Pediatric fracture without radiographic abnormality. Description and significance

With an expanding application of magnetic resonance imaging in acute musculoskeletal injury, an increasing number of occult traumatic lesions of bone are being identified. The authors describe the entity of fracture without radiographic abnormality, which as the name suggests is a bony injury not apparent on plain radiographs. The clinical significance and potential sequelae have not been defined in the pediatric patient. Accordingly, the purpose of this study is to describe and classify the entity of the pediatric fracture without radiographic abnormality and delineate its importance and appropriate management. Twenty-five children were seen primarily or referred to The Children's Hospital of Philadelphia after having sustained an acute traumatic injury; all refused to bear weight or use their extremity, and all had initial plain radiographs that were interpreted as normal. Subsequent magnetic resonance images of all 25 children showed an occult fracture. These included Salter-Harris fracture Types II (two patients), III (one patient), and IV (three patients), intraosseous epiphyseal fractures (18 patients), and a metaphyseal diaphyseal fracture (one patient). Four patients with intraosseous epiphyseal fractures ultimately sloughed a portion of their articular cartilage, as observed at arthroscopy. The decision to proceed with magnetic resonance imaging in the evaluation of a child who refuses to use an extremity depends on many variables. However, magnetic resonance imaging has proven useful in revealing fractures without radiographic abnormality and in ruling out other pathosis.

Accessory soleus muscle. A report of 4 cases and review of literature

Cadaveric studies have demonstrated the incidence of an accessory soleus muscle ranges from 0.7% to 5.5%. The differential diagnosis of a painful soft tissue mass in the posteromedial region of the ankle includes ganglion, lipoma, hemangioma, synovioma, and sarcomas. In light of these possibilities, most of the early reports of accessory soleus included evaluation and treatment with biopsy, fasciotomy, or excision. Four patients, ranging in age from 14 to 66 years of age at the time of presentation, are discussed. Reports in the literature indicate that accessory soleus is a benign condition, and in most patients, a conservative approach is indicated. In addition, magnetic resonance imaging is the preferred study for the evaluation of this condition. If a diagnosis of accessory soleus is made, and the patient has no symptoms, observation is recommended. However, if the patient has symptoms, fasciotomy generally is a successful form of treatment. For symptoms that persist after fasciotomy, excision of the accessory soleus can be curative.

Magnetic resonance imaging of skewfoot

Magnetic resonance imaging was used to visualize the ossified and unossified portions of the bones and soft tissues of the feet in order to evaluate the tarsometatarsal anatomy in sixteen children, three months to six years old (mean, fifteen months old), who were seen in the orthopaedic clinic with a suspected diagnosis of skewfoot. Twenty-seven feet were clinically abnormal and five were normal. Of the abnormal feet, twenty-six had a radiographic diagnosis of skewfoot and one, of simple metatarsus adductus. Of the skewfeet, seven had a talocalcaneal angle of 45 degrees or more as measured on the lateral radiograph and six had a talocalcaneal angle of 45 degrees or more as measured on the anterior radiograph. Valgus deformity of the hindfoot was not apparent on clinical examination in any of the children. The talocalcaneal angles measured on the magnetic resonance images corresponded poorly with those measured on the radiographs, possibly because it is not possible to simulate weight-bearing during magnetic resonance imaging or because the effect of partial volume averaging on thin sections. However, magnetic resonance imaging demonstrated the shapes of the bones and the positions of the unossified portions of the bones. Magnetic resonance imaging showed lateral subluxation of the navicular in twenty-four skewfeet, plantar subluxation in ten, and medial subluxation of the first metatarsal on the medial cuneiform in twenty-five. The alignment of the lateral margin of the calcaneus and cuboid on the magnetic resonance images was normal in all patients. Magnetic resonance imaging has the unique ability to show the cartilaginous and ossified portions of the developing bones of the foot.

Slipped capital femoral epiphysis. The prevalence of late contralateral slip

We evaluated the prevalence of slipped capital femoral epiphysis in the contralateral hip of 169 children who had been managed with pinning in situ and thirty who had been managed with immobilization in a spica cast. Only children who had initially been seen with a unilateral slip and had been followed for a minimum of two years or until skeletal maturity were included in the study. The average duration of follow-up was 3.6 years (range, 0.5 to 9.5 years) for the group that had been managed with a cast and 2.8 years (range, 1.0 to 8.3 years) for the group that had been managed operatively. In sixty-one (36 per cent) of the 169 patients who had had operative treatment and two (7 per cent) of the thirty who had been managed with a spica cast, a slip subsequently developed in the contralateral hip; this difference was significant (p = 0.001). On the basis of these findings, we recommend that closer attention be paid to the potential development of a slip in the contralateral hip after pinning.

