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Lower-limb growth: How predictable are predictions?

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Alain Diméglio
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Abstract and Figures

Purpose: The purpose of this review is to clarify the different methods of predictions for growth of the lower limb and to propose a simplified method to calculate the final limb deficit and the correct timing of epiphysiodesis. Background: Lower-limb growth is characterized by four different periods: antenatal growth (exponential); birth to 5 years (rapid growth); 5 years to puberty (stable growth); and puberty, which is the final growth spurt characterized by a rapid acceleration phase lasting 1 year followed by a more gradual deceleration phase lasting 1.5 years. The younger the child, the less precise is the prediction. Repeating measurements can increase the accuracy of predictions and those calculated at the beginning of puberty are the most accurate. The challenge is to reduce the margin of uncertainty. Confrontation of the different parameters-bone age, Tanner signs, annual growth velocity of the standing height, sub-ischial length and sitting height-is the most accurate method. Charts and diagrams are only models and templates. There are many mathematical equations in the literature; we must be able to step back from these rigid calculations because they are a false guarantee. The dynamic of growth needs a flexible approach. There are, however, some rules of thumb that may be helpful for different clinical scenarios. Calculation of limb length discrepancy: For congenital malformations, at birth the limb length discrepancy must be multiplied by 5 to give the final limb length discrepancy. Multiple by 3 at 1 year of age; by 2 at 3 years in girls and 4 years in boys; by 1.5 at 7 years in girls and boys, by 1.2 at 9 years in girls and 11 years in boys and by 1.1 at the onset of puberty (11 years bone age for girls and 13 years bone age for boys). Timing of epiphysiodesis: For the timing of epiphysiodesis, several simple principles must be observed to reduce the margin of error; strict and repeated measurements, rigorous analysis of the data obtained, perfect evaluation of bone age with elbow plus hand radiographs and confirmation with Tanner signs. The decision should always be taken at the beginning of puberty. A simple rule is that, at the beginning of puberty, there is an average of 5 cm growth remaining at the knee. There are four common different scenarios: (1) A 5-cm discrepancy-epiphysiodesis of both femur and tibia at the beginning of puberty (11 years bone age girls and 13 years in boys). (2) A 4-cm discrepancy-epiphysiodesis of femur and tibia 6 months after the onset of puberty (11 years 6 months bone age girls, 13 years 6 months bone age boys, tri-radiate cartilage open). (3) A 3-cm discrepancy-epiphysiodesis of femur only at the start of puberty, (skeletal age of 11 years in girls and 13 years in boys). (4) A 2-cm discrepancy-epiphysiodesis of femur only, 1 year after the start of puberty (12 years bone age girls and 14 years in boys).
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CURRENT CONCEPT REVIEW
Lower-limb growth: how predictable are predictions?
Paula M. Kelly ÆAlain Dime
´glio
Received: 13 May 2008 / Accepted: 3 July 2008 / Published online: 29 August 2008
ÓEPOS 2008
Abstract
Purpose The purpose of this review is to clarify the dif-
ferent methods of predictions for growth of the lower limb
and to propose a simplified method to calculate the final
limb deficit and the correct timing of epiphysiodesis.
Background Lower-limb growth is characterized by four
different periods: antenatal growth (exponential); birth to
5 years (rapid growth); 5 years to puberty (stable growth);
and puberty, which is the final growth spurt characterized
by a rapid acceleration phase lasting 1 year followed by a
more gradual deceleration phase lasting 1.5 years. The
younger the child, the less precise is the prediction.
Repeating measurements can increase the accuracy of
predictions and those calculated at the beginning of puberty
are the most accurate. The challenge is to reduce the
margin of uncertainty. Confrontation of the different
parameters—bone age, Tanner signs, annual growth
velocity of the standing height, sub-ischial length and sit-
ting height—is the most accurate method. Charts and
diagrams are only models and templates. There are many
mathematical equations in the literature; we must be able to
step back from these rigid calculations because they are a
false guarantee. The dynamic of growth needs a flexible
approach. There are, however, some rules of thumb that
may be helpful for different clinical scenarios.
Calculation of limb length discrepancy For congenital
malformations, at birth the limb length discrepancy must
be multiplied by 5 to give the final limb length discrepancy.
Multiple by 3 at 1 year of age; by 2 at 3 years in girls and
4 years in boys; by 1.5 at 7 years in girls and boys, by 1.2
at 9 years in girls and 11 years in boys and by 1.1 at the
onset of puberty (11 years bone age for girls and 13 years
bone age for boys).
Timing of epiphysiodesis For the timing of epiphysiode-
sis, several simple principles must be observed to reduce
the margin of error; strict and repeated measurements,
rigorous analysis of the data obtained, perfect evaluation of
bone age with elbow plus hand radiographs and confir-
mation with Tanner signs. The decision should always be
taken at the beginning of puberty. A simple rule is that, at
the beginning of puberty, there is an average of 5 cm
growth remaining at the knee. There are four common
different scenarios: (1) A 5-cm discrepancy—epiphysiod-
esis of both femur and tibia at the beginning of puberty
(11 years bone age girls and 13 years in boys). (2) A 4-cm
discrepancy—epiphysiodesis of femur and tibia 6 months
after the onset of puberty (11 years 6 months bone age
girls, 13 years 6 months bone age boys, tri-radiate cartilage
open). (3) A 3-cm discrepancy—epiphysiodesis of femur
only at the start of puberty, (skeletal age of 11 years in girls
and 13 years in boys). (4) A 2-cm discrepancy—epiphy-
siodesis of femur only, 1 year after the start of puberty
(12 years bone age girls and 14 years in boys).
Keywords Lower-limb growth Bone age
Epiphysiodesis Prediction of lower-limb discrepancy
Growth is a change in proportion
At birth, the standing height is 50 cm: 70% (35 cm) for
sitting height and 30% (15 cm) for sub-ischial length. In
contrast, at skeletal maturity, the sitting height accounts for
52% of the standing height and the sub-ischial length is
P. M. Kelly A. Dime
´glio (&)
Department of Paediatric Orthopaedic Surgery,
CHU Lapeyronie, Montpellier, France
e-mail: a-dimeglio@chu-montpellier.fr;
alaindimeglio@wanadoo.fr
123
J Child Orthop (2008) 2:407–415
DOI 10.1007/s11832-008-0119-8
48%. Sitting height will increase by 53 cm in girls and by
57 cm in boys. Sub-ischial length increases from 15 cm at
birth to 81 cm in boys and 74.5 cm in girls at skeletal
maturity.
Thus, from birth to skeletal maturity, lower-limb length
increases by a factor of 5.25 compared with only 2.67 times
for spinal growth. This is the first important factor in the
management of lower-limb growth discrepancies.
Repeated serial measurements of standing height, sitting
height and sub-ischial lengths are the only way to best cap-
ture the complexity of growth. These measurements provide
a real-time image of growth and, when carefully recorded in
a continually updated ‘‘growth notebook’’, they provide
charts that assist in decision-making processes [1,2].
