Prospective evaluation of parental anxiety related to newborn foot disorder

PURPOSE

The presence of a clubfoot is often found prenatally and some families seek counselling with a specialist. The purpose of this study was to compare the parental anxiety levels in families that: a) knew prenatally and had prenatal counselling; b) knew prenatally but did not seek prenatal counselling; and c) did not know until after delivery.

METHODS

This prospective cohort study evaluated the anxiety of parents as they presented to the paediatric orthopaedic clinic with their newborn with a foot disorder (prior to the diagnostic confirmation of clubfoot). Each family filled out the 'Pre-visit orthopaedic surgeon questionnaire' and then after the initial visit with the orthopaedic surgeon (confirming the clubfoot diagnosis) the family filled out the 'Immediately post-visit orthopaedic surgeon questionnaire'. Through these questionnaires, anxiety level was assessed prior to meeting postnatally with the paediatric orthopaedic specialist, as well as after the meeting and compared across groups.

RESULTS

A total of 121 parents completed questionnaires: 71% (86/121) confirmed clubfoot; 69% of families (59/86) received prenatal counselling (Group A); 16% (14/86) knew prenatally but had no counselling (Group B); and 15% (13/86) found out at birth (Group C). There was no difference in anxiety levels across groups before (p = 0.78) or after (p = 0.57) meeting with the paediatric orthopaedic surgeon; however, overall anxiety reduced significantly (p < 0.001).

CONCLUSION

We found no difference in the anxiety levels of across the three groups. Prenatal counselling for parents of children with likely clubfoot may not decrease parental anxiety, but nonetheless is very appreciated by the families who receive it.

LEVEL OF EVIDENCE

Prognostic Level II.

Clubfoot relapse: does presentation differ based on age at initial relapse?

PURPOSE

Treatment of idiopathic clubfoot with the Ponseti method is now standard, but predicting relapse can be difficult. Most experts recommend bracing to the age of four years, but this can be challenging for families, and may not be necessary in all patients. The purpose of this study is to compare patterns of bracing and age of relapse to help determine if predictable patterns exist.

METHODS

The 70 patients with idiopathic clubfoot treated initially with the Ponseti technique who had relapse of their clubfoot were identified. Relapse was defined as a return to casting or surgery due to recurrent deformity. Data collected included demographics, treatment and brace adherence. Patients who sustained initial relapse before the age of two years were compared with those who sustained initial relapse after the age of two years.

RESULTS

In total 56% (39/70) had their initial relapse prior to age two years while 44% (31/70) were after age two years. Of the patients who relapsed prior to the age of two years, 28% (11/39) were adherent with bracing while 72% were non--adherent. For patients who initially relapsed after age two, 74% (23/31) were adherent with bracing while 26% were non-adherent (p < 0.001). Of those who had initial -relapse -prior to age two, a subsequent relapse was seen in 69% (27/39).

CONCLUSION

Patients with idiopathic clubfoot who experienced recurrence prior to age two years are significantly more likely to be non-adherent with bracing than those who sustain recurrence after age two. After initial relapse prior to age two, bracing adherence does not affect likelihood of subsequent recurrence.

Pediatric floating elbow

SUMMARY

A retrospective review of 16 patients with floating elbow injuries over a 9-year period at a tertiary care children's hospital confirms that these injuries are associated with substantial swelling and the potential to develop compartment syndrome, particularly when circumferential cast immobilization is used. Among 10 patients in whom the forearm was treated with closed reduction and plaster immobilization, a compartment syndrome developed in 2, and 4 patients had incipient compartment syndrome that responded to splitting of the cast; 3 of these subsequently required remanipulation of the distal radius. One patient with compartment syndrome had Volkmann ischemic contracture. Six patients underwent stabilization of both the distal humeral and forearm fractures with percutaneously inserted Kirschner wires, thereby allowing postreduction immobilization in a split cast. None of these patients had problems with excessive swelling or compartment syndrome. Percutaneous Kirschner wire fixation of both the humeral and forearm fractures in pediatric floating elbow injuries allows noncircumferential immobilization, thereby reducing the risk of compartment syndrome.

Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors

A cohort of 93 patients with developmental dysplasia of the hip (DDH) treated with a Pavlik harness were evaluated to determine predictors of treatment failure. Failure was defined as failure to achieve or maintain hip reduction in the Pavlik harness. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US alpha angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction.

Brachial plexus palsy as a complication of Pavlik harness use

A 2.75-month-old male infant was referred to our institution due to persistent hip subluxation despite 3 weeks of treatment in a Pavlik harness. Harness treatment was continued for 2 more weeks until it was noted that his left upper extremity function, which had been normal previously, had changed. Radiographs showed no bony abnormality. A compression or traction injury to his brachial plexus from the downward pull of the harness straps, possibly related to his relatively large size, was believed to be causative. Use of the harness was discontinued immediately, and his upper extremity motor function quickly returned to normal.

Uniplanar supracondylar humeral osteotomy with preset Kirschner wires for posttraumatic cubitus varus

Between 1974 and 1989, a lateral closing wedge osteotomy was used to correct posttraumatic cubitus varus in 36 patients. In 35 (97%) of the patients, the deformity was corrected to within 5 degrees of the contralateral elbow, and the patient was satisfied with the result. There were no nerve palsies or infections. Of the nine patients treated before age six years, seven had a minimum 2-year follow-up (average 9 years), and there was no evidence of recurrent deformity. This technique allows good correction of deformity with minimal complications.

Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis

We performed a retrospective analysis of 212 patients (299 hips) with slipped capital femoral epiphysis (SCFE) over a 9-year period to assess the incidence of osteonecrosis of the femoral head. Risk factors for the occurrence of osteonecrosis and the influence of treatment on the development of osteonecrosis were determined. Osteonecrosis occurred in 4 hips with unstable SCFE (4/27) and did not occur in hips with stable SCFE (0/272). The proportion of hips in which osteonecrosis developed was significantly higher among the unstable hips (4/27 vs. 0/272, p < 0.0001). Among those with an unstable hip, younger age at presentation was a predictor of a poorer outcome. Magnitude of the slip, magnitude of reduction, and chronicity of the slip were not predictive of a poorer outcome in the unstable group. In situ fixation of the minimally or moderately displaced "unstable" SCFE demonstrated a favorable outcome. We have identified the hip at risk as an unstable SCFE. The classification of hips as unstable if the epiphysis is displaced from the metaphysis or if the patient is unable to walk is most useful in predicting a hip at risk for osteonecrosis.

Wagner multiple K-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile 'tailor-made' high angle blade plate equivalent

In 1978, Wagner described a technique using multiple Kirschner wires (K-wires) to stabilize an intertrochanteric osteotomy performed for the correction of coxa vara in small children. Multiple K-wires are used to create a custom high-angle blade plate for valgus osteotomy. The authors have evaluated a retrospective series of 17 Wagner intertrochanteric osteotomies that were performed in 10 children with coxa vara between the ages of 1 year and 8 years. The neck-shaft angle was corrected from 93.5 degrees to 129.5 degrees at long-term follow-up, and the Hilgenreiner epiphyseal angle was corrected from 71 degrees to 37.6 degrees at long-term follow-up. Revision surgery was performed on five hips with inadequate initial surgical correction. Complications included a single broken K-wire, a femur fracture after hardware removal, and one hip developed avascular necrosis postoperatively.

Development of a virtual reality arthroscopic knee simulator

The virtual reality arthroscopic knee simulator (VR-AKS) consists of a computer platform, a video display, and two force-feedback (haptic) interfaces which also monitor the position of the instruments in the user's hands. The forces that the user would normally apply to the lower limb during arthroscopy are directed through an instrumented surrogate leg. Proprietary software furnishes the mathematical representation of the physical world and replicates the visual, mechanical, and behavioral aspects of the knee while task-oriented programs monitor and record specific areas of user performance. A prototype has demonstrated the feasibility of the system and work on the first, fully functional simulator will begin soon.

Flexon-type Salter-Harris I injury of the proximal tibial epiphysis

The authors report a case of a flexion-type epiphyseal separation of the proximal tibia. The injury described herein is a displaced Salter-Harris type I injury. Literature pertaining to this rare injury is reviewed, and management options are discussed.

