Table 2.

The orthopedic guidelines

Age group	Guidelines		Evidence
0–11 months	1.	Perform neonatal kyphectomy, if required to facilitate skin closure.	[18]
	2.	Orthopedic evaluations are recommended every three months in the first year of life.	Clinical consensus
	3.	Consider hip imaging using ultrasound in the infant and anteroposterior pelvis radiographs after 6 months in patients with low lumbar and sacral lesions. Consider using a rigid abduction orthosis to treat hip instability, but only in children with low lumbar and sacral lesions.	Clinical consensus
	4.	Ponseti casting or release is recommended for clubfoot or congenital vertical talus deformities.	[19–21]
	5.	Perform spine evaluations by conducting a physical exam. Obtain scoliosis radiographs if a spinal deformity is suspected and monitor the spine for progression of the deformity. In children who have not achieved sitting balance, perform the radiographs in a supine position. Once sitting balance is achieved, perform spinal radiographs in a sitting position.	Clinical consensus
	6.	Consider bracing or casting when there is a documented progression of scoliosis.	[22]
1–2 years11 months	1.	Monitor the spine for development or progression of a deformity that may be due to a tethered cord or syrinx. Obtain anteroposterior and lateral scoliosis radiographs if a deformity is suspected on clinical exam. Perform radiographs in a sitting position if the patient is able to sit but not able to stand or in a standing position if the patient is able to stand. Repeat radiographs every one to two years if the deformity is present, depending on rate of progression.	Clinical consensus
	2.	Evaluate for neurologic changes or progression of scoliosis and discuss with neurosurgery.	Clinical consensus, Neurosurgery guidelines
	3.	Initiate treatment for progressive early onset scoliosis that may involve casting or bracing.	[22]
	4.	Consider tendon releases/transfers for unbalanced foot deformities such as the calcaneus foot, if the foot is unbraceable, to facilitate orthotic management.	[23]
	5.	Consider twister cables for significant rotational deformities to facilitate ambulation until surgical correction is appropriate.	[24]
	6.	Surgical correction of rotational deformities of the tibia or femur is recommended only if they are limiting further motor development and causing difficulty with bracing.	Clinical consensus
	7.	Teach families about fractures and related precautions.	Clinical consensus
3–5 years 11 months	1.	Evaluate gait with careful attention to orthopedic deformities that render gait inefficient and preclude orthotic management.	Clinical consensus
	2.	Consider derotational osteotomy when rotational abnormality adversely impacts ambulation.	[25]
	3.	Consider treating foot deformities with stretching, casting, bracing, soft tissue release or tendon transfers to facilitate orthotic management.	Clinical consensus
	4.	Evaluate the spine clinically and obtain scoliosis radiographs every one to two years if a progressive spinal deformity is suspected. Perform radiographs in a sitting position in children who can sit but not stand and in a standing position in children who can stand.	Clinical consensus
	5.	Work with Neurosurgery to determine whether a neurogenic cause of scoliosis progression is present.	Clinical consensusNeurosurgery guidelines
	6.	Consider bracing for progressive, non-congenital scoliosis in the 25 to 50 degree range.	Clinical consensus
	7.	It is recommended that surgical treatment of scoliosis be reserved for a progressive deformity that is unresponsive to non-operative management. An example is when the scoliosis has progressed in spite of bracing and after a neurosurgical cause, such as a tethered cord, has been ruled out. It is also recommended that management with growing rod surgery and fusionless technique should include spinal cord monitoring in patients with distal neurologic function.	[26]
	8.	Consider surgical treatment of gibbus deformity for intractable skin break down or to free up the upper limbs for independent sitting.	[27]
	9.	Teach children and families about fractures and related precautions.	Clinical consensus
6–12 years	1.	Monitor gait, rotational deformities and foot position.	Clinical consensus
11 months	2.	Consider correction of foot deformities to facilitate orthotic management with soft tissue release, tendon transfer and osteotomy, if necessary. It is recommended that fusion be avoided if possible.	Clinical consensus
	3.	Consider correction of tibial and femoral rotational deformities when they are interfering with gait and precluding orthotic management.	[25]
	4.	Consider conducting computerized gait analysis when available, in children with low lumbar or sacral level lesions who have atypical gait abnormalities. This information will be helpful when making decisions regarding surgery or bracing.	[28]
	5.	Monitor for the development of scoliosis/kyphosis.	Clinical consensus
	6.	Obtain anteroposterior and lateral scoliosis radiographs every one to two years if deformity is suspected clinically. Do so more frequently in patients with progressive spinal deformity. Perform radiographs in a sitting position in children who can sit but not stand and in a standing position in children who can stand.	Clinical consensus