Screw fixation of Grade III slipped capital femoral epiphysis

From 1987 to 1992, 161 children were treated at The Children's Hospital of Philadelphia for slipped capital femoral epiphysis. Of these, 23 patients (23 hips) had Grade III slips (> 50%). Fixation was achieved by 1 or 2 screws in all patients. Twenty-one of 23 patients were available for followup (average followup, 2.8 years). Four slips were acute, 11 were acute-on-chronic, and 6 were chronic. At the most recent followup, radiographs were taken and a Harris Hip Score was assigned for each patient. Stabilization without progression of slip at followup was achieved in all patients. Screw placement was satisfactory per the criteria of Stambough in all patients. Four children (19%) had major complications: Three (1 acute slip and 2 acute-on-chronic slips) had avascular necrosis of the femoral head; One (chronic slip) had chondrolysis. There were no immediate postoperative complications. The mean Harris Hip Score for these 4 patients was 85 points, versus a mean score of 94 points for all 21 patients. Chronic Grade III slipped capital femoral epiphysis can be treated safely and effectively by screw fixation. Five of 6 patients had satisfactory results; the only exception had evidence of chondrolysis preoperatively. Acute and acute-on-chronic Grade III slipped capital femoral epiphyses treated with screw fixation are less predictable. In 15 patients, reduction occurred in 9 hips despite deliberate avoidance of forceful manipulative maneuvers. Avascular necrosis developed in 3 (33%) of these 9 hips. Reduction of the acute component of the slip during screw fixation, whether deliberate or not, indicates gross instability. It is hypothesized that avascular necrosis may be associated with injury to the epiphyseal vasculature occurring at the time of the acute slip.

Valgus slipped capital femoral epiphysis. Fact or fiction?

The cases of 2 patients with valgus slipped capital femoral epiphysis are presented. Additional imaging studies provide support for true posterolateral epiphyseal displacement. Increased femoral anteversion and coxa valga contribute to the pathogenesis of valgus slipped capital femoral epiphysis. In situ pin fixation is recommended for stable valgus slipped capital femoral epiphysis. The importance of valgus slipped capital femoral epiphysis lies in its recognition and appropriate screw placement when internal fixation is used. The percutaneous technique should be used with caution. A limited open technique is recommended when the anterior skin portal is near the femoral neurovascular bundle.

Vascular injuries and their sequelae in pediatric supracondylar humeral fractures: toward a goal of prevention

Between 1988 and 1994, 128 consecutive children with grade III supracondylar humeral fractures presented for treatment at our hospital. Seventeen had absent or diminished (detected with Doppler but not palpable) radial pulses on initial examination. Fourteen of these 17 children recovered pulse (palpable) after reduction and stabilization of their fractures. The remaining three had persistent absence of radial pulse. Each of these three children was explored immediately and found to have a significant vascular injury requiring repair. Two of the 14 children who had initially regained their pulses had a progressive postoperative deterioration in their circulatory status during the first 24-36 h, including loss of the radial pulse. Both of these children had arteriograms that identified vascular injuries. Both underwent exploration and bypass grafting. One of these two children had been transferred 48 h after injury, resulting in delay of management of his vascular impairment. Despite exploration, vascular repair, and fasciotomy, he ultimately developed Volkmann's ischemic contracture. All five children with significant vascular injuries had absent or diminished radial pulses on presentation. Immediate reduction and fixation followed by careful evaluation and treatment of ischemia were associated with excellent outcome in four of the five children.

Perinatal limb ischemia: orthopaedic implications

Fifteen patients (16 ischemic limbs) who ultimately required amputation for perinatal limb ischemia were treated at The Children's Hospital of Philadelphia and the Shriners Hospital for Crippled Children in Philadelphia between 1980 and 1993. The average birth weight of these patients was 1,870 g, and the average gestational age was 30.8 weeks. Ischemic events occurred at an average postnatal age of 5.4 weeks. The causes of the ischemia included (a) arterial thrombosis as a complication of arterial catheterization (eight patients), (b) thromboembolism resulting from a hypercoagulable state (five patients), (c) intravenous infiltrate (one patient), and (d) in utero arterial thrombosis (one patient). Amputation was required at an average postnatal age of 8.5 weeks. The final patient, with concurrent ischemia involving the right hand and left leg, had complete resolution of the ischemic hand with fibrinolytic therapy alone and required only an amputation of the lower extremity. Eleven of the 15 patients were available for follow-up (two dead, two lost to follow-up), at an average of 4.5 years. Nine of these 11 patients (six lower and three upper extremities) are functioning well in prostheses. The two remaining patients are infants who will be fitted for lower-extremity prostheses when they begin to attempt to walk.