Massive subperiosteal hemorrhage and femoral shaft osteonecrosis: a complication of tissue plasminogen activator therapy for purpura fulminans

We present the case of a child who developed a massive subperiosteal hemorrhage and subsequent osteonecrosis of her right femur after treatment with tissue plasminogen activator for post-varicella streptococcal purpura fulminans. Radiographs showed posteromedial translation of the capital femoral epiphysis on the necrotic shaft, and the hip was immobilized. The femur slowly remodeled and has continued to grow. The child is independently ambulatory with a 2.1-cm leg length discrepancy, a varus deformity of the hip, and a valgus distal femur.

Orthopaedic aspects of child abuse

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.

Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm

BACKGROUND

A child who has an acutely irritable hip can pose a diagnostic challenge. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation.

METHODS

We retrospectively reviewed the cases of children who were evaluated at a major tertiary-care children's hospital between 1979 and 1996 because of an acutely irritable hip. Diagnoses of true septic arthritis, presumed septic arthritis, and transient synovitis were explicitly defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression analysis were used to compare groups. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested.

RESULTS

Patients who had septic arthritis differed significantly (p < 0.05) from those who had transient synovitis with regard to the erythrocyte sedimentation rate, serum white blood-cell count and differential, weight-bearing status, history of fever, temperature, evidence of effusion on radiographs, history of chills, history of recent antibiotic use, hematocrit, and gender. Patients who had true septic arthritis differed significantly (p < 0.05) from those who had presumed septic arthritis with regard to history of recent antibiotic use, history of chills, temperature, erythrocyte sedimentation rate, history of fever, gender, and serum white blood-cell differential. Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, erythrocyte sedimentation rate of at least forty millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter). The predicted probability of septic arthritis was determined for all sixteen combinations of these four predictors and is summarized as less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. The chi-square test for trend and the area under the receiver operating characteristic curve indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis.

CONCLUSIONS

Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.

Legg-Calvé-Perthes disease: MR imaging evaluation during manual positioning of the hip--comparison with conventional arthrography

PURPOSE

To evaluate the use of magnetic resonance (MR) imaging during manual positioning of the hip, or multipositional MR imaging, in an open-magnet configuration to study femoral head containment, articular congruency, and femoral head deformity in Legg-Calvé-Perthes disease.

MATERIALS AND METHODS

In 12 children with advanced Legg-Calvé-Perthes disease, multipositional MR imaging and conventional arthrography were compared in the assessment of containment, femoroacetabular congruency, and femoral head deformity. Images of the hips in several positions were compared subjectively and objectively.

RESULTS

MR imging correlated well with arthrography for overall subjective assessment of severity of disease (r = 0.71, P = .01), with good interobserver agreement (kappa = 0.65, P < .001). MR images demonstrated all cases of hinge abduction shown arthrographically. However, MR imaging failed to depict one case of femoral head flattening. MR imaging correlated well with arthrography in the objective evaluation of joint fluid and lateral subluxation (r = 0.80, P < .01). MR imaging correlated poorly with arthrography in the measurement of sphericity of the femoral head.

CONCLUSION

Multipositional MR imaging with an open-magnet configuration was comparable to arthrography for demonstration of femoral head containment and congruency of the articular surfaces of the hip. In the evaluation of deformity, it performed less well.

Radiographic appearance of the normal distal tibiofibular syndesmosis in children

In adults, a tibiofibular clear space (i.e., distance from the incisura fibularis to the medial fibula) of > or = 6 mm or a loss of tibiofibular overlap has been reported to correlate with injury to the distal tibiofibular syndesmosis. We reviewed anteroposterior (AP), lateral, and mortise ankle radiographs from 106 children (50 boys, 56 girls) aged 1-15 years in an attempt to assess whether these criteria are applicable to children. The incisura was detectable at a mean age of 8.2 years for girls and 11.2 years for boys. The range of tibiofibular clear space among the 48 children with a detectable incisura was 2-8 mm; seven (23%) of these 48 children had a clear space of > or = 6 mm in one or more views. The mean age at which the tibiofibular overlap began to appear on the AP view was 5 years for both genders, whereas on the mortise view, it was 10 years for girls and 16 years for boys. The criteria used to evaluate the integrity of the distal tibiofibular syndesmosis in adults do not apply to children in this normal study population.

