Pediatric Connection Fall 2013 by Hospital for Special Surgery

A PUBLICATION OF THE ALFRED AND NORMA LERNER CHILDREN’S PAVILION AT HOSPITAL FOR SPECIAL SURGERY Volume 4 – Issue 1 Fall 2013

Pediatric Fractures by Emily Dodwell, MD, MPH, FRCSC

MEDICAL STAFF Pediatric Orthopedists John S. Blanco, MD Emily R. Dodwell, MD, MPH Shevaun M. Doyle, MD Daniel W. Green, MD Cathleen L. Raggio, MD Leon Root, MD David M. Scher, MD Ernest L. Sink, 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 Nancy Pan, MD Pediatric Anesthesiologists Adam Booser, MD Kathryn (Kate) DelPizzo, MD Naomi Dong, MD Chris R. Edmonds, MD Andrew C. Lee, MD Victor M. Zayas, MD Hospital for Special Surgery is an affiliate of NewYork-Presbyterian Healthcare System and Weill Cornell Medical College. For more information about HSS Pediatrics, visit http://www.hss.edu/peds The Pediatric Orthopedic Service provides coverage to the Phyllis & David Komansky Center for Children’s Health at NewYorkPresbyterian Hospital.

On average, 40% of boys and 30% of girls will have a fracture during childhood. Orthopedic trauma in children requires the expertise of pediatric orthopedic surgeons, primarily due to the sensitive areas of growth within children’s bones: the physes, more commonly known as growth plates. Most long bones have an area of growth on each end. These areas are constructed of discs of cartilage cells. Cartilage cells in this area multiply and grow in size, with eventual replacement by bone cells and calcification into new bone. This process accounts for the lengthening of bones. Physes inherently are less strong than other parts of the bone. When a child has an impact, twisting, bending, or traction injury, they are more likely to fracture through the physis than have a ligament tear to the neighboring joint.

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Mixed Connective Tissue Disease by Thomas J.A. Lehman, MD

Mixed connective tissue disease (MCTD) sounds like a diagnosis made up by doctors to describe a confusing patient. In actuality, the diagnosis is a very specific one that describes a group of patients with a unique condition.

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In the 1970s, Gordon Sharp, MD, a rheumatologist and pioneer in the field of autoimmune and autoantibody research, was testing antinuclear antibodies (ANA) when he discovered that a few patients who were ANA-positive became ANA-negative if cells were exposed to a special buffer. This revelation led to the discovery of extractable nuclear antigens (ENA), which we now know as Ro, La, Sm, and RNP.

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When Sharp looked more carefully at those patients with ENA, he found that they were

For more information about the Komansky Center, visit http://www.cornellpediatrics.org

Approximately 20% of pediatric fractures involve the growth plate. Even when fractures occur in other parts of the bone, they are heavily inﬂuenced by the presence of the physes. Surgeons fixing pediatric fractures need to treat the physes with care; due to the sensitive physes, many fixation techniques used in adults cannot be used in children.

most often patients whose disease looked like a mixture of lupus and rheumatoid arthritis, hence the term “mixed connective tissue disease.” ENA is always present in these patients, usually with a high titer of Ro, and low or no Sm. This is different than “undifferentiated connective tissue disease,” a term that refers to patients where we don’t really know what they have. CONTINUED on page 2

Mixed Connective Tissue Disease

Sports Medicine and Performance Enhancement

CONTINUED from the cover

By Jessica Graziano, PT, DPT, CSCS, FMS

Patients with MCTD typically are ANA-positive in high titer with a speckled pattern. They also tend to have high IgG levels and high sedimentation rates, but milder renal disease or more normal serum complement levels than true SLE patients. Because they rarely get diffuse proliferative glomerulonephritis (DPGN), which was often a fatal complication for SLE patients in the past, MCTD has been characterized as milder than systemic lupus erythematosus (SLE). However, MCTD patients seem to be more vulnerable to infections and have a higher frequency of severe Raynaud’s disease and pulmonary problems. In addition, it has been recognized that some patients develop typical features of scleroderma over time.

As participation in organized sports is on the rise, frequency of sports-related injuries has risen as well. The American Academy of Orthopedic Surgeons reported more than 3.5 million children ages 14 years and under receive medical treatment for sports related injuries each year. Injury predisposition and performance ability have been correlated to undeveloped physical skills and lack of physical fitness. Injury is inevitable if a child lacks adequate strength and fundamental motor skills to meet the demands of the activity. Therefore, youth strength training and injury prevention strategies that follow age-appropriate guidelines have taken the forefront in combating injuries in youth.