Periods of growth
Growth is a complex and well-synchronized phenomenon
that dictates the final stature and proportions in adult life. It
is difficult to capture such complexity with two-dimen-
sional graphs and mathematical equations. However, in
order to facilitate our comprehension of this remarkable
process, we may conveniently separate growth into four
time periods:
1. Antenatal growth
2. Birth to 5 years of age
3. 5 years of age to puberty
4. Puberty
Antenatal growth–exponential growth
At 3 months of intra-uterine life, the cartilaginous anlage is
complete and ossification has begun. By 14 weeks, primary
ossification is sufficient to allow ultrasonographic
measurement of femoral length, and the length of the femur
is 14 mm and the tibia is 11 mm. Longitudinal growth
continues, as shown in Fig. 1, so that by full term the
femoral diaphyseal length is 75 mm and the tibia diaphy-
seal length is 62 mm. At birth, the lower limbs reach 20%
of their final length.
Modern ultrasonography can give an idea of foetal
lower-limb growth during antenatal life, and there are
many established databases for estimating foetal femoral
length [3–6]. The growth curve gives the impression that
growth is linear but, by closer analysis of antenatal growth
velocity, we can see that there is a definite peak of growth
velocity at 4 months (Fig. 2). Ultrasound evaluation,
however, can only measure the ossified portion of the long
bones, i.e. the diaphysis, and thus all subsequent calcula-
tions must take this into account.
Birth to 5 years
From birth to 5 years, the standing height increases from
50 to 105 cm. The sub-ischial length gains about 27 cm
from birth to 5 years of age: 10 cm in the first year; 5 cm in
the second year; and 4 cm in each of the third, fourth and
fifth years (Figs. 3,4).
At birth, the difference between the femur and tibia
length is 1.2 cm, compared with 10 cm at skeletal matu-
rity. Importantly, the tibia remains at a constant length of
80% of femoral length throughout growth. This is very
useful information because the relative lengths remain the
same regardless of the position of the child on the growth
curve.
Five years to puberty
From 5 years to the onset of puberty, growth velocity
stabilizes. The standing height increases from 108 to
Fig. 1 Foetal femoral
diaphyseal growth with
radiographic images at 14, 20,
24 and 40 weeks
408 J Child Orthop (2008) 2:407–415
123
153 cm in boys and from 107 to 143 cm in girls. The
annual growth velocity of the standing height reduces to
5.5 cm/year, of which 3.2 cm/year is the sub-ischial length,
i.e. 65% of height gain is from the lower limbs versus only
35% from the sitting height during this period. The knee
(distal femur plus proximal tibia) grows at an average of
2 cm/year until puberty. This is a relative catch-up time in
terms of growth for the lower limbs in comparison with
spinal growth.
Puberty
The final growth spurt before skeletal maturity commences
at the onset of puberty. This starts at 13 years of bone age
for boys and 11 years of bone age for girls. Growth
velocity increases from 5.5 to 7.8 cm/year. Standing height
increases from 153 cm (±1 cm) to 175 cm (±1 cm) in
boys and from 142 cm (±1 cm) to 162 cm (±1 cm) in
girls. Therefore, the average growth remaining at the onset
of puberty in terms of standing height is 22 cm (±1 cm)
for boys and 20 cm (±1 cm) for girls [2]. The growth
remaining in the lower limbs is *10 cm in boys and 9 cm
in girls (Figs. 5,6). Lower-limb growth velocity increases
from 3.2 to 5 cm/year at the peak of puberty. Peak growth
velocity in the lower limbs occurs 6 months earlier than
spinal growth peak velocity, i.e. at 14 years skeletal age in
boys and 12 years skeletal age in girls. Lower-limb growth
during puberty is characterized by rapid growth accelera-
tion for 1 year only followed by a more gradual
deceleration phase. Growth in the lower limbs will cease
2 years and 6 months after the onset of puberty, after
elbow closure, when the distal phalangeal physes have
fused and at Risser 1 [2].
Therefore, it can be seen that lower-limb growth relative
to spinal growth decreases, with only 45% of height
achieved during puberty coming from the lower limbs. This
is because lower-limb growth ceases before spinal growth.
Once puberty has started the time remaining for lower-
limb growth is very short. Decisions in relation to the
timing of epiphysiodesis must be taken at the very start of
puberty, otherwise it will be too late.
Predicting limb length inequality
When considering limb discrepancy we must answer three
fundamental questions;
Fig. 2 Femoral growth velocity from the foetal period to skeletal
maturity (girls) demonstrating a peak growth velocity at 4 months of
antenatal life
9.9
12.4
5.3
5.3
4
3.2
4.2
2.8
3.9
2.3
3.2
2.3
3.2
2.3
3.2
2.3
3.2
2.3
3.2
2.3
3.2
2.3
3.2
2.3
3.2
2.3
4.7
3.7
3.3
4.8
1.2
2.8
0.6
10.1
0.3
0
5
10
15
20
25
CM/YR
1 2 3 4 5 6 7 8 9 101112131415161718
Skeleatal Age (Years)
GROWTH VELOCITY BOYS
Sitting height
Sub-ischial length
Puberty
Birth to Five Years
Lower Limb gains
27cm
Five Years to Puberty
Lower Limb gains
25.6cm
Puberty
Lower Limb Growth
Remaining 10cm (13%)
Fig. 3 Growth velocity in boys
from birth to skeletal maturity
J Child Orthop (2008) 2:407–415 409
123
What will be the final deficit?
What will be the final stature?
What is the correct timing for epiphysiodesis?
Final deficit estimation
To consider the final deficit, it is important to make the
distinction between congenital limb deficiencies and post-
traumatic growth disturbances. In congenital limb dis-
crepancies, the relative discrepancy remains static
throughout growth. There is usually a constant growth
inhibition such that the percentage shortening remains
constant during skeletal growth [7]. Post-traumatic dis-
crepancies, however, should be calculated by estimating
the amount of growth remaining at the injured growth
plate along with the skeletal age. For example, a boy with
a post-traumatic growth arrest at the distal femur at a
skeletal age of 9 years will have a final discrepancy of
1.1 cm multiplied by 7 (years of growth remaining):
equals 7.7 cm.
Growth of the lower limb was been very well docu-
mented by Anderson and Green [8]. From their work, we
know that, after 5 years, the lower limbs grow 3.5 cm/year;
2 cm/year in the femur and 1.5 cm/year in the tibia. There
are many methods to predict final leg length inequality; the
methods of Lefort, Moseley, Carlioz, Menelaus and Paley
[9–13] are all based on the data of Green and Anderson.
They merely reflect different mathematical formulas of the
same data. There is an easy rule of thumb to predict the
final deficit at skeletal maturity when managing lower-limb
discrepancies.
At birth, the lower limb has reached 20% of its final
length, the multiplier factor is therefore 100/20 =5.
Therefore, for a discrepancy of 3 cm at birth, you multiply
by 5 to give a final predicted discrepancy of 15 cm. At
1 year, the acquired length is 33%, therefore the multiplier
is 100/33 =3; at 4 years in boys and 3 years in girls the
acquired length is 50% and the multiplier is 100/50 =2; at
7 years the acquired growth is 65% and the multiplier is
100/65 =1.5; at the onset of puberty the acquired growth
is 90% and the multiplier is 100/90 =1.1 (Figs. 7and 8).