Protrusio acetabuli and bilateral basicervical femoral neck fractures in a patient with Marfan syndrome

A 22-year-old man with Marfan syndrome and bilateral protrusio acetabuli presented with bilateral femoral neck stress fractures after vigorous stretching exercises for hip "stiffness." Fifteen years later, his fractures, which were treated with internal fixation, have healed, his acetabular protrusion has not worsened, and his perceived hip "stiffness" persists. This case demonstrates a rare manifestation of Marfan syndrome, protrusio acetabuli, and a possible side effect of vigorous stretching in the face of abnormal joint mechanics.

Chronic physeal fractures in myelodysplasia: magnetic resonance analysis, histologic description, treatment, and outcome

Thirteen myelodysplastic children with 19 chronic physeal fractures were treated. All were treated with prolonged immobilization (average, 5.8 months; range, 3-18 months) in either braces or casts; four of the fractures required operative fixation to facilitate healing. All were healed at 4.8-years follow-up but, in four of the fractures, the growth plate closed prematurely. Three of the children underwent magnetic resonance imaging (MRI) of the injured physes, and one underwent physeal biopsy as part of her operative epiphysiodesis. Histologic analysis revealed three distinct zones of physeal pathoanatomy: a normal zone of proliferation; a thickened, disorganized zone of hypertrophy; and a vascularized zone of fibrous tissue adjacent to the metaphysis. On MRI, there was thickening of the physis and irregularity of the zone of provisional calcification. The physeal cartilage and the juxtametaphyseal fibrovascular tissue enhanced with gadolinium. These findings corroborate earlier mechanistic proposals for physeal injury in myelodysplasia: chronic stress or trauma to the poorly sensate limb produces micromotion at the zone of hypertrophy, yielding a widened, disorganized physis, and leading to fracture, displacement, and delayed union.

Postreduction computed tomography in developmental dislocation of the hip: part I: analysis of measurement reliability

Twenty computed tomographic (CT) scans of infants in spica casts after closed or open reduction for developmental hip dislocation (DDH) were analyzed for intra- and interrater reliability. Ten measurements of infant hip anatomy were assessed by three raters by using standard statistical analysis. All six measurements of acetabular anteversion and lateral or posterior displacement of the femoral metaphysis from the acetabulum or from a modified Shenton's line drawn from the pubic rami demonstrated both intra- and interrater reliability. All four measurements of acetabular structure could not be reliably measured either within or between observers. We also introduced a new measurement based on the principle of Shenton's line to aid in the assessment of femoral-head location after reduction in patients with DDH; this was reliably determined both within and among observers.

Postreduction computed tomography in developmental dislocation of the hip: part II: predictive value for outcome

Computed tomographic (CT) scans were performed after closed reduction of 68 dislocated hips in 53 infants in spica casts with developmental hip dislocation (DDH). Ten measurements were made on the CT scans including acetabular indices and anteversion, hip-abduction angle, lateral and posterior displacement of the femur from the acetabulum, and femoral displacement from a modified Shenton's line drawn from the pubic rami. By using analysis of variance, the correlation of each variable with outcome after reduction was determined, including the development of avascular necrosis or the need for further surgery because of residual dysplasia. None of the variables was predictive of the outcome of persistent hip dysplasia. The subsequent development of avascular necrosis was statistically associated with hip-abduction angles >55 degrees as measured on postreduction CT scans, with 20% of the involved hips developing avascular necrosis on subsequent follow-up.

Accuracy of leg length prediction in children younger than 10 years of age

In this study, the authors attempted to predict the ultimate leg length in normal children with normally growing legs, using Green-Anderson and Moseley techniques with chronologic and skeletal age. The predictions were based on serial growth studies of children between 5 and 10 years of age. Using skeletal age for prediction, the absolute mean error in predicting the ultimate leg length was 2.4 cm using the Green-Anderson method and 2.58 cm using the Moseley method. Using the Moseley method for length prediction in boys, the mean error was 3.8 cm using skeletal age and 1.5 cm using chronologic age. For girls, using the Moseley method of leg length prediction, the mean error was 1.55 cm with skeletal age and 2.46 cm with chronologic age. The significance of this study is that skeletal age, as determined by the Gruelich and Pyle Atlas, does not improve the accuracy of prediction of ultimate leg length in children younger than 10 years of age, except in girls with advanced bone age.

