articular contractures).
The problem of muscular contractures is very relevant for these patients, since it is the main reason of the disorders suffered by them, in fascias, in aponeurosis, in ligaments and in tendons.
During this disease development first stage and, as a result of cerebral hypoxia the functional central nervous system is injured giving spasticity to the innervated distal muscles. Moreover, the hypoxia may involve direct and negatively a muscle since it affects all the human body tissues. The spasticity is the result of hypoxia muscles suffering for long time, as they are contracted, and all in all, provokes the degenerative process development of soft textiles structures dystrophy.
After a period of time, with medical efforts and child’s body defences, eradicate or diminish muscles spasticity is achieved. Thus, the blood irrigation, muscles nutrition and other soft tissues are recovered. Their tissue cells begin its healing from the dystrophy degenerative process, but all affected cells cannot be recuperated. A part of cells cannot be recuperated and goes to another low energetic level remaining devitalized in the more damaged cell groups and with a deficient blood circulation. This leads to a formation of contractures in soft tissues.

COMMON LANGUAGE PROBLEMS IN CP
Dysarthria: Dysarthria is defined as a poor articulation of words. This term is related to all the speech disorders, excepting those related to the aphasia. This failure is caused by a trouble in the nervous central system mechanisms which coordinate all the organs related to phonation as the case of people with CP. People affected by dysarthria understand perfectly the spoken and written language. These people understand all the spoken and the meaning of a conversation is not distorted.

-Apraxia: It is the difficulty to sequence and execute the necessary muscular movements to be able to speak. Although apraxia brain damages are not detected with a MRI to some people with apraxia, many children with it have neurologic disorders and brain lesions due to accidents associated to childbirth (before, during and after): Premature birth, umbilical cord around the neck, meconium problems. Many children with CP and speech disorders suffer apraxia, it is normally related to dysarthria.

Scoliosis and kyphosis

It is a lateral curvature of the spine occurred at any level of the upper back. The normal bone alignment protruding the vertebral column is lost. It may take the shape of an “S” or of a “C.” Scoliosis is a deformation and it should not be misunderstood with the scoliotic attitude or a poor posture. Scoliosis in children is not painful and, if it shows ache we should look for an underlying disease.
Parents must realise that the most part of scoliosis are minor and they will not grow enough to require treatment. Just the watchful traumatologist follow-up can be sufficient.

Scoliosis is basically the vertebrae rotation which subsequently presses the ribs to the curvature protuberant side provoking the ribs piling in the concave side. In the most advanced cases, the entire thoracic cage takes an ovoid form provoking that the ribs pile in the hollow side protruyan ahead, while the ribs in the opposite side are depressed. (Young girls with more progressive cases may though become startled because one of their breasts may seem smaller than the other one.) Actually the breast development is normal; and the altered part is in the base where ribs are.

Moreover, the disk spaces become straighter in the curve concave side, and they are wider in the convex side. Vertebrae also are minted and are thicker in the convex side. In the curve hollow side the pedicles and layers are shorter and thin, and the spinal canal is narrower.
The described structural changes are more frequent in the idiopathic forms of scoliosis; the pathology may vary in the paralytic and congenital shapes. Usually in the paralytic curve caused by a serious muscular disproportion, (for example, example in polio) the ribs adopt almost a vertical position in the convex side.

In A, the spinal process is turned away towards the hollow side. In B, the rib is beforehand and laterally pressed. In C, the spine is distorted to the convex side. In D, the rib is pushed by the posterior side and the thoracic cage is narrower.