The younger the child, the less precise are the predictions;
Elbow
Elbow closure
closure
13
13 15
15 18
18 years
years
8.5 cm
8.5 cm 4.5 cm
4.5 cm sitting
sitting height
height
Risser
Risser 1
1
Boys
Boys
8 cm
8 cm 1.5 cm
1.5 cm lower
lower limb
limb
22.5 cm
22.5 cm
(
(±
±1cm)
1cm)
Closure
Closure of
of the
the
triradiate
triradiate cartilage
cartilage
14
14
Bone
Bone Age
Age
Lower limb growth is complete after Risser I
Fig. 5 Pubertal growth in boys [24, p 44]
8.9
12.3
6.1
5.3
4
3.4
4.1
3.3
3.8
3
3.3
2.4
3.3
2.4
3.3
2.4
3.3
2.4
3.3
2.4
3.3
2.4
4.4
3.4
3
4.3
1.2
2.5
0.3
1.1
0.1
0.2
0
5
10
15
20
25
CM/YR
1 2 3 4 5 6 7 8 9 10111213141516
Skeletal Age (Years)
GROWTH VELOCITY GIRLS
Sitting height
Subischial length
Birth to Five Years
Lower Limb gains
27cm
Five years to Puberty
Lower Limb gains
20cm
Puberty
Lower Limb Growth Remaining
9cm ( 11%)
Puberty
Fig. 4 Growth velocity in girls
from birth to skeletal maturity
410 J Child Orthop (2008) 2:407–415
123
however, repeating measurements can increase the accu-
racy of predictions.
Predictions before 5 years of age are approximate at
best, but, after the age of 5 years, measurements give a
more reliable estimation. Predictions calculated at the
beginning of puberty are the most accurate; during this
time it is easy to predict the final deficit in congenital
deficiencies as the remaining growth is 10% in the lower
limbs.
One measurement may be an error, two measurements
give a trend and three measurements allow a curve to be
drawn.
Antenatal multiplier
Predictions are now also possible during antenatal life.
Paley has developed the concept of the multiplying factor
and has recently applied this to the antenatal period [14].
At 14 weeks of intra-uterine life, the femur has acquired
3% of its final length and, therefore, the multiplier is 30; at
24 weeks the acquired length is 10% and the multiplier is
10.
In our opinion, this method gives a rough idea of final
discrepancy but is less accurate than post-natal predictions.
It gives a broad idea of the severity of the discrepancy (i.e.
\5 cm, 5–10 cm or [10 cm) rather than an accurate
measurement which may give some guidance during
antenatal counselling.
Final stature estimation
It is important to know the final stature when managing
children with limb length discrepancies. There are many
methods to predict this. Growth charts are available but the
final stature is ultimately dependent on the timing of the
onset of puberty [15]. All children will follow their growth
curve until the onset of puberty. If puberty commences
early, the final height will be shorter than predicted; if
puberty is delayed, the final height will be taller than
predicted. Once puberty has begun there are no more
uncertainties in relation to growth. Therefore, the best
method to reduce errors is to follow the child on their
growth curve and detect the beginning of puberty. If this
final stature is tall, an epiphysiodesis may be favoured over
a more complicated limb lengthening procedure.
Regardless of the methods used, bone age must always
be taken into account. We consider it to be important to
base our calculations on skeletal age rather than chrono-
logical age, because only 50% of the population have a
chronological age that is in harmony with bone age [2].
Figure 17 demonstrates the growth curve of two sisters.
Sister 1 commenced puberty at a chronological age of
10 years, whereas sister 2 did not commence until age
12 years. The final height difference, despite having the
same original growth curve, was 10 cm. Skeletal age is
therefore important when decisions are taken regarding
final height estimation.
However, the younger the child the less predictable is
the bone age [16]. At puberty, elbow maturation is more
precise than Greulich and Pyle charts for the estimation of
the timing of epiphysiodesis [17,18].
The onset of puberty is heralded by acceleration of the
annual growth velocity of more than 6 cm/year, and the
onset of Tanner signs [19], double ossification of the
olecranon and ossification of the sesamoid of the thumb
[17] (Figs. 9,10).
Timing of epiphysiodesis
The right choice at the right moment. How to increase the
accuracy of predictions
The biggest difficulty with epiphysiodesis is the uncer-
tainty of timing, and the challenge is to reduce the margin
of error. There are many methods available to calculate the
appropriate timing of epiphysiodesis. All calculations are
invariably based on the fundamental measurements of
Green and Anderson [20–22].
Menelaus’s original paper [9] used chronological age to
calculate the growth remaining and assumed that growth
ceases at a chronological age of 16 years in boys and
14 years in girls, thus calculating 3 years of growth from the
onset of puberty. He used the original suggestion of White
and Stubbins [23] that the distal femur grows at 0.9 cm/year
and the proximal tibia 0.6 cm/year. Thus, according to the
Menelaus technique, the growth remaining at the knee from
the onset of puberty is 0.9 cm ?0.6 cm =1.5 cm multi-
plied by 3 years to equal 4.5 cm.
The Dime
´glio method [1] calculates growth at the knee
as 2 cm/year, 1.1 cm from the femur and 0.9 cm from the
Elbow
Elbow closure
closure
11
11 13
13 18
18 years
years
7.5 cm
7.5 cm 4.5 cm
4.5 cm sitting
sitting height
height
Risser
Risser 1 :
1 : menarche
menarche
Girls
Girls
7 cm
7 cm 1.5 cm
1.5 cm lower
lower limb
limb
20.5 cm
20.5 cm
(
(±
±1cm)
1cm)
Closure
Closure of
of the
the
triradiate
triradiate cartilage
cartilage
12
12
Bone
Bone Age
Age
Lower limb growth is complete after Risser I and menarche
Fig. 6 Pubertal growth in girls [24, p 43]
J Child Orthop (2008) 2:407–415 411
123
tibia. However, in contrast to Menelaus, we calculate the
time for growth remaining as 2.5 years because the
pubertal diagram for the lower limb is characterized by a
short and rapid acceleration, followed by a more gradual
deceleration with lower-limb growth ceasing by bone age
of 15 years and 6 months for boys and 13 years 6 months
for girls (Risser 1). The final results are approximately the
same (Menelaus 1.6 cm 93 years =4.8 cm versus
Dime
´glio 2 cm 92.5 years =5 cm). It is merely to
emphasize that the lower-limb growth spurt at puberty is
short and, as such, decisions must be taken early relative to
the timing of epiphysiodesis. It must be emphasized that, of
the 5-cm growth remaining at the knee at the onset of
puberty, 2.6 cm (i.e. [50%) occurs during the first year.
Several simple principles must be observed to reduce the
margin of error: (1) strict and meticulous repeated mea-
surements; (2) rigorous analysis of the data obtained
(simple miscalculations have been shown to occur in 18%
of cases [20]); (3) perfect evaluation of bone age using
elbow plus hand radiographs [17]; (4) the decision always
taken at the beginning of puberty.
When considering the Anderson and Green curve, the
average remaining growth of the knee at the beginning of
puberty is about 5 cm (3 cm femoral and 2 cm tibial).