Ulnar nerve instability in children

We carried out a cross-sectional study to define the prevalence of ulnar nerve instability and its relationship to ligamentous laxity in the pediatric population. Children were divided into three age groups: group I (0-5 years), group II (6-10 years), and group III (11-18 years). Of children in group I 17.7%, of children in group II 7.7%, and 5.7% of children in group III had dislocating ulnar nerves. With the exception of one patient, nerve instability was bilateral. Of those children possessing all five Wynne-Davies signs of ligamentous laxity, 25.4% had dislocating nerves, 71.9% had subluxing nerves, and 2.6% had stable nerves. Age, ulnar nerve instability, and ligamentous laxity were statistically associated (p < 0.0001).

MR imaging in congenital lower limb deformities

Treatment for children with congenital deformities of the lower extremities may vary, depending on the state of the unossified skeletal structures and surrounding soft tissues. The purpose of our study was to demonstrate the spectrum of the osteochondral and extrasosseous abnormalities as depicted with MR imaging. We retrospectively reviewed MR examinations of 13 limbs of ten children (aged 1 month-9 years, mean 2.1 years) with longitudinal and transverse deformities of the lower extremities. The lesions imaged were fibular hemimelia (n = 5), tibial hemimelia (n = 5), and congenital constriction bands (n = 3). Each examination was assessed for abnormalities in the osteocartilaginous and extraosseous (articular or periarticular components such as ligaments, tendons, and menisci; the muscles and the arteries) structures. Abnormalities were seen in all patients. Osteocartilaginous abnormalities in the patients with longitudinal deformities included abnormal distal femoral epiphyses, abnormal proximal tibial physes, hypertrophied and dislocated proximal fibular epiphyses, unsuspected fibular and tibial remnants, and absence or coalition of the tarsal bones. No osteocartilaginous abnormalities were seen in the patients with congenital constriction bands. Articular abnormalities about the knee in patients with either form of hemimelia included absent cruciate ligaments and menisci, dislocated or absent cartilaginous patellae, absent patellar tendons, and abnormal collateral ligaments. All but one limb imaged had absent or attenuated muscle groups. Of the nine MR arteriograms performed at the level of the knee, eight were abnormal. The normal popliteal trifurcation was absent or in an abnormal location. We conclude that MR imaging of children with congenital lower extremity deformities shows many osteochondral and extraosseous abnormalities that are not depicted by conventional radiography. This information can help to plan early surgical intervention and prosthetic rehabilitation.

Cartilaginous abnormalities and growth disturbances in Legg-Calvé-Perthes disease: evaluation with MR imaging

PURPOSE

To evaluate the magnetic resonance (MR) imaging appearance of cartilaginous abnormalities in Legg-Calvé-Perthes (LCP) disease and their association with growth arrest.

MATERIALS AND METHODS

Twenty-seven MR images and radiographs of 25 hips in 23 patients were reviewed for epiphyseal, physeal, and metaphyseal abnormalities. Follow-up radiographs (mean time, 20.5 months) were evaluated for growth arrest.

RESULTS

Epiphyseal abnormality seen in 74% of cases was not related to growth disturbances. Transphyseal bone bridging on MR images, the strongest predictor of abnormal growth (P < .01), was found in 63% of femurs. MR imaging helped detect physeal abnormalities with greater sensitivity (94%), specificity (89%), and positive predictive value (94%) than radiography. Metaphyseal extension of physeal cartilage seen in 81% of cases was associated with growth abnormality (P < .01), particularly when detected at radiography.

CONCLUSION

Cartilaginous physeal and metaphyseal abnormalities in LCP disease are common and frequently result in growth arrest.

The Pavlik harness and developmental dysplasia of the hip: has ultrasound changed treatment patterns?

Monitoring Pavlik harness therapy for developmental dysplasia of the hip (DDH) has been used at our institution since 1986. In this study, we compared Pavlik therapy for DDH without ultrasound monitoring (group A) to similar therapy with ultrasound monitoring (group B). Both groups had similar age at diagnosis. Treatment failure was recognized earlier in group B than in group A (4.9 vs. 9.3 weeks). The total number of radiographs was significantly decreased in group B. The duration of therapy was less in group B than in group A. Successfully treated hips had an average increase in alpha angle of 8.4 degrees per month. The average failure rate in hips resting in a dislocated position at the onset of Pavlik therapy was unchanged by Pavlik monitoring.