Symptoms
Scoliosis happens to children and adolescents, and rarely to adults. Overall, scoliosis is diagnosed in adults as a result of an unnoticed child scoliosis.
The deformity may be begun at childhood (0-3 years), youth (4-10 years) or adolescence (over 10.) Mostly part of them is detected from the age of 10. Hence, parents must be watchful from this age and they must monitor their son’s back every 3-6 months. The deformity can be detected at a glance, depending on the aesthetic disorders produced, as:
• Hump or back “hunch”.
• Shoulders at different levels or prominent.
• Raised hip with waists asymmetry.
• One side tendency
The younger child develop a structural curve, he has a worse prognosis because the progression risk is more extended. If a girl matures later or she has a delayed menarche, there is also a proportional curve progression appearance. Albeit many curves are firstly discovered at approx. 12-13 years-old, these were already present since some time ago, but they were not observed until the adolescence growth acceleration was initiated.
Many early curves are identified with the school medical examination and children can be followed since they are very young.

Risk factors
The origin of scoliosis is unknown but there are clinical factors closely related to the deformity:
• Sex: girls are 10 times more likely to develop a curve progression than boys
• Age: as more early appears scoliosis, best opportunity for the curve progression
• Size or curve angle: as big is the curve angle, worse will be the damage.
• Localization: lumbar scoliosis or low back is less progressive
• Height: scoliosis is worse for tall girls
• Spine disorder at birth: babies born with congenital scoliosis have more chances to have a curve development.
Types of scoliosis
• Idiopathic: when the cause is unknown
• Congenital or with vertebrae malformations
• Secondary to different diseases
• Trauma: due to bad unconsolidated fractures
• Infectious: destroys vertebra
• Inflammatory
• Tumoral
• Others
Typical patterns
Thoracic curve on the right side is one of the more common idiopathic patterns. The curve is spreads including D4, D5 or D6 in its upper termination and D11, D12 6 L1 in its lower limit. Typically these curves are highly structural (do not correct the lateral slant.) Due to the severe spinal rotation, convex side ribs are seriously deformed resulting in a marked aesthetic defect and a serious damage of the cardiopulmonary function when the curve surpasses 60º. The right thoracic curves may develop quickly and must be treated soon in order to achieve an aesthetic improvement and an acceptable functionality.
Although the right thoracic curve is a bigger curve (that is, the curve is structural and relevant), there are often smaller curves opposite over and under the curve. These curves are subsequent or compensatory and often are associated to smaller curves. A compensatory curve tends to support the patient’s head on the pelvis in a body effort to sustain the spine in “balance.”
The curve thoracolumbar is a quite common idiopathic curve pattern. The upper termination spreads and includes D4, D5 6 D6 and the lower termination includes L2, L3 and L4.

As in right thoracic curves there are usually upper and minor lower lumbar thoracic curves. Typically, the thoracolumbar curve is less aesthetic distorting than the thoracic curve; even so, it may cause a serious rib distortion and the side resulting from a spine rotation.
The main lumbar curve is quite common and generally goes from D11 or D12 to LO5. In the 65% of cases the curve is to the left. Dorsal spine over the curve does not develop an structural compensation curve and remain flexible. The main lumbar curves are not quite deforming but they turn stiff and may lead to a deep lumbalgia in elder ages and during pregnancy and delivery.
Double major curve is based in two structural curves of a similar protrusions.

They may be a right thoracic curve associated to a left lumbar (the most common) or a double thoracic curve (upper right thoracic and left low thoracic.) When these curves are similar in opposite directions it is highly difficult to identify them because there is only small deformity aesthetic evidence. Nevertheless, in upper thoracic curves, the shoulders outline is very distorted and the deformity is really obvious.
Increase or progression of idiopathic scoliosis

The small scoliosis halts progression after the sexual development and the skeletal maturity. The curves reaches as much as 60º and 90º may keep increasing in adult age in an average of a speed of 1º per year. This fact was studied by Spanish authors in the 80s (Dr. Ceballos).
There may exist also factors favouring the progression during the adult life, like for example, patients with an important genetic burden, or a curve pattern that it is much destabilizing (thoracic curve, thoracolumbar or lumbar), or an extremely poor muscular tone, especially in women who have become sedentary and have gained weight.