When puberty starts, the remaining growth of the knee is
about 5 cm (girls and boys average, Figs. 15 and 16).
There are four common different scenarios (Fig. 13):
5-cm discrepancy: epiphysiodesis of both femur and
tibia at the beginning of puberty (11 years bone age in girls
and 13 years in boys) (Fig. 11).
4-cm discrepancy: epiphysiodesis femur and tibia
6 months after the start of puberty (i.e. 11 years 6 months
Multiplier factor Boys
10 20 33 50 65 82 87
3
14 weeks
Acquired growth Remaining growth
X30 X5X3X2X1.5 X1.2 X1.1X10
13117
4
1
Birth24 weeks
Fig. 7 Multiplier factor for boys from fetal life to skeletal maturity.
At birth the acquired length is 20% therefore multiplier by 5 to
calculate the estimated limb length discrepancy; multiply by 2 at 4
years of age and by 1.1 at the onset of puberty
Multiplier factor Girls
10 20 33 50 65 82 87
3
Acquired growth Remaining growth
X30 X5X3X2X1.5 X1.2 X1.1X10
14 weeks 119731Birth24 weeks
Fig. 8 Multiplier factor for girls from fetal life to skeletal maturity.
At birth the acquired length is 20% therefore multiplier by 5 to
calculate the estimated limb length discrepancy; multiply by 2 at 3
years of age and by 1.1 at the onset of puberty
STANDING HEIGHT
STANDING HEIGHT
ANNUAL VELOCITY > 7 cm/
ANNUAL VELOCITY > 7 cm/year
year
Fig. 9 Radiological changes at the onset of puberty, sesamoid
ossification left hand, double ossification left olecranon apophysis
Skeletal
Skeletal
Age
Age
11 11.5 12 12.5 13 Girls 18 years
13 13.5 14 14.5 15 Boys 18 years
Risser
Risser I
I
Double
ossification
Partial
Fusion
Quadrangular
Semilunar
Complete
fusion
RISSER 1
Fig. 10 Pubertal diagram showing characteristic morphology of the
left olecranon apophysis during puberty. Double ossification at onset
of puberty, semilunar apophysis at puberty plus 6 months, quadran-
gular apophysis at puberty plus 1 year and complete fusion at peak
pubertal growth velocity (puberty plus 2 years). (with permission
Dimeglio et al., Accuracy of the sauvegrain method in determining
skeletal age during puberty. JBJS (Am). 2005;87:1689–96.)
412 J Child Orthop (2008) 2:407–415
123
bone age in girls, tri-radiate cartilage open; 13 years
6 months bone age in boys) (Fig. 12).
3-cm discrepancy: epiphysiodesis femur only at the start
of puberty (11 years bone age in girls and 13 years in boys)
(Fig. 13).
2-cm discrepancy: epiphysiodesis femur only, 1 year
after the start of puberty or tibia only at the beginning of
puberty (12 years bone age in girls and 14 years in boys)
(Fig. 14).
Obviously this can be adapted to individual cases. For
instance, if there is only 2 cm of tibial shortening, epiphy-
siodesis can be done on the tibia only at the onset of puberty.
Moseley has emphasized that skeletal age is important
when considering limb length discrepancies [16]. In the
example of the two sisters in Fig. 17, we can see that
skeletal age is essential for accurately predicting the
correct timing of epiphysiodesis. If an epiphysiodesis
of the distal femur and proximal tibia is performed in
sister 1 at a chronological age of 11 years, she would
have 2.9 cm of growth remaining. If an epiphysiodesis
of the distal femur and proximal tibia is performed
in sister 2 at a chronological age of 11 years, she
would have 7.3 cm of growth remaining, a difference of
4.4 cm.
Elbow
Elbow closure
closure
Risser
Risser 1
1
GIRLS:
GIRLS: 11
11 years skeletal age
years skeletal age
BOYS:
BOYS: 13
13 years skeletal age
years skeletal age
5 cm
Girls
Girls 11
11 12
12 13
13
Boys
Boys 13
13 14 15
14 15
Triradiate
Triradiate cartilage
cartilage
closure
closure
5 cm = Epiphysiodesis femur and tibia
at beginning of puberty
Double ossification
Fig. 11 A 5-cm discrepancy can be corrected by performing an
epiphysiodesis of both distal femur and proximal tibia at the
beginning of puberty (11 years skeletal age girls, 13 years skeletal
age boys).
Elbow
Elbow closure
closure
Risser
Risser 1
1
GIRLS
GIRLS:
:12
12 yrs skeletal age
yrs skeletal age
BOYS
BOYS:
:14 yrs skeletal age
14 yrs skeletal age
2cm
Girls
Girls 11
11 12 13
12 13
Boys
Boys 13
13 14 15
14 15
Triradiate
Triradiate cartilage
cartilage
closure
closure
2 cm = Epiphysiodesis femur only 1
year after beginning of puberty
Quadrangular ap ophysis
Fig. 14 A 2-cm discrepancy can be corrected by performing an
epiphysiodesis of distal femur only at puberty plus 1 year (12 years
skeletal age girls, 14 years skeletal age boys)
Elbow
Elbow closure
closure
Risser
Risser 1
1
GIRLS: 11
GIRLS: 11 yrs 6 months skeletal age
yrs 6 months skeletal age
BOYS:
BOYS: 13
13 yrs 6 months skeletal age
yrs 6 months skeletal age
4cm
Girls
Girls 11
11 12 13
12 13
Boys
Boys 13
13 14 15
14 15
Triradiate
Triradiate cartilage
cartilage
closure
closure
4 cm = Epiphysiodesis femur and tibia
6 months after beginning of puberty
Semilunar apophysis
Fig. 12 A 4-cm discrepancy can be corrected by performing an
epiphysiodesis of both distal femur and proximal tibia at puberty plus
6 months (11 years 6 months skeletal age girls, 13 years 6 months
skeletal age boys)
Elbow
Elbow closure
closure
Risser
Risser 1
1
GIRLS:
GIRLS: 11
11 years skeletal age
years skeletal age
BOYS:
BOYS: 13
13 years skeletal age
years skeletal age
3cm
Girls
Girls 11
11 12
12 13
13
Boys
Boys 13
13 14 15
14 15
Triradiate
Triradiate cartilage
cartilage
closure
closure
3 cm = Epiphysiodesis femur only
at beginning of puberty
Double ossification
Fig. 13 A 3-cm discrepancy can be corrected by performing an
epiphysiodesis of distal femur only at the beginning of puberty
(11 years skeletal age girls, 13 years skeletal age boys)
J Child Orthop (2008) 2:407–415 413
123
Lessons learned from growth
Predictions may be predictable
The challenge of understanding growth is the essence
of paediatric orthopaedic surgery. There are many
mathematical equations and rigid formulas in the literature
that have been honestly created in order to try and capture
the complexity of growth. However, we must be able to
step back from these. It is a false guarantee to be guided by
mathematical equations. The dynamic of growth needs a
flexible approach. Measurement of the standing height
without annual growth velocity is meaningless, as is bone
age without Tanner signs. Reliance on chronological age
for estimation of timing of epiphysiodesis may lead to
serious errors—50% of children have an advanced or
retarded skeletal age. Decisions in relation to the timing of
epiphysiodesis must be taken at the beginning of puberty,
the onset of which can be more accurately determined by
annual growth velocity, Tanner signs and radiographs of
left wrist and elbow.
