Session 3: Paediatrics

18. November
09:00 - 10:30
Lokale: 202-203
Chairmen: Vilhelm Engell & Peter Buxbom

21. Does lower extremity passive range of motion associate with gross motor capacity or gross motor performance in children and adolescents with cerebral palsy? A cross-sectional study
Christina Esmann Fonvig, Jens Troelsen , Anders Holsgaard-Larsen
Orthopaedic Research Unit, Department of Orthopaedics and Traumatology, Odense University Hospital & Department of Clinical Research, University of Southern Denmark; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark

Background: Cerebral palsy (CP) is the most common motor disability in childhood, affecting 2 per 1000 live births. In the Nordic countries, findings from standardized clinical examinations are registered in the national clinical quality database; Cerebral Palsy Follow-Up Program (CPUP). The CPUP uses a traffic light system, with red/yellow/green thresholds for passive range of motion (ROM), as an easy-to-understand interpretation of the measurement, and to guide decisions about future examinations and interventions. However, the threshold values are arbitrary, and serve primarily as a pragmatic indication.
Aim: The aim of this study is to test the hypothesis that ROM values in the lower extremity are positively associated to gross motor capacity and gross motor performance in children and adolescents with independent gait, and that gross motor capacity and gross motor performance scores differ between CPUP’s traffic light ROM thresholds
Materials and Methods: A retrospective cross-sectional analysis of CPUP data, including 841 children and adolescents aged 8-15 years, at a Gross Motor Function Classification System level I-III. Continuous and categorical analysis between 10 ROM measures from the lower extremity versus gross motor capacity (Gross Motor Function Measure), and gross motor performance (Functional Mobility Scale (FMS 5m, 50, 500m)) were assessed using regression analysis with an alpha level of 0.01.
Results: No positive association between ROM versus gross motor capacity (p=0.82-0.94), or between ROM versus gross motor performance (p=0.13-0.99), was observed. No categorical differences between CPUP’s traffic light ROM thresholds were identified except for hip abduction (FMS 50m (R2=0.60, p=0.001), (FMS 500m (R2=0.56, p=0.001)) and the popliteal angle (FMS 500m (R2=0.56, p=0.006)).
Interpretation / Conclusion: Opposed to our hypothesis, the findings suggest that the degree of lower extremity ROM does not associate with the child’s gross motor capacity or gross motor performance. The results suggest that ROM, and categorical traffic light threshold values used in the CPUP, are of limited clinical value in assessing overall gross motor capacity and gross motor performance.

22. Controlled rotation of long bones by guided growth – A proof of concept study of a novel plate in cadavers
Abood Ahmed A., Hellfritzsch Michel B., Møller-Madsen Bjarne, Brüel Annemarie, Westersø Thomas S., Vedel-Smith Nikolaj K., Rahbek Ole , Rölfing Jan D.
Department of Orthopaedics, Aarhus University Hospital; Department of Radiology, Aarhus University Hospital; Department of Biomedicine, Health, Aarhus University; Additive Manufacturing, Danish Technological Institute; Department of Orthopaedics, Aalborg University Hospital

Background: Rotational deformities in children are currently treated by osteotomy, acute correction and fixation. This procedure is associated with substantial pain and hospitalisation. Hence, a patented novel plate design has been developed to accurately correct rotational deformities by guided growth in children.
Aim: To evaluate the mechanical ability and precision of the novel plate in femoral rotation.
Materials and Methods: Twelve cadaverous femora of six adults (right = 6, left = 6) underwent an osteotomy at the level of the physeal scar and the plates were inserted on each side of the distal femur. Growth was simulated by manual axial distraction of the bone segments. The femur was stabilized using a unilateral external fixator. Femoral torsion was assessed with CT and with an electric goniometer before and after distraction. The obtained rotation was compared with the predicted rotation based on the dimension of the plate and the bone.
Results: All femora were rotated as intended. The mean obtained rotation was 26.3 degrees and the mean predicted rotation was 28.2 degrees (p > 0.82). Mean axial distraction was 19.5 mm (CI 95% 17.7 - 21.3).
Interpretation / Conclusion: The predicted rotation of the femora was similar to the obtained values on CT and by goniometer. This suggests a potential for controlled rotation of the femur based on the circumference of the bone and plate dimensions which occurs simultaneously with axial distraction. Studies in large animal models are needed and planned.