The patients with scoliosis that get pregnant women do not experience necessary an increase of his curve, but it can increase their backache, as can happen to pregnant women without scoliosis.

Patients with scoliosis must be submitted to medical examinations to determine the curve progression and to start the treatment, if indicated.
Neither the patient nor the traumatologist must ignore scoliosis once the child becomes an adult.

Orthopaedic treatment: Bracing
Bracing for used firstly during the Middle Age when social rich groups mainly kings and court members asked armourers to make braces to stop the scoliosis progress.

Unfortunately, it was, simply, passive devices and not incorporating active correctors that finally were described by Blount and Schmit in 1946 with the Milwaukee brace development for treating both diseases, scoliosis and kyphosis.
In latest years, low profile braces have been developed. In these braces it is not necessary a neck collar to be efficient. The patient approval is much greater because they are barely seen under the clothing. They are especially useful in low and lumbar thoracic curves.
At first, it is recommended to wear brace during 23 hours a day. Children can relatively easily run and play with them. They are set over a long T-shirt; the exercises are daily done with or without brace to muscles strengthen, which are immobilized by the brace.

Exercises by themselves do not remedy scoliosis, but they help to keep a good back muscular tone which often is lost after immobilization.
Children with medium curves and s advanced may be part-time controlled with the brace application during 17 hours a day. This way the child does not need to wear brace at school.

Worldwide experts agree in that the most of curves finish approximately where they started when brace is applied for the first time.
Put differently, if a child shows a thoracic right curve of 30º and the brace treatment succeed reducing it 20º after the brace withdrawal at the end of the growth, the curve will worsen at the utmost before the treatment. This loss of correction is not a therapeutical frustration but a great success, since the progression of this curve has been prevented in 50º or 60º, surgical size.
Brace carriers wearers must be checked in regular consultations for readjusting the brace.
It is recommended at 5-8 months gaps, moments to perform a monitoring x-ray. The brace using period is often of several months until completing the full bone development (Risser 5).
The brain application most important factor is that the family must absolutely contribute, and the patient must be willing to wear the brace until his growth is finished.
The children have learned to accept orthodontics which actually has become a status symbol of many rich neighbourhoods. Instead, the brace never will reach a similar social status as certainly it is as important for the functional and aesthetic appearance to have a straight spine and without pain.
In most cases the early performance and the brace may help to avoid surgery.

