Fractures of the tibia in children

A total of 102 children, aged 1-15 years, treated for fissures, infractions, and fractures of the tibia were studied to elucidate the influence of age, type of fracture, and mechanism of trauma upon the course of union. In addition, an assessment was made of the possibilities the child has of correcting deformities of the diaphysis during continued growth. Eight-five of the children were followed up clinically and radiologically. The time taken for union to occur increased with increasing age. The "high energy" injuries were found to be more apt to cause transverse and comminuted fractures, with injury to the skin, than the "low energy" fractures. At the time of union, 25 patients had angular deformities. The mean correction of this deformity up to the time of follow-up was only 10 per cent. The tendency to correct the deformity ceased 18 months after the accident, and was independent of the child's age at the time of the accident.

Continuous trans-physeal traction: a simple method of bone lengthening

Leg length increments utilizing continuous traction across the epiphyseal plate of growing puppies produces a cleavage fracture at the level of the primary metaphyseal trabeculae which neither anatomically nor physiologically alters the growth plate. These fractures heal readily and growth resumes following removal of the traction device. This method is relatively atraumatic to the extremity. It does not require an open operation and the controlled distraction rate has not caused neurological or vascular complications. The study was designed to determine the anatomic site of fracture; no attempt was made to achieve maximal leg length increments.

[A case of fatigue fracture at the border between tibial head and shaft after removal of a small corticocancellous graft (author's transl)]

Report on a case. Causes were: 1. faulty technique of removing graft. 2. Osteoporosis due to immobilisation in plaster after several previous operations. 3. functional overloading with mechanical after-treatment. The need for a proper technique of removing the graft - particularly for the operation after Maquet - is once more emphasized.

Experimental biomechanics of the human leg. A basis for interpreting typical skiing injury mechanisms

In 1965 the continually increasing number of injured skiers inspired us to consider a special program for the prevention of injuries in alpine skiing (Fig. 1A). All the common measures used to prevent injuries resulting from a dangerous fall by the skier were apparently insufficient. Release bindings provided only limited protection for the leg, for in 63 per cent of the cases of injury the binding had not released. Moreover, no definite information was available concerning the adjustment of release bindings for maximal safety. Finally, the mechanical and dynamic characteristics of safe release bindings were not known. In alpine skiing the tibia is the most frequent site of severe injury. In such a fall the tibia is the weakest link in the lower extremity. Thus, biomechanical research was started in 1965 to study the injury threshold of this body segment. Initially we determined the relationships of bone dimensions, sex, and age to the biomechanical characteristics of the tibia.

The importance of proper adjustment of safety bindings

The ski bindings in 50 consecutive patients with fractures of the lower leg were tested. All patients had broken the leg while skiing at two of Sweden's most popular ski resorts. There were 21 boot top fractures, 20 spiral fractures of the tibial shaft, eight malleolar fractures, and one fracture of the lateral tuberosity of the tibia. The tension required for release of the bindings laterally at the toe and vertically at the heel was measured and compared with the values recommended by the International Association for Skiing Safety. The ski bindings in no less than 49 of the 50 patients did not release in both directions at a tension 10 per cent higher than the recommended values. The ski bindings of 50 skiers randomly taken from a ski lift queue at one of the ski resorts studied were tested for comparison. The bindings in 48 of these 50 persons were found to be overadjusted; i.e., their bindings did not release in both directions at values comparable to those recommended by IAS. An analysis of the series stresses the need for bindings releasing also laterally at the heel, with a consistent release mechanism and a tamperproof tension adjustment screw.

Boot top fractures

Low transverse fractures of the tibiofibular complex due to ski injuries were formerly virtually unknown but are now met in ever increasing numbers. A series of 126 such fractures occurring in patients 13 years or older was analyzed. The sex and age distributions of these patients were found to differ significantly from those in skiers with other tibial shaft fractures. Among boot top fractures cases, boys younger than 20 years predominated much more than among patients with other fractures of the tibial shaft. In the boot top fracture there is characteristically a backward angulation, which may be combined with a forward displacement of the distal fragment. A simple technique for reduction of this typical deformity is described. According to this technique the surgeon should take a steady grip on the foot held in extreme plantar flexion. By applying strong traction, disimpaction is achieved after which the distal fragment is forced back into position and the fracture is immobilized with the foot in full equinus. This technique was successfully applied in the majority of our cases (112 of 126). Patients with boot top fractures were hospitalized for shorter periods than were skiers with other tibial fractures, and they were able to resume their normal activities much sooner. This held true even when allowance was made for differences in age. During the last few years a new type of boot top fracture has been observed. In this type there is a forward instead of a backward angulation. Its occurrence is most probably related to the new "scoot foot" or "sitting back" technique in downhill skiing. The appearance of this new type of boot top fracture implies that successful prevention can be achieved only with safety bindings that release not only at rotation but also when the skier falls backward.