23. Evaluation of somatosensory profiles in children and adolescents with cerebral palsy and chronic pain by quantitative sensory testing
Johanne Jørgensen, Mads Werner, Josephine Michelsen, Christian Wong
Department of Orthopedic Surgery, Hvidovre Hospital; Multidisciplinary Pain Center, Rigshospitalet; Danish Multiple Sclerosis Center, Rigshospitalet Glostrup; Department of Orthopedic Surgery, Hvidovre Hospital

Background: Chronic pain in children and adolescents with cerebral palsy (CP) is a partly overlooked and undertreated clinical problem, while being a major determinant for quality of life.
Aim: To better understand the underlying pain mechanisms, we investigated the somatosensory profiles of children and adolescents with and without CP, and chronic pain, with quantitative sensory testing (QST).
Materials and Methods: This prospective cross-sectional, explorative study investigated 51 subjects; 25 with CP (9 with chronic pain [CP-P], 16 without [CP-NP]), and 26 without CP (14 with chronic pain [non- CP-P], 12 without [controls]). All subjects were recruited from the outpatient orthopedic clinic. The subjects had their reaction time tested prior to the QST. The QST included assessments of warmth (WDT), cool (CDT), mechanical (MDT) and vibration (VDT) detection thresholds; heat (HPT), pressure (PPT), and mechanical (MPT) pain thresholds; and tests of wind-up (WUR), dynamic mechanical allodynia (DMA) and conditioned pain modulation (CPM).
Results: There were no statistical differences in QST results between subjects with CP-P and CP-NP. Reaction times were longer in subjects with CP compared to subjects without CP (P=0.010). Subjects with CP demonstrated hypoesthesia in WDT (P=0.031) and CDT (P=0.029), with a trend for mechanical hypoesthesia in MDT (P=0.052), and no difference in HPT compared to controls. When rating pain during HPT-assessment, more subjects with CP rated the pain intensity as high (13/25 vs. 2/12, P=0.008), and in WUR, fewer subjects with CP registered increasing pain over time (6/25 vs. 7/12, P=0.041), compared to controls. Subjects in the non-CP-P group demonstrated hypoesthesia in WDT (P=0.008) and HPT (P=0.021), and more subjects rated the pain intensity as high (9/14 vs. 2/12, P=0.014), compared to controls. Regarding the rest of the QST variables, no significant differences were shown.
Interpretation / Conclusion: The somatosensory profiles of subjects with CP demonstrated similarities regardless of the pain phenotype; thermal and mechanical hypoesthesia and decreasing pain in responses to WUR. Further sensory studies are warranted examining the pathophysiological mechanism of pain in children and adolescents with CP.

24. Seasonal variation in children’s fractures: A population-based study of 20,654 pediatric fractures.
Rønnov Lund Anja, Lauritsen Jens Martin, Færgemann Christian
Accident Analysis Group and Section for Pediatric Orthopaedic, Department of Orthopaedics and Traumatology, Odense University Hospital, Odense, Denmark