Normally, most of traumatologist suggests the braces application in curves from 24º but this depends on its potential evolution, age, bone development and scoliosis cause.
Nevertheless, as the thoracic vertebrae rotation may imply a really serious aesthetic problem in curves under this figure, it is possible to place curves of minor size presenting a high vertebral rotation or an upper girdle unesthetic. Later, the brace will only be worn at night until the spine is completely matured.
All patients treated with brace must themselves monitor at 2-3-year life intervals to value their progress in the adult curve. As remarkable is the curve correction with brace, lesser possibilities are that the curve is significantly increasing at adult age.
Surgical treatment.
In 1911, the first spinal fusion was performed by Dr. Russefl Hibbs in the Orthopaedic Hospital of New York. Since then, the surgical techniques advances have successfully increased in scoliosis spinal surgery.
Usually is believed that brace is a conservative method. His performance during 5-8 years hardly may be called conservative. Actually, the surgery in many cases is more conservative than non-surgical treatment. Scoliosis surgical correction performed by an expert team in a modern hospital is statistically harmless for a child than a car trip. For a twelve years-old girl with a progressive curve of a 40º, a quick and suitable surgery is preferable than wearing a brace during some years in her most important period of life. After surgery, patients only have small incapability and can resume their normal life without curve progression worry. The idea of delaying surgery until the complete patient’s maturing is not always valid, in particular, if the curve increases relentlessly and there is not a response to the brace application. When there is a confirmation proving that the patient is progressing despite the brace, surgery must be just performed to obtain a better correction.
The main prescriptions for surgery are:
• Continuous curve progression.
• Greater curve progression despite the brace.
• Patient’s incapacity to leave the brace.
• Significant thoracic and lumbar pain.
• Progressive thoracic lordosis.
• Progressive loss of pulmonary function.
• Emotional or psychological incapacity to accept the brace.
• Shoulder and trunk serious aesthetic disorders.
The first goal of scoliosis surgery is to achieve a spinal fusion and to settle the curve. Some curves may be notably corrected specially in younger and flexible patients. In general, the metallic instrumentation set inside the body has the purpose to preserve the column in be best achievable position while there is performed a spinal bony fusion that the vertebrae must do naturally. In surgery the vertebral joints and other bone structures are “scratched” causing a bleeding in order to increase the vertebral bony union index. If the spine fusion is not accurately performed, the instrumentation will be damaged and the surgery will be failed.
After surgery most of the patients stay in the hospital during 7 or 8 days, adults a bit more. Scoliosis surgery is much complex to perform in adults than in children. Adults’ curves are affected by longer permanency, a greater number of severe medical complications and anxiety. Postsurgical fusion or the brace usages are not usually necessary with the most innovative instrumentation techniques. It is advisable sometimes a low-profile brace during various months to protect the patient before accidents, especially at school. This could seriously affect the surgical result.
After surgery, almost all patients come back to school or work in the next two or three weeks. During the first months it is not recommended energetic exercises as riding a bicycle. However, many patients are able to play or make sports as tennis, 3 or 4 months after surgery. Finally, almost all the exercises ways can be resumed, avoiding maybe the extreme sport as ski or riding due to the metallic fixation to the back.

Spinal fusion needs generally one year to strengthen and a second one to become strong bone.
The scoliotic patients’ difficult care and manipulation cannot be rushed. The patient and his family require monitoring and treatment during a long period of time. It is needed a focus group including the orthopaedics, the physiotherapist, the nurse, the physician and the family working together to achieve the best possible results.
The earlier examination and the quick treatment are the common goals that we as traumatologists are promoting and they are essential to prevent progressive spinal deformities that still are too much frequent worldwide.
Scoliosis may be overwhelming, both for the patient as for his family, but their future is really brilliant.
The treatment goal is to resume the patient to a useful and functional life with the minor emotional and physical feasible trauma.
New researches are still continuously being developed making possible less aggressive new techniques and more efficient.

 

KYPHOSIS OR ANTERO-POTERIOR CURVE
ADOLESCENT’S ROUND BACK or POSTURAL KYPHOSIS
Kyphosis is defined as a postural deviation of the spine in the sagittal plane outside its limits. Generally normal kyphosis is between 20º and 40º (Cobb method). The most common kyphosis is postural kyphosis. It is not a direct pathologic condition but it seems to be part of the adolescent posture, which is becoming too much common actually. Children adopt rare attitudes sat and when they are standing, they intensify his postural kyphosis, especially during the acceleration of the adolescent growth, unless therapeutic measures are taken. The postural kyphosis is especially common in teenager girls. Their breast development sometimes makes them extremely shy; adopting a roundback crestfallen when walking, hiding the incipient breasts, in particular, if the girl is tall for her age. If it is early treated these type of kyphosis may be generally corrected with postural exercises. In some cases, a spinal brace can be also very corrective.
SCHEUERMANN’S PATHOLOGICAL KYPHOSIS
It is the most frequent, burden back. It is called Scheuermann’s kyphosis and it is characterized by a long arched and fixed kyphosis developed during the adolescence. It is due to a cuneiform deformity of normally 3 to 5 vertebrae with specific radiological disorders. The characteristic anterior wedging of vertebrae bodies with a previous diminished size. In 1920, for the first time, it was described, by Scheuermann, which clarified that the illness only could be definitely diagnosed after a radiological examination. Scheuermann’s thoracic kyphosis radiological definition was developed by Sorensen; it is a kyphosis including, at least, three joined vertebrae, each one with a wedge of 5º or more.
The etiology of Scheuermann’s kyphosis is unknown; nevertheless, hundreds of theories have been suggested. The Scheuermann’s disease is a common cause of thoracic kyphosis; rarely painful and, typically, patients are more concerned by the aesthetic deformity.
There are two main types of Scheuermann’s kyphosis: the thoracic, hereditary, progressive and painless shape and the low back type, generally painful.
Clinically, the Scheuermann’s low back disease goes into a pain period rather strong with the activity. The low back kyphosis is more often produced in boys than in girls (2: l). And it is observed especially between the 13 and 17 years and is more aggressive during the rapid growth. Since it happens so often in young athletes, it is suspected a stress injury, located in the vertebral bodies of growth. In most cases, the early Scheuermann’s disease can be treated by a corrective brace. The patients who have kyphosis may also associated scoliosis. Therefore, it is necessary to take x-rays in anteroposterior erect and lateral positions.