Insufficiency and stress fractures of the long bones occurring in patients with rheumatoid arthritis

The occurrence of stress and insufficiency fractures in patients with long-standing rheumatoid arthritis has not been sufficiently emphasized. Osteoporosis due to rheumatoid arthritis and corticosteroid therapy, joint stiffness, contracture, and angular deformity of the extremity, and the unaccustomed exercise after reconstructive joint surgery combine to predispose to the occurrence of these fractures in these patients. The pain and disability caused by these fracture is often attributed to rheumatoid joint involvement. The fracture may not be visible on radiographs obtained near the onset of symptoms, and serial examinations may be needed for diagnosis.

Fractures of the tibial shaft after skiing and other accidents

Fractures of the tibial shaft from skiing accidents were compared with fractures of other etiology. Skiing fractures more often affected the lower third of the tibia and they seldom were open. Many were comminuted or transverse but displacement tended to be slight. The incidence of complications was low and the periods of hospitalization, of healing, and of inability to work were shorter than for the other fractures. The highly favorable prognosis was evident whatever the method used for treatment. Methods of treatment of tibial fractures should not be compared on the basis of experience with skiing fractures, because of the exceedingly favorable prognosis of the latter.

[Fatigue fracture of the tibia and fibroma non ossificans in a girl (author's transl)]

Stress, fatigue or march fractures rarely occur in children. Usually the bones do not show any other pathological alterations. The authors observed a 10 year old girl with stress fracture of the tibia, and additional skeletal alterations like "fibroma non ossificans" which probably are not connected with the main disease.

The Walldius hinge arthroplasty

Eighty-three Walldius arthroplasties, performed by one surgeon as salvage operation on the knee joint between 1966 and 1972, were independently reviewed. The fifty-seven living patients with sixty-seven arthroplasties were interviewed and examined and the clinical records of the deceased patients were inspected. Sixty-seven arthroplasties (81 per cent) were successful and sixteen failed (19 per cent). Acrylic cement was used to secure the prosthesis on eight occasions only. There were two primary infections (2-4 per cent) and two delayed (2-4 per cent). Major loosening occurred in three arthroplasties (3-6 per cent). Minor loosening was compatible with a good result. Arthrodesis was successful on the two occasions on which it became necessary to remove the implant. There were no disasters. On the basis of these results it is considered that the Walldius arthroplasty can justifiably be offered as an alternative to primary arthrodesis of the knee.

[Fatigue fractures of the leg bones. Apropos of 19 cases]

The authors report non-traumatic fracture occurring in healthy bond, fatigue fractures of the leg, much less common than fatigue of the metatarsal bones. The authors report here 19 cases, characterised by periosteal apposition and a limited bony fissure which could only be demonstrated towards the second or third week. Its radiological appearance consisted of peri-osteal apposition and bony fissure, and is quite characteristic. However, it is not always obvious and, in some cases, a misdiagnosis of reticulosarcoma was made. It is treated by plaster immobilisation or simple rest and this leads to a cure without sequelae. Progressive and sufficiently prolonged physiotherapy permits recovery of the normal bony structure submitted to new stresses in intensity and duration and should prevent further fractures.

Posterior psoas transfer and hip instability in lumbar myelomeningocele

Seventy-two posterior psoas transfer operations performed in forty-four children with lumbar myelomeningocele were reviewed one to eight years after operation in an attempt to assess its value. Muscle charting, an objective recording of the child's walking ability, and radiographic examination of the hips were done. Hip stability was improved: 49 per cent were stable at the time of psoas transfer and 94 per cent at review. Functional results depend mainly on the level of neurological activity present: 57 per cent of the children had an acceptable functional result. Usually, posterior psoas transfer should be done as soon after the age of nine months as the child's condition will allow. Over the age of two years it should be restricted to children with activity in the third and fourth segments of the lumbar cord.

Pitfalls of proximal tibial osteotomy

Proximal tibial osteotomy for degenerative genu varus and valgus has an excellent success rate with proper patient selection and technical proficiency. The following are some infrequently recognized pitfalls. Excessive bone loss prevents two plateau weight-bearing after osteotomy, introduces a "teeter effect," and is therefore a contraindication. Patellofemoral arthritis may produce symptoms, particularly on stair climbing and necessitate secondary surgery. Varus and planning indicates postoperative articular surface obliquity in excess of 10 to 15 degrees another type of reconstruction is indicated. Secure fixation, closing wedge osteotomy, and non-displacement of the d-stal fragment prevent loss of correction. Peroneal nerve palsy may be avoided by careful surgical technique and postoperative dressings. Cracking the apical cortex and visualization of the plateau fragment will usually prevent fracture.