Proximal tibiofibular synostosis as a source of ankle pain: a case report

We report the case of a 61-year-old man who presented with ankle pain of unknown etiology. The actual cause for his pain was missed during his two initial visits when only ankle radiographs were taken. During his third visit, a full-length tibia film revealed a proximal tibiofibular synostosis. He successfully underwent a fibular osteotomy with complete symptomatic relief. A literature review of this topic is presented.

Three diagnostic signs in Williams syndrome

In a series of 48 patients with Williams syndrome examined from 1984 to 1988, 3 physical manifestations were noted which have not been emphasized in previous reports of this condition. Unusual sacral creases were found in 25/48 patients, a linear array of hemangiomas (nevus flammeus) on the back in 3/48, and limitation of supination in 5/48.

Surgical correction of metopic synostosis

BACKGROUND

Premature closure of the metopic suture results in deformation of the anterior portion of the calvarium, which can vary from mild to severe. In mild forms, there is only prominent ridging of the metopic suture; more severe forms result in a marked narrowing of the frontal and temporal regions that in turn affects the supraorbital rims and produces hypotelorism.

METHODS

The authors retrospectively reviewed 39 consecutive cases of metopic synostosis treated over a 12-year period.

RESULTS

The average age at referral was 5 months, with surgery performed at an average age of 7.5 months. Fifteen infants had other congenital anomalies, with eight having synostosis of other sutures. Follow-up ranged from 7 months to 6 years, with an average of 29 months. In three mild cases, burring of the metopic ridge was performed with excellent aesthetic results in all cases. The other 36 patients had significant deformity of the supraorbital ridges and temporal regions, with obvious hypotelorism for over 50% of the time. In these cases, the patients underwent craniofacial reconstruction to normalize their appearance. In addition, the lateral aspect of the sphenoid ridges, including the orbital roof and lateral orbital wall to the infraorbital fissure, was removed to free the cranial base. The average blood loss was under 400 ml and the average hospital stay was 3.6 days. Results were considered good to excellent in all except three cases, which had recurrence of a prominent metopic ridge; two required a second operation after 6 months for burring of this ridge, whereas the third was treated conservatively with an orthotic headband.

CONCLUSION

Mild forms of metopic synostosis can be successfully treated with burring of the metopic ridge alone. Severe forms require craniofacial reconstruction and may be associated with other congenital abnormalities, additional synostosis, and developmental delay. In all cases, the operative procedure must be tailored to the nature and severity of the deformity.

A neonate with severe thrombocytopenia and radio-ulnar synostosis

Bone marrow failure syndromes can be associated with abnormalities of the forearms. We observed a neonate with congenital thrombocytopenia who had bilateral radio-ulnar synostosis and fifth finger clinodactly. We performed an evaluation of the mechanism causing the thrombocytopenia using a combination of direct and indirect measures of thrombopoiesis. These tests indicated decreased platelet production. This entity of congenital hyporegenerative thrombocytopenia with bilateral radio-ulnar synostosis and fifth-finger clinodactly is an uncommon but easily recognizable form of congenital amegakaryocytic thrombocytopenia (CAMT). This entity can be distinguished from the TAR syndrome (thrombocytopenia and absent radii) by the distinctive orthopedic issues, different underlying genetic mutations, and a more worrisome prognosis for CAMT than for TAR.

Tibiofibular synostosis stress fracture: a case report

A case of tibiofibular synostosis stress fracture is reported with its clinical and radiographic appearance as well as treatment.

Bilateral elbow malformation in a cat caused by radio-ulnar synostosis

A 9-month-old neutered male cat was referred because of left forelimb lameness. Physical examination, laboratory analysis, and radiographic examination of the entire skeleton were performed. The radiographic diagnosis was bilateral radio-ulnar synostosis with secondary elbow malformation. A comparison between clinical and radiographic findings of the cat and those described in children affected by radio-ulnar synostosis is reported. Correlations and differences are discussed.

Congenital thrombocytopenia and radio-ulnar synostosis: a new familial syndrome

The association of bone marrow failure and skeletal defects has been frequently noted, however, the genetic basis for most of these syndromes remains unclear. We describe a previously uncharacterized autosomal dominant syndrome of amegakaryocytic thrombocytopenia associated with radial-ulnar synostosis. The clinical features of this syndrome appear to be distinct from other similar conditions, including Fanconi's anaemia and thrombocytopenia-absent radii (TAR). The physical findings at diagnosis and clinical management of each case are detailed, as well as a discussion of this disorder in the context of other syndromes in which marrow failure and skeletal defects are prominent features. We also review recent developments in molecular genetics that may provide important clues to the underlying aetiology of this condition.

Altered fibular growth patterns after tibiofibular synostosis in children

BACKGROUND

Iatrogenic synostosis of the tibia and fibula following an operation on the leg in a child has been reported rarely in the literature, and the effects of this complication on future growth, alignment, and function are not known. This is a retrospective case series, from one institution, of crossunions of the distal parts of the tibia and fibula complicating operations on the leg in children. The purpose is to alert surgeons to this possible complication.

METHODS

The senior author identified eight cases of iatrogenic tibiofibular synostosis seen in children since 1985. The patients had various diagnoses and were from the practices of four pediatric orthopaedic surgeons. Synostosis developed in six patients after osteotomies of the distal parts of the tibia and fibula, in one after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision, and in one after posterior transfer of the anterior tibialis tendon through the interosseous membrane combined with peroneus brevis transfer to the calcaneus. Medical records were reviewed, and preoperative and follow-up radiographs were analyzed for changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle.

