NEURODEVELOPMENTAL DISABILITIES Effect of hemiplegia on skeletal maturation Cathleen Doman Roberts, DO, Laura Vogtle, OTR, and Richard D. Stevenson, MD From the Department of Pediatrics, University of Virginia School of Medicine, Charlottesville Children with cerebral palsy have been reported to have poor growth and de- layed skeletal maturation, but it is unclear whether these effects are related to the underlying brain injury or to concomitant malnutrition. This study was designed to evaluate the effects of hemiplegic cerebral palsy on skeletal mat- uration and growth, with the unaffected side used as each subject's control. Bi- lateral hand-wrist radiographs were obtainedfor 19 children with spastic hemi- plegia. Skeletal maturation was determined in a blinded fashion with the Fels method. The skeletal age of the affected (hemiplegic) side was less than that of the unaffected (control) side in all 19 subjects; the mean difference in skel- etal age was 7.3 months (p <0.001). The delay in skeletal maturation of the af- fected side correlated linearly with age and upper extremity function. These findings show that brain injury results in delayed skeletal maturation indepen- dent of malnutrition. This effect on skeletal maturation may explain, in part, the reason that some children with cerebral palsy grow poorly. (J PEDIATR1994; 125:824"8) Poor growth has been well documented in children with ce- rebral palsy. TM This poor growth is most likely multifacto- rial, but the contributing causes have not been investigated extensively.5 Both nutritional and nonnutritional factors have been hypothesized to contribute to poor growth. 6 Nu- tritional factors include inadequate nutrient intake, 7 increased energy expenditure, s and poor oral motor func- tion.9, 10 Nonnutritional factors possibly encompass endo- erinopathies, decreased activity, or direct neurologic influ- ences. 6 Attempts to examine such nonnutritional factors have been hampered by the unavailability of comparison subjects and the high prevalence of malnutrition among children with cerebral palsy. Skeletal maturation (skeletal age) is an accepted mea- sure of physical maturity and growth. Normally, skeletal Study supported by the Kluge Research Fund of the Children's Medical Center at the University of Virginia. Publication supported by a grant from the Society for Develop- mental Pediatrics. Submitted for publication March 29, 1994; accepted May 18, 1994. Reprint requests: Richard D. Stevenson, M.D., Kluge Children's Rehabilitation Center, 2270 Ivy Road, Charlottesville, VA 22903 Copyright © 1994 by Mosby-Year Book, Inc. 0022-3476/94/$3.00 + 0 9/73/57680 maturation is a symmetric process. Previous studies of nor- mal children have documented slight asymmetries; how- ever, these differences were thought to be so small as to be insignificant.2,11 Thus, by convention, hand-wrist radio- graphs of the left hand have arbitrarily become the standard for assessment of skeletal age. Investigations of skeletal age in children with cerebral palsy are few but have shown a significant degree of delayed skeletal maturation. 1214 However, all these studies involve QUEST Quality of Upper Extremity Skills Test samples with a high prevalence of malnutrition, which is known to lead to delayed skeletal maturation15; the finding of delayed skeletal maturation in these studies may have been due to the malnutrition of the subjects rather than to the cerebral palsy. Thus, although these studies suggest an association between neurologic impairment and delayed skeletal maturation, the results remain difficult to interpret. We chose to study children with hemiplegia and normal growth to better characterize the influence of nonnutritional factors on skeletal maturation in children with cerebral palsy. Asymmetry of growth and skeletal maturation be- tween affected and unaffected extremities in children with hemiplegia has been recognized for many years ~6, 17; how- 824