Background: Pediatric fractures are common. A Scandinavian reported a fracture life- time risk (0-14 years) of 42 % in boys and 27 % in girls. The fracture incidence varies with the seasons. Most studies have showed an increase in spring or summer. Other studies have showed an increase in the winter. Few previous Scandinavian studies have described the seasonal variation in pediatric fractures.
Aim: The aim of the study was to describe the seasonal variation in the incidence rate of pediatric fractures 1996-2019 in a Danish population.
Materials and Methods: We extracted data from the existing emergency department register at Odense University Hospital 1996- 2019. We included all radiologic confirmed fractures in children aged 0-14 years living in the Odense Municipality at the time of fracture. Seasonal and monthly incidence rates were calculated using population counts stratified by age, gender, and fracture site.
Results: Overall, 20,654 fractures were included. Boys accounted for 11,818 (57 %) of the fractures. The median was 9 years. We found a significant increase in the incidence rate in spring and summer, except for a drop in July. For boys the incidence rate ranged from 206 (95 % C.I.: 192-222) in December to 404 (95 % C.I.: 382-426) per 10,000 person-years in June. For girls the incidence ranged from 156 (95 % C.I.: 142-170) in December to 317 (95 % C.I.: 298-337) in May. Fractures were more frequent in the upper extremities and were up to 6 times more frequent in the epiphysis and metaphysis than on the shafts. All fracture sites showed significant variation with a peak in spring and summer except for July, and lowest incidence in the winter.
Interpretation / Conclusion: The present study shoved seasonal variation in pediatric fractures with a peak in the spring and summer and a drop in July. The results correspond with the increased physical activity in the spring and summer. The low incidence in July corresponds with low sport activities due to summer vacation and travel abroad. This study gives useful information for coordinating the optimal medical resources at the hospitals and for planning preventive campaigns.

25. Ankle contractures are frequent among children with cerebral palsy and associated with lower gross motor function and degree of spasticity
Lærke Hartvig Krarup, Pia Kjær Kristensen, Louise Strand, Sofie Langbo Bredtoft, Inger Mechlenburg, Kirsten Nordbye-Nielsen
Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Clinical Medicine, Aarhus University; CPNorth: Living Life With Cerebral Palsy in the Nordic Countries,

Background: Cerebral Palsy (CP) is the most common chronic motor disability in childhood. Studies report that muscle contractures, limiting joint range of motion (ROM), are a common secondary condition in children with CP. Contractures may contribute to reduce functional capacity and limit overall skills considerably, causing limitations to activity and participation restrictions. Prevention of ankle contractures is especially important among children with CP since adequate ROM in the ankle joint is essential to ankle dorsiflexion, and thereby to maintain the ability to walk. Reduced ROM in the lower limbs, including ankle contractures, might negatively affect gross motor development, which is related to quality of life, including physically well- being.
Aim: To estimate yearly prevalence of ankle contractures among children with cerebral palsy. Moreover, to investigate whether age, gross motor function or spasticity are associated with ankle contracture.
Materials and Methods: We examined yearly prevalence of ankle contractures among 933 children based on data from a national clinical quality database from 2012 to 2019. We used the Gross Motor Function Classification System (GMFCS) and the Modified Ashworth Scale (MAS) to assess gross motor function and spasticity in the plantar flexors. Ankle contracture was defined as dorsiflexion with an extended knee equal to or below 0 degrees. Associations between age, GMFCS, spasticity and ankle contractures were analysed using multivariable regression and presented as odds ratios (OR) with 95% confidence intervals (95%CI).
Results: The prevalence of ankle contracture was 32% and did not change with calendar year. GMFCS IV–V compared to I–III (40.6% vs. 28.9%, OR = 1.5 (95%CI: 1.07– 2.11) and MAS 2–4 compared to 0 (44.6% vs. 24.4%, OR = 2.5 (95%CI: 1.59–3.91) were associated with a higher prevalence of ankle contracture. Age was not associated with ankle contracture.
Interpretation / Conclusion: Ankle contractures are frequent among children with CP. Lower gross motor function and severe spasticity were associated with ankle contracture.