Proximal fibular osteochondroma with associated peroneal nerve palsy: a review of six cases

Osteochondroma of the proximal fibula is relatively common, but reports of this lesion in conjunction with peroneal nerve palsy have been scarce. Six patients with peroneal nerve palsy and fibular exostosis are presented with the results of electrical studies, radiographic evaluation, physical examination, and operative treatment. A wide variation in presentation and outcome was observed. Preoperative and postoperative electromyography and nerve-conduction studies are useful in evaluation. A heightened awareness of this entity is required to avoid permanent damage in an otherwise treatable condition.

Complications in children managed with immobilization in a halo vest

Thirty-seven patients who were three to sixteen years old were managed with immobilization in a halo vest between 1987 and 1993. Twenty-four patients (65 per cent) had the halo vest applied in conjunction with operative arthrodesis of the cervical spine; the remaining thirteen patients (35 per cent) had the halo vest applied to immobilize the cervical spine after trauma. Complications occurred in twenty-five patients (68 per cent). Pin-site infections were the most common complications, developing in twenty-two patients. Grade-II infections (purulent drainage) developed more frequently in children who were eleven years old or more: they were identified in five of fourteen such patients, compared with two of twenty-three patients who were ten years old or less. There was a tendency toward more grade-I infections (non-purulent drainage, with or without erythema) and loosening of the pins in the children who were ten years old or less: eleven of twenty-three such patients had each of those complications, compared with four of fourteen children who were eleven years old or more. Both loosening and infection occurred more frequently at the anterior pin sites. Other complications included one dural penetration, one transient injury of the supraorbital nerve, and three pin-site scars that were considered by the family to be objectionable. There were no complications related to the vest part of the halo vest. Younger patients who had a halo construct with more than four pins (multiple-pin constructs) had a similar rate of complications compared with patients who were managed with a standard four-pin halo construct.(ABSTRACT TRUNCATED AT 250 WORDS)

MRI of focal fibrocartilaginous dysplasia

Focal fibrocartilaginous dysplasia (FFCD) is an uncommon, benign condition associated with unilateral tibia vara in young children. The clinical, pathologic, plain film, and magnetic resonance imaging (MRI) findings of FFCD were reviewed in two children. MRI findings were virtually identical in both patients and correlated well with the plain film and pathologic findings. We believe that FFCD has a typical MRI appearance. However, FFCD also has characteristic plain film findings, and when these are present, MRI is indicated for only an atypical clinical presentation.

Distraction osteogenesis for congenitally short lesser metatarsals

Six lesser metatarsal lengthening procedures were performed in three patients using a miniature external fixator to perform distraction osteogenesis. The metatarsals were lengthened an average of 15.5 mm. The external fixator was left in place for an average of 15.5 weeks, with additional time in a cast or cast shoe. Complications included five occurrences of infection, two cases of premature healing of the osteotomy, one nondisplaced fracture through the new bone formation, and hypertrophic granulation at a pin site. While all metarasals were successfully lengthened, two rays (one patient) had symptomatic stiffness at the metatarsophalangeal joint with continued metatarsalgia.

Major lower extremity lawn mower injuries in children

Between 1983 and 1993, 16 children with 18 lower extremity power lawn mower-related injuries were treated at Children's Hospital of Philadelphia. Eleven of 16 patients (69%) were bystanders or nonoperators. The average age at injury was 4 years 9 months. Length of follow-up averaged 3 years 10 months. There was an average of 4.9 procedures per patient. Fourteen of the 18 limbs injured required eventual amputation (78%). We propose a new classification of lawn mower injuries in children. The most common injury (16 of 18 limbs) was a shredding type injury and was either intercalary or distal. The second was a paucilaceration type (two of 18 limbs). Of the four salvaged limbs, there were two shredding type injuries, and on most recent follow-up are considered to have poor results. The two patients with the paucilaceration type injuries and limb salvage are considered to have excellent results. All patients with a shredding type injury ultimately required amputation or had poor results with the salvaged limb. Limb salvage surgery was associated with prolonged hospitalizations, a higher incidence of surgical problems, a longer treatment course, and more complications than early ablative procedures.