Serial measurements of several parameters must be
made for each child; a measurement in isolation is mean-
ingless. Percentages provide an extremely objective tool
for evaluating residual growth. Under these conditions,
predictions may be more accurate.
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Femur
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cm
cm
10
10 11
11 12
12 13
13 14
14
Boys
Boys
7.5
7.5
4.8
4.8
6.2
6.2 4.8
4.8
3
32
2
3.3
3.3
0.1
0.1
0.9
0.9 0.3
0.3
15
15 16
16
Tibia
Tibia
KNEE REMAINING GROWTH
KNEE REMAINING GROWTH
1.9
1.9
1
1
4
4
0.5
0.5
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with a resultant 10-cm difference in final height
KNEE REMAINING GROWTH
KNEE REMAINING GROWTH
cm
cm
10
10
2.9
2.9
1.8
1.8
11
11
12
12
13
13
14
14
1.6
1.6
1.3
1.3
0.2
0.2
Girls
Girls
0.1
0.1
Femur
Femur
Tibia
Tibia
0.6
0.6
0.9
0.9
4.5
4.5
2.8
2.8
Puberty
Fig. 15 Knee growth (distal femur and proximal tibia) remaining in
girls 10–14 years of age [24, p 59]
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123
... Patients were grouped by age, with the pediatric cohort made up of patients between 5 and 13 years of age and the adolescent cohort between 14 and 19 years, to characterize the effects of puberty and the transition toward skeletal maturity on the risk of concomitant surgery. 16,22 Patients were also compared based on their participation in high-risk sports according to the classification proposed by Moksnes et al, 27 who adapted the original system developed by Hefti et al. 18 With this system, level 1 activities include frequent jumping, cutting, and pivoting (eg, soccer, basketball); level 2 activities involve lateral movements with less pivoting (eg, racket sports, gymnastics); and level 3 activities include primarily y straight-ahead activities without jumping or pivoting (eg, running, weightlifting). 26 All surgeries were performed by 1 of 8 sports medicine fellowship-trained orthopaedic specialists, 4 of whom also completed general pediatric orthopaedic surgery fellowships. ...
Prevalence and Predictors of Concomitant Meniscal Surgery During Pediatric and Adolescent ACL Reconstruction: Analysis of 4729 Patients Over 20 Years at a Tertiary-Care Regional Children's Hospital
Article
Full-text available
  • Mar 2024
Background The rate of concomitant meniscal procedures performed in conjunction with anterior cruciate ligament (ACL) reconstruction is increasing. Few studies have examined these procedures in high-risk pediatric cohorts. Hypotheses That (1) the rates of meniscal repair compared with meniscectomy would increase throughout the study period and (2) patient-related factors would be able to predict the type of meniscal operation, which would differ according to age. Study Design Cohort study (prevalence); Level of evidence, 2. Methods Natural language processing was used to extract clinical variables from notes of patients who underwent ACL reconstruction between 2000 and 2020 at a single institution. Patients were stratified to pediatric (5-13 years) and adolescent (14-19 years) cohorts. Linear regression was used to evaluate changes in the prevalence of concomitant meniscal surgery during the study period. Logistic regression was used to determine predictors of the need for and type of meniscal procedure. Results Of 4729 patients (mean age, 16 ± 2 years; 54.7% female) identified, 2458 patients (52%) underwent concomitant meniscal procedures (55% repair rate). The prevalence of lateral meniscal (LM) procedures increased in both pediatric and adolescent cohorts, whereas the prevalence of medial meniscal (MM) repair increased in the adolescent cohort ( P = .02). In the adolescent cohort, older age was predictive of concomitant medial meniscectomy ( P = .031). In the pediatric cohort, female sex was predictive of concomitant MM surgery and of undergoing lateral meniscectomy versus repair ( P≤ .029). Female sex was associated with decreased odds of concomitant LM surgery in both cohorts ( P≤ .018). Revision ACLR was predictive of concomitant MM surgery and of meniscectomy (medial and lateral) in the adolescent cohort ( P < .001). Higher body mass index was associated with increased odds of undergoing medial meniscectomy versus repair in the pediatric cohort ( P = .03). Conclusion More than half of the young patients who underwent ACLR had meniscal pathology warranting surgical intervention. The prevalence of MM repair compared with meniscectomy in adolescents increased throughout the study period. Patients who underwent revision ACLR were more likely to undergo concomitant meniscal surgeries, which were more often meniscectomy. Female sex had mixed effects in both the pediatric and adolescent cohorts.
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... Growth disorders should be considered when there is a considerable discrepancy between chronological and observed bone ages (discrepancy > 2 standard deviations [SDs]) [1,2]. Determining bone age is also useful for making surgical decisions in orthopedics [3] and forensics [4]. Among the methods available for bone age determination, the atlas-based Greulich-Pyle (GP) method is one of the most widely used methods [5]. ...
Bone Age Assessment Using Artificial Intelligence in Korean Pediatric Population: A Comparison of Deep-Learning Models Trained With Healthy Chronological and Greulich-Pyle Ages as Labels
Article
Full-text available
  • Nov 2023
Objective: To develop a deep-learning-based bone age prediction model optimized for Korean children and adolescents and evaluate its feasibility by comparing it with a Greulich-Pyle-based deep-learning model. Materials and methods: A convolutional neural network was trained to predict age according to the bone development shown on a hand radiograph (bone age) using 21036 hand radiographs of Korean children and adolescents without known bone development-affecting diseases/conditions obtained between 1998 and 2019 (median age [interquartile range {IQR}], 9 [7-12] years; male:female, 11794:9242) and their chronological ages as labels (Korean model). We constructed 2 separate external datasets consisting of Korean children and adolescents with healthy bone development (Institution 1: n = 343; median age [IQR], 10 [4-15] years; male: female, 183:160; Institution 2: n = 321; median age [IQR], 9 [5-14] years; male: female, 164:157) to test the model performance. The mean absolute error (MAE), root mean square error (RMSE), and proportions of bone age predictions within 6, 12, 18, and 24 months of the reference age (chronological age) were compared between the Korean model and a commercial model (VUNO Med-BoneAge version 1.1; VUNO) trained with Greulich-Pyle-based age as the label (GP-based model). Results: Compared with the GP-based model, the Korean model showed a lower RMSE (11.2 vs. 13.8 months; P = 0.004) and MAE (8.2 vs. 10.5 months; P = 0.002), a higher proportion of bone age predictions within 18 months of chronological age (88.3% vs. 82.2%; P = 0.031) for Institution 1, and a lower MAE (9.5 vs. 11.0 months; P = 0.022) and higher proportion of bone age predictions within 6 months (44.5% vs. 36.4%; P = 0.044) for Institution 2. Conclusion: The Korean model trained using the chronological ages of Korean children and adolescents without known bone development-affecting diseases/conditions as labels performed better in bone age assessment than the GP-based model in the Korean pediatric population. Further validation is required to confirm its accuracy.