Osteomyelitis and septic arthritis in children: appropriate use of imaging to guide treatment

Modern imaging techniques have become essential components of the management of acute osteomyelitis and septic arthritis in children. This article addresses the role of these techniques, based on clinical practice guidelines recently developed at a children's hospital by an interdisciplinary group. The recommendations reflect a review of the literature and an analysis of our own experience with 84 children treated for musculoskeletal sepsis during the past 3 years. We attempt to optimize imaging resources by analyzing the unique aspects of these infections in the pediatric skeleton, the clinical needs at different stages of the disease, and the relative strengths and weaknesses of the various imaging procedures. Our goal was to define the use of imaging in cases of osteomyelitis and septic arthritis in children in specific clinical scenarios in which additional information is likely to lead to management modification.

Neurovascular injury and displacement in type III supracondylar humerus fractures

From July 1987 to January 1991, 59 consecutive type III supracondylar humerus fractures in children were identified at Children's Hospital, Boston. Twenty-nine patients (49%) had evidence of neurovascular compromise. The median nerve was involved in 15 (52%) of these patients and was associated with posterolateral displacement in 87% of cases. The radial nerve was involved in eight (28%) of these patients and was associated with posteromedial displacement in every case. Injuries to the brachial artery occurred in 11 (38%) of these patients and was associated with posterolateral displacement in 64% and posteromedial displacement in 36% of cases. We conclude that posterolateral displacement in type III supracondylar humerus fractures is strongly associated with median nerve injuries. Posteromedial displacement is responsible for injuries. Posteromedial displacement is responsible for injuries to the radial nerve in virtually every instance. Brachial artery injuries may occur with either type of displacement. Neurovascular injury is higher than previously reported in these fractures.

Osteochondroma formation after a Salter II fracture

Osteochondromas are one of the most commonly observed benign bone tumors. Although there have been a number of experimental studies carried out to determine the origin of osteochondromas, their etiology remains a controversial issue. A well-documented case is presented in which a displaced Salter-Harris type II physeal fracture preceded the development of an osteochondroma.

Spinal deformity associated with neurenteric cysts in children

STUDY DESIGN

Neurenteric cysts are uncommon lesions originating from the primitive foregut that may involve adjacent vertebrae and spinal cord. Little is known regarding the natural history of these cysts and associated spinal deformity in children. Five patients with these cysts managed at the authors' institution from 1955 to 1993 were reviewed.

OBJECTIVES

The goal of this retrospective review was to determine the natural history of these cysts in children, and to assess the surgical management in each of the five patients.

METHODS

Medical charts and radiographic records were reviewed and, when possible, the patients were re-evaluated clinically.

RESULTS

All patients had significant anterior vertebral defects, and four had severe kyphosis at presentation. Major complications occurred in three of the four patients treated surgically.

CONCLUSIONS

Iatrogenic complications of surgical management of these cysts can be limited by combined anterior and posterior approaches, providing the most complete exposure and maximal stabilization of the associated deformity.

Percutaneous pinning in the treatment of displaced lateral condyle fractures

This is a review of a unique group of 12 children with lateral condyle fractures of the distal humerus with displacement of > 2 mm. Intraoperative arthrograms of each elbow demonstrated no articular incongruity associated with minimal rotation of the distal fracture fragment. After closed reduction the lateral condyle fractures were percutaneously pinned, obviating the need for open reduction and internal fixation. The results in this study group were uniformly excellent as based on the rating system of Hardcare. Each child had a normal range of elbow motion and all cases healed clinically and radiographically without complication. Previous literature has recommended that all lateral condyle fractures displaced > 2 mm be treated with open reduction and internal fixation. The authors feel that in selected cases of lateral condyle fractures with > 2 mm displacement and an arthrographically demonstrated congruent joint surface, percutaneous pinning may safely and effectively be performed.