Ultrasonographic evaluation of the elbow in infants and young children after suspected trauma

Fractures and epiphyseal injuries in the region of the elbow are uncommon in infants and young children, but they can be very difficult to diagnose and delineate accurately. In addition to plain radiography, invasive or costly procedures such as arthrography and magnetic resonance imaging traditionally have been used to evaluate these injuries. We used high-resolution real-time ultrasonography to evaluate a suspected injury of the elbow in seven infants and one ten-year-old child. Three of the infants had a physeal separation, two had a supracondylar fracture, and two had no skeletal injury. The child had an avulsion fracture of the lateral epicondyle of the humerus and an effusion in the joint. The ultrasonographic findings were confirmed by arthrography in three patients, by open reduction in one, and by follow-up radiographs in all. None of the ultrasonographic studies were performed with the patient under general anesthesia. Ultrasonography, a readily available, non-invasive technique, can be used to evaluate the unossified epiphysis about the elbow of infants and young children; to demonstrate dislocations, fractures, and physeal separations; to identify a hinge of soft tissue at the site of a fracture; to identify interposition of soft tissue between fracture fragments; and to aid in the planning of closed and open reductions.

Intraoperative anaphylaxis due to exposure to latex (natural rubber) in children

Intraoperative anaphylaxis secondary to exposure to latex is a serious and potentially life-threatening phenomenon that has been recognized more frequently in recent years. Between 1989 and 1992, twenty-one patients had a Type-I (anaphylactic) reaction to latex intraoperatively at The Children's Hospital of Philadelphia. Twelve (57 per cent) of these patients had spina bifida. Six patients (29 per cent) had cerebral palsy, and five of them had a ventriculoperitoneal shunt. Of the remaining three patients, one (5 per cent) had exstrophy of the bladder, one had VATER syndrome, and one had Duchenne muscular dystrophy. All of the patients had had at least two previous operative procedures. Overall, sixteen patients (76 per cent) had a ventriculoperitoneal shunt. The manifestations of the allergic reaction included a rash in fifteen patients (71 per cent), hypotension in fifteen, tachycardia in eleven (52 per cent), bronchospasm in ten (48 per cent), bradycardia in two (10 per ent), and cardiac arrest in two. The symptoms occurred within minutes after the induction of the anesthesia in all but one patient, in whom hypotension and cardiovascular arrest developed approximately one hour after the beginning of the operation. Two patients had a full cardiopulmonary arrest while under the anesthesia. All twenty-one patients responded to management; there were no deaths. Of the six patients who had cerebral palsy, five had been managed with a ventriculoperitoneal shunt because of hydrocephalus following a previous intraventricular hemorrhage that was related to prematurity.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between the ossification center and cartilaginous anlage in the normal hindfoot in children: study with MR imaging

OBJECTIVE

Although many reports have documented when ossification centers can first be visualized on radiographs, few studies have evaluated the position of the ossification center within its cartilaginous anlage. In the skeletally immature child, the ossification centers of the tarsals are used to evaluate the positions of the tarsals and their interrelationships. It is convenient to assume that tarsal ossification begins in the center of its cartilaginous anlage and proceeds in a radial fashion; however, this may not be the case. Accordingly, we used MR imaging to evaluate the location of the ossification centers of the tarsals within their cartilaginous anlage in the mid and hindfoot in children.

MATERIALS AND METHODS

MR studies of 69 feet in 40 children, 3 months to 7 years old (mean, 2.5 years), were reviewed retrospectively. The location of the ossification center within its cartilaginous anlage and the percentage of ossification of the cartilaginous anlagen of the talus, calcaneus, cuboid bone, and navicular bone were determined from coronal and sagittal images. In the talus, the difference between the orientation of the long axis of its ossification center and the long axis of its cartilaginous anlage was measured on coronal and sagittal images.

RESULTS

Early talar ossification was centered on the neck of the talus; the proximal aspect of the bone ossified last. The long axis of the talar ossification center and the long axis of its cartilaginous anlage differed in orientation. Early calcaneal ossification was centered on the distal two thirds of the cartilaginous anlage of the calcaneus; the proximal aspect and the area of the subtalar joint ossified last. Early navicular ossification was centered on the central or lateral third of the navicular cartilaginous anlage; the medial aspect ossified last. The ossification center of the cuboid bone was in the middle of the cuboidal cartilaginous anlage.

CONCLUSION

Our results show that early ossification in the talus, calcaneus, and navicular bones does not begin in the center of the bones' cartilaginous anlagen. The orientations of the long axis of the talar ossification center and the long mid axis of its cartilaginous anlage are different. Therefore, part of the changes in the alignment of the tarsals seen on radiographs with growth is due to ossification beginning and proceeding eccentrically within the cartilaginous anlage and not to a true change in the alignment of the tarsals. These data provide new information about the normal development of the child's hindfoot and midfoot.