RESULTS

Five patients were symptomatic after crossunion; they presented with prominence of the proximal part of the fibula, ankle deformity, or ankle pain. Three patients were asymptomatic, and a synostosis was identified on routine follow-up radiographs. Intraoperative technical errors caused two of the crossunions; the cause of the others was unknown. Following tibiofibular synostosis, growth disturbances were noted radiographically in every patient. The normal growth pattern of distal migration of the fibula relative to the tibia was reversed, resulting in a decreased distance between the proximal physes of the tibia and fibula as well as proximal migration of the distal fibular physis relative to the distal part of the tibia. Shortening of the lateral malleolus led to greater valgus alignment of the ankle.

CONCLUSIONS

Tibiofibular synostosis can complicate an operation on the leg in a child. After crossunion, the normal distal movement of the fibula relative to the tibia is disrupted, resulting in shortening of the lateral malleolus and ankle valgus as well as prominence of the fibular head at the knee. The synostosis also interferes with the normal motion that occurs between the tibia and fibula with weight-bearing, potentially leading to ankle pain.

The C sign: more specific for flatfoot deformity than subtalar coalition

OBJECTIVE

To assess the sensitivity and specificity of the C sign, a C-shaped line created by the outline of the talar dome and the inferior margin of the sustentaculum tali on lateral ankle radiographs, for patients with both flatfoot deformity and specifically talocalcaneal (TC) coalition.

DESIGN AND PATIENTS

All patients in this retrospective study were under 35 years of age and had a lateral ankle radiograph and follow-up CT scan for a non-traumatic indication. Forty-eight cases over the past 5 years fulfilled these criteria. Two masked musculoskeletal radiologists determined the presence or absence of the C sign for each lateral radiograph by consensus. Each CT study was then assessed by a third musculoskeletal radiologist for the presence of tarsal coalition. Observations were correlated with clinical history regarding presence or absence of flatfoot deformity.

RESULTS

Ten cases of TC coalition were diagnosed, four of which demonstrated a C sign (40%). Eight cases with a C sign were encountered, four of which had TC coalition (50%) and four did not. All patients with a positive C sign had a flatfoot clinically (100%), while only eight of 24 flatfooted patients had a C sign (33%).

CONCLUSION

The C sign is specific, but not sensitive, for flatfoot deformity, and is neither sensitive nor specific for subtalar coalition.

Non-osseous coalition of the medial cuneiform-first metatarsal joint: a case report

Isolated non-osseous tarsal coalition of the medial cuneiform-first metatarsal joint is rare. Resection of the coalition was performed in a 32-year-old patient, with excellent results. This procedure is an effective option for treatment of small lesions.

Congenital synostosis between the scaphoid and the trapezium as a cause of tenosynovitis simulating de Quervain's disease

This report describes a case of congenital synostosis between the scaphoid and the trapezium resulting in tenosynovitis simulating de Quervain's disease, an association not previously reported.

The rigid flatfoot. Tarsal coalitions

Tarsal coalitions are the major cause of painful rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalitions are the most common sites. They are often bilateral and may be asymptomatic. They represent a failure of fetal mesenchymal differentiation, and onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilaginous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerized tomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and interposition of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, with arthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions.

[Neurological aspects of two patients with non-mosaic and mosaic polysomy of the X and Y chromosomes]

Clinical features were compared of a patient with the 48,XXYY karyotype and a case of 47,XXY/48,XXYY mosaicism. In the former patient tremor of the upper extremities of unclear aetiology was present. In both cases epilepsy was suspected. Similarly as in other cases of 48,XXYY karyotype the first patient had skeletal anomalies, abnormalities of dermatoglyphics and personality changes. These features are rarely found in Klinefelter syndrome. The differences in relation to the syndrome were less evident in the case of mosaicism 47,XXY/48,XXYY.

[Fixed mallear head syndrome]

Fixed head malleus syndrome is a rare anatomoclinical entity first described by Goodhill in 1966. We present a series of 9 patients who underwent surgery between 1991 and 1997 and discuss the technical procedures used and functional outcome. Ossicular mobility can be re-established with two surgical methods. The more simple method consists in a classical incus transposition with malleus neck section. The more physiological method consists in drilling the synostosis fixing the malleus without disrupting the ossicular chain; stapedotomy is associated in certain cases (Type III).

Tarsal coalition in an adult with cavovarus feet

Symptomatic tarsal coalition is often considered to be synonymous with peroneal spastic flatfoot. The association of the cavovarus foot type with tarsal coalition is less well established and has been described only in children. This article describes a case of an adult female with symptomatic cavovarus feet with talocalcaneal coalition. The authors theorize about the pathology of muscle spasm and pain in patients with this condition.

Pediatric peroneal spastic flatfoot in the absence of coalition. A suggested protocol

While most pediatric patients with peroneal spastic flatfoot demonstrate tarsal coalitions, not all do. The absence of coalition may present a diagnostic challenge and make appropriate treatment difficult. Past and present etiologic theories, diagnostic modalities, and treatments are outlined in this article. The common peroneal nerve block is of great value in the diagnosis and treatment of peroneal spastic flatfoot with or without coalition. With adjunctive treatments, increased motion and decreased symptomatology are often obtained. A protocol, applied to five cases described herein, is suggested.