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Cytat
Do celu tam się wysiada. Lec Stanisław Jerzy (pierw. de Tusch-Letz, 1909-1966)
A bogowie grają w kości i nie pytają wcale czy chcesz przyłączyć się do gry (. . . ) Bogowie kpią sobie z twojego poukładanego życia (. . . ) nie przejmują się zbytnio ani naszymi planami na przyszłość ani oczekiwaniami. Gdzieś we wszechświecie rzucają kości i przypadkiem wypada twoja kolej. I odtąd zwyciężyć lub przegrać - to tylko kwestia szczęścia. Borys Pasternak
Idąc po kurzych jajach nie podskakuj. Przysłowie szkockie
I Herkules nie poradzi przeciwko wielu.
Dialog półinteligentów równa się monologowi ćwierćinteligenta. Stanisław Jerzy Lec (pierw. de Tusch - Letz, 1909-1966)
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.Weight and height/length charts (Harlow Printing Company 2007)BMI charts (Harlow Printing Company 2007)Waist circumference centile charts (Child Growth Foundation 2007).(5) Sphygmomanometer with a range of cuffs of different sizes.(6) Skinfold calipers.Though as we explained in Chapter 2, we do not findskinfold measurements useful in assessing childhood obesity.Skinfoldcentiles for British children are very out of date (Tanner andWhitehouse 1975). 6What complications should we lookfor now and later?Obesity in childhood is not simply a matter of being too fat.In UK and manyother countries conditions previously associated with adult obesity are nowseen not only in obese adolescents but in quite young children (Pinhas-Hamiel et al.1996).With many of these children there may be a geneticpredisposition to the medical complication (for example an underlyingfamilial hyperlipidaemia or a family history of type 2 diabetes) but the child sobesity precipitates clinical manifestations of disease decades earlier thanwould have been expected had there been no obesity.Not all studies are sogloomy (Srinivasan et al.2003; Lawlor et al.2006) but it has been suggestedthat a consequence of the high prevalence of obesity and its co-morbidities inchildhood, if these persist, will be a fall in the mean lifespan of the currentgeneration of children compared with that expected for their parents(Olshansky et al.2005).Table 6.1 lists some of the complications which maydevelop or be exacerbated by obesity in childhood.In Chapter 5 we outlinedsome specific points in the clinical examination of obese children whichincluded looking for clinical signs of these conditions.Here we elaborate onthe conditions that may be found and their implications.Orthopaedic problemsNon-specific aches and pains are not uncommon amongst obese children.These may be due to the weight of the child putting a strain on joints andligaments or they may be the consequence of mild exercise in children whoselifestyle has made them unfit and thus uncomfortable with even minoractivity.Occasionally muscular pains are exaggerated or fabricated in theexpectation of being excused the misery of physical education (PE) and theundressing which may accompany this at school, or other activity at home.However such pains should not be glossed over as the inevitable conse-quences of overweight since occasionally they are symptoms of important72 Orthopaedic problems 73Table 6.1.Conditions that complicate overweight/obesity in childhood andadolescenceOrthopaedic problems Flat feetBlount s diseaseGenu valgumSlipped upper (capital) femoral epiphysisSkin conditions IntertrigoCandida infectionAcanthosis nigricansStriaeCardiorespiratory problems Increased prevalence of asthmaObstructive sleep apnoea syndromeHypertensionPulmonary hypertension and cor pulmonalePickwick syndromeMetabolic problems Type 2 diabetes mellitusHepatosteatosisHyperinsulinaemic syndrome/metabolic syndromePolycystic ovary syndrome (PCOS)Other Pseudotumor cerebriorthopaedic conditions.Table 6.1 includes some of the orthopaedic problemsfor which the overweight and obese are particularly at risk.Flat feetMany obese children have collapsed arches.These may cause few problemsbut can contribute to ungainly gait and therefore teasing.Blount s diseaseThis condition is not common but 60% to 80% of cases are reported asoccurring in obese children (Henderson 1992).The condition results fromabnormal growth in the proximal medial tibial epiphysis (Thompson andCarter 1990).The leg or, since the condition is commonly bilateral, both legs,become progressively more angulated laterally at the knee.The appearanceis of bowed legs although the condition differs from rickets and someosteogenic dysplasias in that the shafts of the bones are normal in shape.The alignment of the tibia in relation to the femur gives the bowedappearance.The problem can develop at any age in childhood although onsetis often divided into early (1 3 years), juvenile (4 10 years) and adolescent 74 What complications should we look for?(>11 years) (Dietz et al.1982).Whilst Blount s disease is worth diagnosingbecause of the difficulties in ambulation it may cause, spontaneous cure bythe age of 40 is quite common even with adolescent onset.Vigorous weightcontrol is the most important aspect of management since, whilst surgerymay be deemed appropriate, relapse after surgery is likely if the children donot lose weight.Genu valgumIn contrast to Blount s disease we have found that many obese older childrenhave some degree of knock knees or genu valgum and may be unable tostand with their feet together as a consequence.Older children and youngadolescents with very severe obesity seem the most likely to be affected.Possibly genu valgum develops as a consequence of internal rotation of theknees occurring subconsciously so as to reduce the discomfort of fat innerthighs rubbing together.Slipped upper (capital) femoral epiphysisSlipped upper femoral epiphysis (SUFE) is the most worrying orthopaedicproblem likely to develop in overweight children.If it occurs acutely the childwill have sudden severe hip pain which draws attention to the problem(Loder et al.1993).If the slippage is partial, chronic less severe pain in the hipor referred pain in the ipsilateral knee can easily be attributed to non-specificaches and pains of overweight.The diagnosis of SUFE should be consideredin any young adolescent with obesity, hip or knee pain and a limp.Childrenwith hypothyroidism and hypercortisolism have increased risk of SUFE.Thyroid function tests should probably be checked in any child with SUFE
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