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... Kelly i Dimeglio przedstawili tabele ilustrujące potencjał wzrostowy nasady dalszej kości udowej i bliższej kości piszczelowej na podstawie wieku kostnego pacjenta. Tabele te dzielą pacjentów na 3 grupy w oparciu o po zostały przyrost kości: < 1 cm; 1-5 cm oraz > 5 cm [27]. ...
Pediatric Anterior Cruciate Ligament Reconstruction
Article
Full-text available
  • Aug 2023
The incidence of anterior cruciate ligament (ACL) injuries in children and adolescents has been growing recently. This problem is a challenge for the treating orthopedic surgeon, especially when the patient is in the prepubertal period with a high growth potential. Since reconstructive procedures require interventions close to active growth plates, they are associated with the risk of postoperative limb length discrepancies and limb deformities. Postponing ACL reconstruction until the end of growth is not a solution, as persistent knee instability increases the risk of secondary intra-articular damage. The key to success is not only knowledge of the anatomy and biomechanics of the pediatric knee but also the ability to predict the remaining growth potential and familiarity with a wide range of reconstructive surgical procedures available for patients at different ages.
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... This is because the distal femoral and proximal tibial physes are major contributors to lower extremity length and injury to either could result in a limb length discrepancy or an angular deformity [46]. The final growth spurt that children experience begins at puberty, around a bone age of 11 years in girls and 14 years in boys, with peak growth velocity occurring within approximately 1 year, after which there is growth deceleration till cessation of lower limb growth approximately 2.5 years after the initiation of the pubertal growth spurt [50]. Therefore, until skeletal maturity around the knee occurs, approximately 14 years in girls and 16 years in boys ACL, reconstruction procedures must respect the growing distal femoral and proximal tibial physes [46]. ...
Imaging the pediatric anterior cruciate ligament: not little adults
Article
Full-text available
  • Mar 2023
  • PEDIATR RADIOL
An increased incidence of anterior cruciate ligament (ACL) injuries in children over the last few decades has led to a corresponding increase in ACL reconstruction procedures in children. In this review, we will illustrate unique features seen when imaging the ACL in children versus adults. After briefly reviewing relevant normal ACL anatomy, we will review imaging findings of congenital ACL dysplasia. This is followed by a discussion of imaging ACL avulsions. Lastly, we will review the different types of ACL reconstruction procedures performed in skeletally immature children and their post-operative appearances.
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Correlations Between Eight Comprehensive Skeletal Maturity Systems in a Modern Peripubertal Pediatric Population
Article
  • Sep 2023
  • J PEDIATR ORTHOPED
Background Several skeletal maturity systems allow for accurate skeletal age assessment from a wide variety of joints. However, discrepancies in estimates have been noted when applying systems concurrently. The aims of our study were to (1) compare the agreement among 8 different skeletal maturity systems in modern pediatric patients and (2) compare these discrepancy trends qbetween modern and historic children. Methods We performed a retrospective (January 2000 to May 2022) query of our picture archiving and communication systems and included peripubertal patients who had at least two radiographs of different anatomic regions obtained ≤3 months apart for 8 systems: (1) proximal humerus ossification system (PHOS), (2) olecranon apophysis ossification staging system (OAOSS), (3) lateral elbow system, (4) modified Fels wrist system, (5) Sanders Hand Classification, (6) optimized oxford hip system, (7) modified Fels knee system, and (8) calcaneal apophysis ossification staging system (CAOSS). Any abnormal (ie, evidence of fracture or congenital deformity) or low-quality radiographs were excluded. These were compared with a cohort from a historic longitudinal study. SEM skeletal age, representing the variance of skeletal age estimates, was calculated for each system and used to compare system precision. Results A total of 700 radiographs from 350 modern patients and 954 radiographs from 66 historic patients were evaluated. In the modern cohort, the greatest variance was seen in PHOS (SEM: 0.28 y), Sanders Hand (0.26 y), and CAOSS (0.25 y). The modified Fels knee system demonstrated the smallest variance (0.20 y). For historic children, the PHOS, OAOSS, and CAOSS were the least precise (0.20 y for all). All other systems performed similarly in historic children with lower SEMs (range: 0.18 to 0.19 y). The lateral elbow system was more precise than the OAOSS in both cohorts. Conclusions The precision of skeletal maturity systems varies across anatomic regions. Staged, single-parameter systems (eg, PHOS, Sanders Hand, OAOSS, and CAOSS) may correlate less with other systems than those with more parameters. Level of Evidence Level III—retrospective study.
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Demandas energéticas de actividades de subsistencia en individuos subadultos. Contribuciones a la ecología del comportamiento humano. Energy demands of subsistence activities in subadult individuals. Contributions to the Human Behavioral Ecology.
Thesis
Full-text available
  • May 2022
Esta tesis doctoral responde al interés de comprender el papel de la energía en las relaciones entre el ser humano y su entorno, siendo la energía la que modela y ajusta las adaptaciones biológicas y conductuales de los organismos terrestres y, por extensión, de la especie humana. Son varios los estudios dentro de la ecología del comportamiento humano que han utilizado la energía para comprender la adaptación y la adaptabilidad humana. Dicha adaptabilidad es fruto de la flexibilidad que muestra nuestra especie, adquirida gracias a la prolongada inmadurez de Homo sapiens. Sin embargo, son menores los estudios que se han centrado en comprender cómo actúa la energía en la conducta y la biología de los individuos subadultos. Por ello, el principal interés de esta investigación es estudiar cómo afecta la energía a la puesta en marcha de diferentes actividades de subsistencia imprescindibles en los grupos de cazadores y recolectores. Concretamente, se evaluará si el inicio de la división de labores por sexo se explica en base a diferencias en el coste y la eficiencia energética de los distintos individuos. Así mismo, se valorará el papel activo y la productividad de los individuos subadultos dentro de un grupo humano, y si ello se ve limitado por cuestiones energéticas. Finalmente, se analizará si el coste de la locomoción y la velocidad óptima alcanzada por sujetos subadultos puede limitar la movilidad y la puesta en marcha de actividades que dependen de la locomoción en grupos humanos. Con todo, se tratará de conocer si la energía actúa como un limitante a la hora de aprender y desarrollar actividades complejas propias de nuestra especie y cómo afecta esto a las dinámicas energéticas del resto de individuos de un grupo humano. Para ello se han empleado datos de dos estudios experimentales, llevados a cabo en el Laboratorio de Bioenergía y Análisis del Movimiento del Centro Nacional de Investigación sobre la Evolución Humana (CENIEH). Estos corresponden a 118 voluntarios de entre 7 y 14 años de edad, y recogen diferentes medidas antropométricas, de composición corporal y de gasto energético. Los dos estudios experimentales incluían simulaciones de actividades comunes entre los individuos subadultos de ciertos grupos de cazadores y recolectores de la actualidad, como la recolección y la extracción de