26. Epidemiology and incidence of paediatric orthopaedic trauma workload during the COVID-19 pandemic—A multicenter cohort study of 3171 patients
Morten Kjerri Rasmussen, Peter Larsen, Jan Duedal Rölfing, Bertram Lahn Kirkegaard, Rikke Thorninger, Rasmus Elsøe,
Department of Orthopaedic Surgery, Aalborg University Hospital; Department of Physiotherapy, Aalborg University Hospital; Department of Orthopaedic Surgery, Aarhus University Hospital; Department of Clinical Medicine, Aarhus University; Department of Orthopaedic Surgery, Regional Hospital Randers; Department of Orthopaedic Surgery, Regional Hospital Viborg

Background: A danish national lockdown was issued on the 11th of March 2020 including closure of schools and cessation of sports. Therefore a reduction in paediatric injuries was expected. Although current literature investigates the frequencies of paediatric injuries during the COVID-19 pandemic, no overview of the pandemic’s consequences on population-based incidences of paediatric injuries and related trauma mechanisms is available.
Aim: To examine the consequences of the national lockdown and political initiatives during the first surge of the COVID-19 pandemic expressed by changes in incidences of musculoskeletal paediatric injuries at the emergency departments across multiple hospitals.
Materials and Methods: The study design was a retrospective cohort study investigating the incidence of paediatric musculoskeletal injuries in patients aged 0– 15 years. A ‘pandemic’ cohort was established from 16 March 2020 to 21 April 2020, where all institutions including day care and schools were closed. A ‘pre-pandemic’ cohort was established from the same period in 2019 for comparison. Included were all patients admitted at the emergency departments with paediatric musculoskeletal injuries identified by a relevant musculoskeletal ICD-10 diagnosis (DSxxx), concussions (DZ033D), or burns (DT2xx). Clinical information about diagnosis, age, gender, date, and mode of injury was obtained.
Results: The ‘pre-pandemic’ cohort consisted of 2101 patients, and the ‘pandemic’ cohort consisted of 1070 patients, indicating a decrease of paediatric musculoskeletal injuries of 51% during the COVID-19 pandemic. The overall incidence of paediatric injury in the ‘pre-pandemic’ cohort was 10,460/100,000/year. In the ‘pandemic’ cohort, the overall incidence was 5,344/100,000/year, indicating a twofold decrease in paediatric emergency patients during the COVID19 pandemic.
Interpretation / Conclusion: The overall incidence rate for paediatric injury in the ‘pre-pandemic’ cohort was 10,460/100,000 persons/year. The overall incidence rate decreased to 5,344/100,000 persons/year in the ‘pandemic’ cohort. A resource re-allocation to help serve the COVID-19 patients might be possible without reducing the level of care for injury-related paediatric patients.

27. Positive predictive values in clinical screening for developmental dysplasia of the hip
Hans-Christen Husum, Arash Gaffari, Laura Rytoft, Jens Svendsson, Søren Harving, Søren Kold, Ole Rahbek
Interdisciplinary Orthopaedics, Aalborg University Hospital

Background: The Danish selective screening programme for developmental dysplasia of the hip (DDH) is based on clinical examinations and screening for risk factors of all newborns. Studies have shown a low positive predictive value (PPV) of clinical hip examinations performed by a heterogenic group of screeners in the United Kingdom. As no true definition of DDH exists, the PPV is difficult to assess.
Aim: To establish the positive predictive value (PPV) of clinical hip examinations performed by referrers in the Danish screening programme for Developmental Dysplasia of the Hip (DDH) utilising three definitions of true positive DDH diagnosis.
Materials and Methods: We retrospectively identified 290 children (169 female) referred during a four-year period to the orthopaedic outpatient clinic at our institution with a positive clinical hip examination. We calculated PPV for clinical hip examinations across three definitions of a true positive clinical hip examination for all referrers and subgroups consisting of general practitioners, midwives and paediatricians. The PPV for clinical hip examinations was calculated for paediatric orthopaedic surgeons, who were blinded to the results of ultrasound examination, using one of the three definitions.
Results: PPV of clinical hip examinations for all referrers were 5.4%, 3.6% and 1.8% with the definition of a true positive DDH diagnosis defined as clinical instability found by orthopaedic surgeon, ultrasound classification = Graf IIc or both definitions combined, respectively. PPV of clinical hip examinations performed by orthopaedic surgeons was 33.3% with a true positive clinical examination defined as an ultrasound classification = Graf IIc.
Interpretation / Conclusion: In this first review of results from the Danish screening programme for DDH, we conclude that the positive predictive value of clinical hip examinations made by referrers in the Danish screening programme for DDH is low. As clinical examinations are a critical part of the selective screening for DDH, this study demonstrates a need for focused training of screeners in clinical hip examinations to improve the screening of DDH in Denmark.