The key to proper care for a child with MCTD is early recognition of the proper diagnosis and promptly starting the appropriate therapy, which includes both corticosteroids and immunosuppressive drugs. These drugs can be scary for families and physicians who are unfamiliar with their use, but are commonly used by the pediatric rheumatologists at Hospital for Special Surgery. The key to getting the best outcome for children with any difficult condition is knowledgeable care from knowledgeable physicians. At Hospital for Special Surgery, our pediatric rheumatologists are truly experts. They haven’t simply read about MCTD; they’ve dealt with this condition many times before and are familiar with its ins and outs. In the hands of skilled physicians, children with MCTD most often can be restored to good health and full normal life styles. 2

Hospital for Special Surgery’s Tisch Sports Performance Center provides sports-specific services such as injury prevention and performance enhancement programs, sports-specific analysis, and strength training sessions. Young athletes recovering from injuries are encouraged to transition into the program after physical therapy is completed at the CA Technologies Rehabilitation Center to achieve a sufficient strength base to meet the demands of their sport. This strengthening will help to prevent re-injury or injury secondary to compensatory movement patterns. The multidisciplinary team includes physicians, physical therapists, athletic trainers, exercise physiologists and performance specialists who work collaboratively with the child to achieve safe return to activity, prevention of re-injury and maximizing performance. For example, a youth soccer player tears the anterior cruciate ligament (ACL), has surgery and begins physical therapy when deemed appropriate by the surgeon. The physical therapist then performs an evaluation including a thorough musculoskeletal assessment and discussion of goals with the child/caregiver to develop a rehabilitative program tailored specifically to the young athlete’s needs. The therapist rehabilitates the child while respecting soft tissue healing or surgical repair. An appropriate functional progression is followed and, once the athlete is pain-free, has an appropriate strength base and has met all goals included in the plan of care, he/she is transitioned to a performance specialist who works with the child in progressive functional strength training, technique development and performance enhancement. ACL injury is becoming increasingly common in youth athletes. HSS’s Tisch Sports Performance Center offers an ACL Injury Prevention Assessment aimed at identifying and correcting movement patterns that are associated with increased risk for injury in young athletes. During this assessment, a physical therapist and an exercise physiologist observe the athlete perform a variety of movements, as well as analyze the athlete’s training and sports history, current training program, and videotaped analysis of dynamic alignment to identify strategies to reduce risk of lower extremity injury. The athlete is taken through a training progression to further strengthen muscles and correct faulty movement patterns to prevent re-injury and time away from sport. The goal of the Center is to keep child athletes on the field doing what they enjoy. Programs Offered Include: • Sport specific analysis: Baseball, Softball, Running • Sports Specific Strength Training • ACL Injury Prevention For more information or to schedule an appointment contact us at: (212) 606-1005.

Pediatric Fractures CONTINUED from the cover Due to the lack of calcification in the region of the growth plate, physeal fractures can be difficult to diagnose. Following fractures, the physes can continue to grow normally, but in some cases a bony scar forms across the physis such that growth is limited in all or part of the physis. When this happens, limb length discrepancy or angular deformity can develop. For this reason, growth plate fractures need to be treated appropriately, and frequently require prolonged follow up. Hospital for Special Surgery has nine pediatric orthopedic surgeons on staff. Drs. Blanco, Dodwell, Doyle, Green, Scher,

Sink, and Widmann have a special interest in trauma, and provide emergency coverage 24 hours per day, seven days per week at Hospital for Special Surgery and NewYorkPresbyterian Hospital/Weill Cornell Medical Center. Drs. Blanco, Dodwell, and Green also provide pediatric orthopedic emergency coverage at New York Hospital Queens. Children with orthopedic injuries can typically be seen in orthopedic consultation within hours, either through the pediatric ambulatory surgery center at HSS or through one of the pediatric emergency rooms. In many cases surgery can be arranged for the same day. Twenty-four hour access to a pediatric orthopedic surgeon can be obtained by dialing 1.877.HSS.1KID (or 1.877.477.1543).