recursos y caminar a diferentes velocidades. Los resultados obtenidos en el conjunto de las pruebas revelan que, tanto la energía gastada, como la eficiencia en una actividad productiva, no explican la diferencia de labores entre sexos, pero tampoco entre edades si se comparan con las velocidades óptimas adultas. Se propone que la división de labores en base al sexo debe responder a otras cuestiones, relacionadas con el aprendizaje temprano en habilidades complejas específicas para cada sexo. Además, debido a la relación entre el gasto energético y el tamaño corporal en actividades productivas en las que se aprenden esas habilidades, los individuos juveniles gozan de una ventaja, ya que comienzan a aprender en una fase en la que el crecimiento corporal se retiene y se consume menos energía porque se tiene un tamaño menor. Por ello, practicar durante esta etapa, supone un ahorro en forma de energía respecto a otras fases en las que se tiene un mayor tamaño corporal y sí se invierte más energía en crecimiento y desarrollo, como en la adolescencia. Por otro lado, el gasto energético de la prueba de extracción de recursos bien se cubriría con el retorno calórico facilitado por diferentes autores, pero no podríamos confirmar que se alcancen ya tasas de productividad adulta. En esta prueba también se ha demostrado que, igual que se observa en el gasto energético del resto de actividades aquí desarrolladas, tampoco existen diferencias entre sexos en la eficiencia derivada de extraer recursos del suelo. Este resultado se ha obtenido al tener en cuenta la tasa de eficiencia (energía gastada/retorno conseguido). Respecto a las actividades que dependen de la locomoción bípeda, no existen diferencias entre sexos en la velocidad óptima, ni el gasto derivado de alcanzar esta velocidad. Por lo tanto, se propone que ambas variables no condicionarían a los individuos aquí estudiados a la hora de acompañar a un grupo adulto de cazadores y recolectores, ni durante la movilidad ni mientras se captan recursos. Por otro lado, la capacidad para alcanzar velocidades óptimas semejantes a las publicadas para individuos adultos, podría suponer a los subadultos ventajas al consumir menos energía por ser más pequeños. No obstante, en determinadas sociedades estos individuos no se involucran en ciertas actividades de manera temprana, por lo que existen otras causas, más allá de la velocidad o el gasto energético, que pueden dificultar la participación de los subadultos en algunas actividades adultas. Todas estas ventajas han podido propiciar en la especie Homo sapiens un ahorro de energía que directamente, no solo beneficia al individuo subadulto, sino también a otros individuos del grupo. Muchas de las ventajas aquí expuestas se ven acompasadas por la peculiar historia biológica humana. Por ello, otras especies de homininos que hayan requerido del aprendizaje de habilidades complejas para subsistir, se habrían beneficiado de las mismas ventajas que exponemos en esta investigación, solo si hubiesen tenido los mismos patrones de desarrollo y crecimiento encontrados en Homo sapiens. The main interest of this Ph.D. Dissertation is to understand the key-role of the energy in the relationship between humans and the environment, since energy is the factor that models and adjusts the biological and behavioural adaptations of all living organisms and, by extension, of humans too. Several studies within the Human Behavioural Ecology have used the energy to understand human adaptation and adaptability. This adaptability is the main result of human plasticity, acquired thanks to the prolonged immaturity of Homo sapiens. However, fewer studies have focused on understanding how energy affects subadult behaviour and biology. Therefore, the main interest of this research is to study how energy affects the implementation of different essential human behaviours in hunter-gatherer societies. Specifically, it will be evaluated if the onset of division of labour by sex is caused by differences in the efficiency and the energetic demands of different individuals. In addition, the active role and the productivity of non-adult individuals will be assessed, together with possible energetic limitations in this regard. Finally, the cost of locomotion and the optimal speed will be analysed to test if non-adult individuals limit group mobility or the participation in foraging activities involving locomotion. Consequently, it will be discussed if energy is a limitation while learning-by-doing complex activities, commonly practiced by Homo sapiens species, and how this affects the energetic dynamics of a human group. To achieve this, data from two experimental studies carried out in the Laboratory of Bioenergy and Analysis of the Movement of the CENIEH have been used. Data were obtained from 118 volunteers between 7 and 14 years of age, and referred to different anthropometric, body composition and energy expenditure measurements. The two experimental studies consisted of three trials, simulating common activities among subadult individuals of certain groups of current hunter-gatherers. The recreated activities were a gathering test, a digging tubers trial, and a locomotion activity at different speeds. The results obtained in all of the experimental studies reveal that the energy expended and the efficiency in a productive activity do not explain the onset of sex division of labor. It is proposed that the division of labor is caused by other questions related to the early learning in sex-specific complex skills. In addition, due to the relationship between energy expenditure and body size in some productive activities (through which non-adults learn these skills), juvenile individuals have an energetic advantage, because they decelerate the body growth in this phase and they consume less energy due to their smaller body size. Therefore, learning-by-doing at this stage promotes energy savings compared to other phases with a larger body size and a greater somatic investment, like adolescence. On the other hand, the energy expenditure of digging would be covered with the energetic return reported by other investigations, but we cannot confirm that our individuals have already achieved adult productivity rates. In this test, taking into account the results of the efficiency index (energy expended/items reported) it has also been shown that there are no differences among sexes based on the efficiency of extracting tubers from the ground, as we have observed for the energy expenditure of the rest of the activities carried out here. Regarding the locomotion test, there are no differences among sexes, or ages when compared with adult values from other studies, neither comparing the optimal walking speed, nor the energy expenditure at this speed. Thus, it is proposed that both variables are not a limitation for the individuals here studied if they would be part of a hunter-gatherer group, neither during the mobility of the group, nor while foraging. On the other hand, our volunteers reach similar optimal speeds as those reported in the literature for adult individuals. This could constitute and advantage for non-adult individuals, as they are consuming less energy because they are smaller. Nonetheless, in certain societies, non-adult individuals are not involved in some activities anyway, thus there may be other causes, beyond speed or energy costs, that can hinder the participation of non-adults in some adult activities. All the mentioned advantages would allow energy savings for Homo sapiens. This savings would directly benefit the non-adult individual, but also the rest of the group. However, most of the advantages highlighted here are linked to the peculiar Homo sapiens Life History. Therefore, the advantages we expose in this research would benefit other extinct species with subsistence complex skills, only if Homo sapiens-like development and growth patterns were already present.