28. What is the association between MRI and radiography in measuring femoral head migration?
Hans-Christen Husum, Michel Bach Hellfritzsch, Mads Henriksen, Kirsten Skjaerbaek Duch, Martin Gottliebsen, Ole Rahbek
Interdisciplinary Orthopaedics, Aalborg University Hospital; Department of Radiology, Aarhus University Hospital; Department of Orthopedics, Aarhus University Hospital; Danish Pediatric Orthopaedic Research; Unit of Epidemiology and Biostatistics, Aalborg University

Background: Conventional pelvic radiographs are traditionally used for assessing femoral head migration in residual acetabular dysplasia (RAD). Knowledge of the importance of cartilaginous structures in this condition has led to increased use of magnetic resonance imaging (MRI) in assessing both osseous and cartilaginous structures of the pediatric hip.
Aim: Therefore, we assessed the relationship between migration percentages (MP) found in MRI and conventional radiographs. Secondly, we analyzed the reliability of MP in MRI and radiographs.
Materials and Methods: We retrospectively identified a consecutive series of 16 patients (2 male, mean age 5 years (2 to 8 years)), examined for RAD during a period of 2½ years. Four raters performed blinded repeated measurements of osseous migration percentage (MP), cartilaginous migration percentage (CMP), in MRI and radiographs. Pelvic rotation and tilt indices were measured in radiographs to account for influence of pelvic positioning. Bland Altman (BA) plots and intraclass correlation coefficients (ICC) were calculated for agreement and reliability.
Results: BA plots for MP(R) and MP(MRI) produced a mean difference of 6.4 Limits of agreement (-11 to 24) with higher disagreements at low average MP values. Mean MP(R) differed from mean MP(MRI) (17% versus 23%, P<0.001) MP(R) had the best interrater reliability with an ICC of 0.92 (0.86-0.96), compared to MP(MRI) and CMP with ICC values of 0.61 (0.45-0.70) and 0.52 (0.26-0.69), respectively. Intrarater reliability for MP(R), MP(MRI) and CMP all had ICC values above 0.75 and did not differ statistically significantly. Differences in MP(MRI) and MP(R) showed no correlation to pelvic rotation index, pelvic tilt index or interval between radiograph and MRI exams.
Interpretation / Conclusion: Pelvic radiographs underestimated MP when compared to pelvic MRI. These results should prompt the clinician to consider which image modality to use when assessing RAD cases. We propose CMP as a new imaging measurement, and conclude that it has good intrarater reliability but moderate interrater reliability. Measurement of MP in radiographs and MRI had mediocre to excellent reliability.

29. Correlation of clinical tests and patient-reported measures in adolescents with Osgood Schlatter: a cross-sectional study
Kasper Krommes, Kristian Thorborg, Per Hölmich
Orthopedic Department, Sports Orthopedic Research Center - Copenhagen, Hvidovre Hospital