CONGENITAL KYPHOSIS
The kyphotic deformity is minor to a segmentation defect (congenital bar or block vertebrae), and rarely it provokes any neurological loss.
Nevertheless, a progressive kyphosis caused by a structure defect (vertebrae in wedge or hemi vertebrae) may lead to paraplegia.
With a partial structure defect, the vertebral channel may continue in correct alignment or luxation, but the neurological losses can or not produce a channel luxation.
Even if it is possible to observe the functional damage at birth or at the beginning of childhood, in the adolescence it is mostly produced at the peak moment of growth.
Once they occur, the neurological deficits gradually decline or quickly progress if they are intensified by a minor traumatism. In a congenital kyphosis, the spasticity (an early symptom of polyneuropathy) indicates the need for an evaluation for a spinal fusion with anterior decompression of the spinal cord.
The image from magnetic resonance (MRI) has replaced the tomographic computerized myelography as the preferred procedure for diagnosing the intraspinal anomalies.
In breast-fed children and small children whose posterior elements are still cartilaginous, the ultrasound scanning is an excellent research tool.
Braces and other non-surgical techniques have a very limited application area for dealing with congenital kyphosis.
Before a significant kyphosis development, the spinal fusion can often be done by a posterior approach. In children with secondary neurological deficit to a congenital or secondary kyphosis and a fixed deformity, the spinal canal decompression is essential.
If kyphosis or the kyphoscoliosis is flexible, a gradual traction may improve the neurological function, but the traction of a rigid kyphosis is contraindicated.

BACKACHE
At least, the 90% of population has suffered one backache seizure. It is a very disabling clinical case, so much that it has become one of the first causes of sick leave.
Just a simple backache may be hiding plenty of diseases. It can be the leading symptom or an additional disease symptom.
Causes.
The anatomical spine condition predisposes it to suffer particular lesions in a determined clinical manifestation (as sciatica, for example) in some special regions.
• Spine arthrosis
• Disc hernia
• Posterior facet syndrome
• Narrow duct
• Extremely developed scoliosis
• Vertebral infections
• Bone or medullar tumors
Treatment
• Physical measurements: Postural hygiene
• Physiotherapy /rehabilitation
• Medicines: NSAID and muscle relaxants
• Surgery in particular cases
• Ozonoterapia: Shows spectacular results related to the remittance of mostly part of the backache causes
Information and patient advices:
• Avoid painful movements of trunk
• Straight trunk: Avoid slant positions supported for long time
• Standing: Keep hip flexed
• Take loads near body axis.
• Appropriate physical exercise: specific spine gymnastic exercises
• Physiotherapy measures: Deep heat

SERVICES PORTFOLIO

-Diagnostic tests: Hip arthroscopy:
-Specific treatments: orthopaedic hip reduction, hip osteotomies, elongation with external fasteners and for angle corrections, apophysiodesis and epiphysiodesis.