The Connection Inspection... Back in the Game Following Growth Plate Fracture Like most girls her age, Sophie Morello enjoys physical activities with her friends and family. Five years ago, she was playing with her cousin when she suffered an injury that would dramatically change her life. While the two girls were jumping on a trampoline, Sophie had a hard landing that resulted in a right ankle fracture. “When my cousin bounced, I went in the air after her, and the surface was hard when I landed so my ankle just cracked,” explains Sophie. “I couldn’t get back up because it hurt too much.” What had once been a minor ankle fracture became a serious problem as the years progressed. Sophie says, “Last summer, my mom saw something wrong with my leg. It looked like it bowed out.” At age eleven, Sophie’s left leg was noticeably longer than her right. This discrepancy in the length of her legs was beginning to cause Sophie significant discomfort. “My hips were uneven, so after soccer games, my hip and my behind would hurt. They didn’t feel broken, just really sore.” Her pediatrician recommended that Sophie visit Dr. Roger Widmann, chief of Pediatric Orthopedic Surgery at Hospital for Special Surgery. Using state-of-the-art diagnostics and imaging in the Alfred and Norma Lerner Children’s Pavilion at HSS, Dr. Widmann determined that Sophie’s fall on the trampoline had resulted in a break to the growth plate on the bottom of her right tibia, impeding its normal growth. “Certain growth plates are more sensitive to fracture than others. Fractures that cross the growth plate can result in malalignment of the cells that affect growth,” explains Dr. Widmann. “If you have that, it can either stop the growth completely or you can get a partial growth arrest, which is what happened to Sophie.” Part of Sophie’s growth plate was growing, but part of it wasn’t, causing her right leg to bow and be shorter than her left (an angular deformity and leg length discrepancy). Since there is no way to regenerate the growth plate cartilage after a partial growth arrest, Dr. Widmann performed surgery to divide the tibia into two parts and placed a spatial frame to Sophie’s right leg with pins and wires. The spatial frame allows for growth of new bone between the two parts of the tibia by gradual distraction. Sophie says, “At first I thought it looked like a bird cage and I did not want it. But then I learned how it was going to fix my leg and that I would be okay in the end.” Twice a day for several months, Sophie and her parents adjusted the screws on the spatial frame according to a carefully calculated plan gradually straightening and lengthening her leg with each turn. Determined to get back in the game, Sophie pushed past her discomfort during physical therapy and was back on the soccer field just four months after the procedure – two months ahead of schedule. Dr. Widmann says he is very pleased with her recovery. “We rely on our physical therapists to make sure that our results are as good as they can be. Sophie’s treatment and successful results were a team effort.” In June, Sophie had her second and final surgery. Six weeks later she was back to physical therapy and jogging. Because of her hard work and determination, Sophie surpassed her recovery goals and is now back to scoring goals on the soccer field. 3

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A PUBLICATION OF THE ALFRED AND NORMA LERNER CHILDREN’S PAVILION AT HOSPITAL FOR SPECIAL SURGERY

Pediatric Orthopedics at HSS Increases Focus on Pediatric Hand Surgery The Pediatric Orthopedic service at Hospital for Special Surgery is pleased to announce an increased focus on pediatric hand surgery by Aaron Daluiski, MD, Assistant Attending Orthopedic Surgeon at HSS. A member of the HSS Hand service since 2002, Dr. Daluiski specializes in treating pediatric patients with congenital hand conditions. Dr. Daluiski has trained with leaders in the field of pediatric hand surgery nationally and internationally since 2011, and continues to focus his clinical work and research on hand and upper extremity conditions in the pediatric patient. Dr. Daluiski will be seeing pediatric patients in the Lerner Children’s Pavilion at HSS. Dr. Daluiski treats patients of all ages with a wide variety of musculoskeletal issues including disorders of the hand, wrist and elbow in both adults and children, including fractures, carpal tunnel syndrome, trigger fingers, tennis elbow and congenital deformities. As a clinician-scientist, Dr. Daluiski is dedicated to www.hss.edu/peds improving the care of pediatric patients with hand conditions through research Editor: Shevaun M. Doyle, MD that focuses on the biology of bone healing. For inquiries, please call (877) HSS-1KID Dr. Daluiski received his medical degree from the University of California, or e-mail: Peds@hss.edu Los Angeles, and completed his clinical training in the Department of Find us on Facebook at Orthopaedic Surgery at UCLA. Dr. Daluiski has also completed a research www.facebook.com/HSpecialSurgery. fellowship concentrating on the biology of the developing limb and bone Follow us on Twitter @HSpecialSurgery development and repair. He completed the Hand and Microvascular Surgery #hsspeds. clinical fellowship at Hospital for Special Surgery. The recipient of numerous grants and awards for his work, Dr. Daluiski was recently elected into the Young Leaders Program of the American Society for Surgery of the Hand. Dr. Daluiski is a member of several professional medical associations including the American Academy of Orthopedic Surgeons and the American Society for Surgery of the Hand.

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