Pediatric Connection A PUBLICATION OF THE PEDIATRIC MUSCULOSKELETAL DEPARTMENT OF HOSPITAL FOR SPECIAL SURGERY VOLUME 2 – ISSUE 1 SUMMER 2009
MEDICAL STAFF
Cerebral Palsy
Pediatric Orthopedists John S. Blanco, MD Shevaun M. Doyle, MD Daniel W. Green, MD
by David M. Scher, MD
Cathleen L. Raggio, MD Leon Root, MD David M. Scher, MD Roger F. Widmann, MD Pediatricians H. Susan Cha, MD Lisa S. Ipp, MD Stephanie L. Perlman, MD Pediatric Rheumatologists Alexa B. Adams, MD Thomas J.A. Lehman, MD Emma Jane MacDermott, MD
Cerebral palsy (CP) has been recognized as a distinct condition for more than a century. During much of that time, there were limited options for improving the lives of affected children. Today, advances in medicine, science, and technology have all contributed to dramatic progress in our ability to improve function and enhance the lives of children with CP. In young children with CP who are just learning to walk, many of our efforts are directed at managing the spasticity of the muscles that impairs muscle function. When young children with spastic muscles are learning to walk, their muscles become tight and their legs can not get into the right position at the right time. One of the most effective ways to decrease spasticity is with the use of Botox (botulinum toxin). Botox works by blocking some of the activity at the neuromuscular junction to “turn off ” a portion of the signal moving from the nerve to the muscle. Another commonly used and effective technique for managing spasticity is brace (orthotic) treatment. An appropriately prescribed orthosis counteracts the spastic tone in the calf muscles that causes the foot to point down. Other techniques such as nerve surgery (rhizotomy) and direct delivery of medication to the central nervous system (intrathecal Baclofen) enable us to manage muscle spasticity.
Pre-Op
Post-Op
Between age five and adolescence, we can realign surgically the bones and joints of the lower extremities to improve how children walk. Over the past two decades, dramatic advances help us to understanding the science of gait, and allow us to use modern surgical techniques to optimize a child’s gait. Much of the theory behind this process unfolded with gait analysis technology (see related article). The concept used to describe abnormal gait in ambulatory children with CP is called “lever-arm dysfunction”. This is akin to turning a bolt with a wrench that is too short and made of rubber. A wrench that is longer and rigid is more effective than one that is short and floppy. The extremities of children with CP become malpositioned, analogous to the short, floppy wrench. By improving alignment, we can provide children with their optimal power for walking. (Continued on page 3)
CONTENTS Cerebral Palsy . . . . . . . . 1 Lyme Disease . . . . . . . . 1 Measuring Walking: Gait Analysis . . . . . . . . . . 2 The Connection Inspection . . . . . . . . . . . . 3 Question of the Quarter . . . . . . . . . . . 4
Lyme disease by Emma Jane MacDermott, MD
Lyme disease as a cause of childhood arthritis is something we see frequently at HSS. Lyme disease is very familiar to those living in the northeastern United States. The ticks that carry the disease are found in this area, and up to 90% of cases occur here. However, Lyme disease is not caused by ticks; rather it is caused by a small spiral shaped organism called Borrelia burgdorferi that lives for part of its life cycle (Continued on page 2)