Background: A common knee complaint during adolescence is Osgood Schlatter (OS). As research into OS is only just emerging, little is known on how findings from clinical tests correlates with self-reported measures.
Aim: To capture how clinical tests correlates with self- reported factors in OS patients.
Materials and Methods: Adolescent OS patients from a specialized orthopedic clinic completed patient-reported surveys within 6 domains (dependent outcome variables) on pain (maximal numerical pain rating past week and past 24 hours, KOOS child ‘pain’, EQ-D5-Y-4), mental health (EQ-D5-Y-5), kinesiophobia (Tampa Scale), quality of life (KOOS child ‘QoL’), sports function (KOOS child ‘sport/rec’), self-rated health (EQ-D5-Y-VAS), and underwent a test battery of knee function containing 5 tests (independent predictor variables). For continuous variables correlations were computed using Pearsons r, and Spearmans rank for non-continuous variables.
Results: Thirty-three patients (age 13.5±1.7 years, symptom-duration 23.6±16.1 months) participated. Lower normalized isometric knee extension strength (Nm/kg) correlated with self-reported pain (past 24 hours, r=0.595; EQ-D5- Y-4, r=0.509), and satisfaction with sport participation level (r=0.430). Decreased pressure-pain threshold at the tibial tubercle correlated with other pain measures, and level of kinesiophobia (r=0.447). Higher pain evoked from the Anterior Knee Pain Provocation Test correlated with other pain measures, problems with sports participation (r=0.548), and QoL (r=0.396). Pain during maximal isometric knee extension correlated with other pain measures, problems with sports participation (r=0.600), mental health (r=0.411), and QoL (r=0.593). Knee extensor flexibility was not associated with any self-reported measures (p>0.05). No tests were associated with self-rated health (p>0.05).
Interpretation / Conclusion: There is moderate to strong correlation between clinical test results and self-reported measures of pain, mental health, QoL, sports function, and self- rated health. This can help clinicians to more easily gauge an understanding of potentially affected self- reported factors, based of a few clinical measures.

30. Measuring effects on pain and quality of life after Dysport® injection in children with cerebral palsy
Jospehine Michelsen, christian wong
Department of Orthopedic Surgery, Copenhagen University Hospital, Hvidovre, Denmark

Background: Studies have shown that 30-70 % of children with cerebral palsy (CP) experience chronic pain. This is closely interrelated to poor quality of life. Despite this, pain is an overlooked and undertreated clinical problem. The effect of Botulinum toxin injections has been used to diminish spasticity but not on pain.
Aim: The aim was to examine the analgesic effect of a single intramuscular injection of botulinum toxin A (Dysport) in the most painful muscles of the lower extremities.
Materials and Methods: In this study, we examined 25 children with spastic CP, age 5-17, GMFCS I-V. The most painful muscles during passive range of motion (pROM) were the targets for treatment. The children had to have at least moderate muscle pain (r-FLACC=4) at inclusion to be enrolled in the study. Pain levels were measured before and at 4, 12 and 28 weeks after a single injection cycle of abobotulinum toxin (Dysport). The localized pain was evaluated by r-FLACC during pROM. The effect on daily pain was evaluated by the Paediatric Pain Profile (PPP). The effect on clinically relevant problems was evaluated by individual SMART goals using the goal attainment scale and quality of life by the CPChild.
Results: A significant pain reduction was observed 4,12 and 28 weeks post-treatment for localized muscle pain (p<0.001 at 4 weeks) and the impact on daily activities/pain intensity were significantly reduced after 4 and 12 weeks, but not 24 weeks. For daily pain, a significant analgesic effect was seen at all timepoints (p=0.003 at 4 weeks). Moreover, a clinically meaningful effect was seen since almost all participants achieving their therapeutic SMART goals at all timepoints (p<0.001 at 4 weeks). Quality of life was significantly improved at 4 weeks, but not at 12 and 24 weeks. Adverse effects of soreness and temporary muscle weakness were observed in 8 incidences.
Interpretation / Conclusion: Even though botulinum toxins, such as Dysport, have been utilized for spasticity modulation in children with CP, it also appears to have a significant analgesic effect, when muscle pain is targeted. Moreover, the localized pain reduction seems to have a positive effect on activities of daily living, level of daily pain, SMART goals, and quality of life.