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Intestinal malrotation in a female newborn affected by Osteopathia Striata with Cranial Sclerosis due to a de novo heterozygous nonsense mutation of the AMER1 gene
Article
Full-text available
  • Dec 2022
  • Riv Ital Pediatr Ital J Pediatr
Background Osteopathia Striata with Cranial Sclerosis (OS-CS), also known as Horan-Beighton Syndrome, is a rare genetic disease; about 90 cases have been reported to date. It is associated with mutations (heterozygous for female subjects and hemizygous for males) of the AMER1 gene, located at Xq11.2, and shows an X-linked pattern of transmission. Typical clinical manifestations include macrocephaly, characteristic facial features (frontal bossing, epicanthal folds, hypertelorism, depressed nasal bridge, orofacial cleft, prominent jaw), hearing loss and developmental delay. Males usually present a more severe phenotype than females and rarely survive. Diagnostic suspicion is based on clinical signs, radiographic findings of cranial and long bones sclerosis and metaphyseal striations, subsequent genetic testing may confirm it. Case presentation Hereby, we report on a female newborn with frontal and parietal bossing, narrow bitemporal diameter, dysplastic , low-set and posteriorly rotated ears, microretrognathia, cleft palate, and rhizomelic shortening of lower limbs. Postnatally, she manifested feeding intolerance with biliary vomiting and abdominal distension. Therefore, in the suspicion of bowel obstruction, she underwent surgery, which evidenced and corrected an intestinal malrotation. Limbs X-ray and skull computed tomography investigations did not show cranial sclerosis and/or metaphyseal striations. Array-CGH analysis revealed normal findings. Then, a target next generation sequencing (NGS) analysis, including the genes involved in skeletal dysplasias, was performed and revealed a de novo heterozygous nonsense mutation of the AMER1 gene. The patient was discharged at 2 months of age and included in a multidisciplinary follow-up. Aged 9 months, she now shows developmental and growth (except for relative macrocephaly) delay. The surgical correction of cleft palate has been planned. Conclusions Our report shows the uncommon association of intestinal malrotation in a female newborn with OS-CS. It highlights that neonatologists have to consider such a diagnosis, even in absence of cranial sclerosis and long bones striations, as these usually appear over time. Other syndromes with cranial malformations and skeletal dysplasia must be included in the differential diagnosis. The phenotypic spectrum is wide and variable in both genders. Due to variable X-inactivation, females may also show a severe and early-onset clinical picture. Multidisciplinary management and careful, early and long-term follow-up should be offered to these patients, in order to promptly identify any associated morbidities and prevent possible complications or adverse outcomes.
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Seasonal effects on physical growth and development
Chapter
  • Oct 1993
Seasonality has effects on a wide range of human functions and activities, and is important in the understanding of human-environment relationships. In this volume, distinguished contributors including human biologists, anthropologists, physiologists and nutritionists consider many of the different ways in which seasonality influences human biology and behaviour. Topics addressed include the influence of seasonality on hominid evolution, seasonal climatic effects on human physiology, fertility and physical growth, seasonality in morbidity, mortality and nutritional state, and seasonal factors in food production, modernization and work organization in Third World economies. This book will be of interest to graduate students and researchers in human biology, anthropology and nutrition.
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A straight-line graph for leg-length discrepancies
Article
  • Mar 1977
A graphic method is presented that facilitates the recording and interpretation of data in cases of leg-length discrepancy. It provides a mechanism for predicting future growth that automatically takes into account the child's growth percentile and the degree of growth inhibition in the short leg. It can be used to predict the effects of corrective surgical procedures and to choose a surgical timetable. A series of cases of epiphyseodesis is presented, showing the straight-line graph method to be significantly more accurate than the so-called growth-remaining method, particularly in cases of growth inhibition.
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Growth arrest for equalizing leg lengths
Article
  • Jan 1944
  • J Am Med Assoc
Our purpose in this paper is to popularize a simple surgical procedure which we have found to be of great value in solving the problem when in children one leg is enough shorter than the other to produce immediate or probable future disability. Since Phemister's1 important article reporting the original conception was published eleven years ago, and as other articles discussing the complicated bone growth problem and still others reporting uncertain end results from his operation have appeared, it is felt that a discussion of the procedure would be justified after doing over two hundred and fifty epiphysiodiaphysial fusions in which few difficulties or complications have been encountered.We wish to call attention to three important points which we feel should be emphasized in order to dispel some of the apprehension existing relative to the performance of this so-called irretrievable operation.First of all we will describe briefly a
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The Classic: Growth and Predictions of Growth in the Lower Extremities
Article
  • Oct 1978
  • CLIN ORTHOP RELAT R
William T. Green, born in 1901, was resident at the Henry Ford Hospital in both general surgery and orthopedic surgery under Roy D. McClure. He was appointed to the staff of the Brigham Hospital and the Boston Children's Hospital where he performed experimental and clinical investigations of major significance. W. T. Green demonstrated that wire, nail or tendon implants through the center of the epiphysis do not arrest epiphyseal growth, whereas compression and screw fixation in the same area cause fusion of the epiphysis. These observations were readily applicable to the problem of tendon transplantation and epiphysiolysis and to treatment of injuries of the growth zones of the skeleton. He also investigated the circulation of the head of the femur in children, the function of the retinacula of Weitbrecht, and standardized the closed treatment of congenital dislocation of the hip as well as open reduction of slipped femoral capital epiphysis. William T. Green designed a program for children with chronic arthritis and cerebral palsy with special reference to prevention of deformity. He developed and recorded a set of principles of treatment of hematogenous osteomyelitis (previous to the era of antibiotics). In 1946, Green was appointed Chief Orthopaedic Surgeon of the Children's Hospital and Peter Bent Brigham Hospital, Harvard Medical School Orthopaedic Service. From 1954-56 he was President of the American Board of Orthopaedic Surgery, in 1957 President of the American Academy of Orthopaedic Surgeons, and in 1958, President of the American Academy of Cerebral Palsy. In 1962 William T. Green was awarded the first Harriet M. Peabody Professorship of Orthopaedic Surgery at Harvard Medical School. The most important of these many achievements of William T. Green are the tables and graphs formulated by him and his associates which are based on direct recordings and careful measurements of the rate of growth of the extremities in normal and paralytic conditions which enable physicians to predict the eventual leg length discrepancy in adult life. (C) Lippincott-Raven Publishers.
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Charts of fetal size: 4. Femur length
Article
  • Feb 1994
  • BJOG-INT J OBSTET GY
Objective To construct a new size chart for fetal femur length. Design A prospective, cross sectional study of fetuses scanned once only for the purpose of the study at gestations between 12 and 42 weeks. Setting The routine ultrasound department of a London teaching hospital. Subject The fetuses of 663 women seen in the routine antenatal booking clinic whose ultrasound and menstrual dates agreed within 10 days. Results Femur length was measured on 649 of the 663 fetuses. A linear‐cubic regression model was fitted to estimate the mean and a separate linear regression to estimate the standard deviation. Gentiles were derived by combining these two regression models, assuming that the measurements have a normal distribution at each gestational age. A new chart for femur size is presented and compared with previously published data. Conclusions We have constructed a new size chart for fetal femur length taking into consideration the increasing variability with increasing gestational age. We have compared our chart with other published data, and believe that the differences seen may be largely due to methodological differences.
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Skelettaltersbestimmung am Ellbogen während des pubertären Wachstums
Article
  • Jan 2005
The Sauvegrain et al. method of assessing skeletal age from elbow radiographs is useful during the 2 years of the pubertal growth spurt: between 11 and 13 years in girls and between 13 and 15 years in boys. This method uses four ossification centers of the elbow: lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores of these structures are summed, a total score is determined, and a graph is then used to determine the skeletal age. This simple, reliable, and reproducible method complements the Greulich and Pyle atlas, which does not allow assessment of skeletal age in 6-month intervals during the phase of accelerating growth velocity. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and Tanner stages. Skeletal age assessment from the elbow is useful to plan the timing of epiphysiodesis in limb length inequality or to evaluate the progression risk of idiopathic scoliosis.
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