Sonography of the elbow in infants and children

High-resolution real-time sonography of the musculoskeletal system of infants and young children is being used with increasing frequency, in part because of the inability of plain film radiography to visualize unossified cartilage. Real-time sonography now plays an important role in the evaluation of infantile hip dysplasia, as well as in the identification and aspiration of joint effusion. The purpose of this essay is to illustrate clinical situations in which sonography of the elbow is helpful.

Cognitive motivations for drinking among alcoholics: factor structure and correlates

The aims of this study were to: a) Identify factors reflecting reasons for drinking and expectancies regarding the effects of drinking among inpatient alcoholics; b) Examine the relationship between these cognitive "motivations" for drinking and both patterns of alcohol consumption and various personal and social consequences of consumption. The factors which emerged relate to negative mood reduction, positive mood enhancement, and social functioning. Although the factors identified in this investigation were not associated with quantity of alcohol consumed, small to moderate associations were found between scores on three of four factors and a variety of adverse physical and occupational consequences of alcohol abuse.

Osteolysis of the calcaneus in a child with localized scleroderma

In a young girl with localized scleroderma a circumscribed area of lysis developed in the calcaneus beneath the involved skin and soft tissues of the foot. A biopsy revealed vascular changes characteristic of scleroderma associated with infarction and severe resorption of the bone. A geographic pattern of bone destruction in a child with localized scleroderma has not previously been reported.

Torticollis in children

Torticollis is a common clinical sign that is found in a variety of disorders. Childhood torticollis differs from the adult form in that congenital types are common and many frequently encountered disorders found in adults are unusual. Pediatric torticollis related to otolaryngologic conditions is reviewed, and three illustrative cases are presented.

Development and evaluation of the revised Alcohol Evaluation Instrument

This study reports on the development of a revised version of the Alcohol Evaluation Instrument (ALCEVAL-R). Items in the four major areas of the ALCEVAL-R were factor analyzed separately and relationships among factors were examined. Results suggest that the ALCEVAL-R measures clinically meaningful aspects of the alcoholic patient's occupational and social status, and reveals important dimensions of alcohol consumption and of the personal and social consequences of alcohol abuse.

A comparison of continuous and episodic drinkers using the MCMI, MMPI, and ALCEVAL-R

This study was designed to identify clinically meaningful differences between continuous and episodic drinkers who were entering inpatient treatment (N = 125) on the basis of information from intake administrations of the revised Alcohol Evaluation Instrument, the Million Clinical Multiaxial Inventory, and the Minnesota Multiphasic Personality Inventory. Separate discriminant analyses based upon (a) the MCMI and ALCEVAL-R and (b) MMPI and ALCEVAL-R yielded correct classification rates of 86% and 85%, respectively. Both analyses suggest that continuous drinkers may be characterized by greater confused and disorganized thinking, agitation, and cynicism and distrust in interpersonal relationships than are episodic drinkers. In contrast, episodic drinkers appear to have somewhat more socially conforming attitudes that may inhibit daily social drinking. Despite this, episodic drinking was associated with a higher divorce rate (71% vs. 32%) and less occupational stability.

Neural injuries associated with supracondylar fractures of the humerus in children

A retrospective review of displaced extension-type supracondylar fractures of the humerus in 101 children who were seen consecutively revealed eighteen associated neural injuries in thirteen children. Nine of the neural injuries in eight patients spontaneously resolved at a mean of 2.5 months (range, 1.5 to five months) after injury. The remaining nine lesions in five patients were explored at a mean of 7.5 months (range, five to fourteen months) after injury, because clinical and electromyographic studies showed no return of function. Neurolysis was performed on eight of the nerves that were explored (in five patients), and the remaining radial nerve was found to be completely lacerated and needed nerve-grafting. The length of follow-up after neurolysis averaged twenty-five months (range, thirteen to forty-four months). All five patients had functional recovery, as documented by range-of-motion, grip-strength and lateral pinch-strength, and von Frey and two-point-discrimination sensory testing. The patient who had had nerve-grafting never recovered neural function, and tendon transfers were needed. We concluded that observation and supportive therapy is the preferred initial approach for children who have a neural injury associated with a closed, displaced supracondylar fracture of the humerus. However, if there is no clinical or electromyographic evidence of return of neural function at five months after injury, exploration and neurolysis should be performed. If the nerve is in continuity, the prognosis after neurolysis is excellent.