Leg length discrepancy associated with vivid cutis marmorata

Cutis marmorata telangiectatica congenita (CMTC), a rare benign condition usually present at birth, is characterized by areas of cutaneous marbling that often become more pronounced with low temperatures. The skin lesions typically become less prominent with age, but may be associated with a variety of abnormalities. Reported are three patients with vivid cutis marmorata who had leg length discrepancies (LLD) which, unlike most limb discrepancies caused by vascular malformations, involved relative growth retardation of the affected leg.

The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old

Thirty-three patients who had been managed for an isolated, closed fracture of the femoral shaft when they were less than seventeen years old were examined at an average of thirty-three months (range, eighteen to fifty-six months) after the injury. Thirteen patients (39 per cent) had a persistent deficit in the strength of the quadriceps of the fractured limb, as identified on testing with a Cybex-II isokinetic dynamometer. Six patients (18 per cent) had a deficit according to the one-leg-hop for distance test, fourteen (42 per cent) had an average loss of ten millimeters in the circumference of the thigh, and sixteen (48 per cent) had an average loss of 10 degrees of flexion of the knee. The etiological factors that were thought to possibly be responsible for the weakness of the quadriceps were evaluated. The amount of maximum displacement of the fracture, as seen on the initial radiographs, was the only factor that was significant for the prediction of weakness of the quadriceps (p = 0.006) at both test speeds of the Cybex dynamometer and in all statistical analyses. Despite the persistent weakness of the quadriceps, none of the patients had a clinical problem at the latest follow-up examination. A subclinical deficit in the strength of the quadriceps may be related to damage sustained by the muscle at the time of the fracture. On the basis of the results of this study, we do not recommend a change from the traditional methods of treatment, which involve early application of a spica cast or use of traction followed by application of a spica cast.

Incidence of spondylolisthesis in ambulatory cerebral palsy patients

We prospectively studied 50 consecutive ambulatory cerebral palsy (CP) patients to determine the incidence of isthmic spondylolisthesis. In addition, we examined the relationship of hip flexion contractures to development of spondylolisthesis and low back pain. Three patients who had undergone previous spine operation were eliminated from the study group. Of the remaining 47 patients, one patient (2%) demonstrated an asymptomatic grade I spondylolisthesis. Another patient (2%) demonstrated spondylolysis without spondylolisthesis. Only six patients reported occasional low back pain. Pain did not correlate with increasing age, increasing hip flexion contracture, or decreasing sacrofemoral angle. The incidence of spondylolisthesis in this group of ambulatory CP patients with hip flexion contractures is similar to that in the general population. Hip flexion contractures did not predispose the group to spondylolisthesis or low back pain. Periodic screening of asymptomatic ambulatory CP patients for spondylolisthesis is not recommended.

Slipped capital femoral epiphysis. A quantitative analysis of motion, gait, and femoral remodeling after in situ fixation

A prospective clinical study was done for quantitative examination of motion of the hip, gait, and proximal femoral remodeling after in situ fixation of a slipped capital femoral epiphysis. In situ fixation was performed in forty-five consecutively treated patients (fifty-six hips). Thirty-nine (87 per cent) of the patients returned for examination two years after treatment. The greatest percentage of motion of the hip returned within six months after treatment. Despite loss of internal rotation of the hip, the mean foot-progression angle was 10.8 degrees. Radiography and computerized tomographic scanning revealed minimum change in the relationship of the femoral head to the femoral shaft and no change in the neck-shaft angle. Motion returned despite minimum osseous remodeling. The early return of motion (in the first three months) may have been due to relief of pain, spasm, and synovitis, while soft-tissue stretching and resorption of bone in the anterolateral part of the femoral neck may have accounted for the remainder of the increase in internal rotation.

Neurologic complications after K-wire fixation of supracondylar humerus fractures in children

A retrospective review of 143 supracondylar humerus fractures in children treated with K-wire fixation disclosed four neurologic complications after treatment. There were two late ulnar neuropraxias. One ulnar nerve injury and one radial nerve injury resulted from direct trauma during insertion of a K-wire. All patients regained full neurologic function.

Acute septic arthritis in infancy and childhood

Despite intensive study of acute septic arthritis in infancy and childhood, poor outcomes continue to occur. Failures are often due to delayed diagnosis and inadequate therapy, but can be due to factors beyond physicians' control such as associated osteomyelitis and occurrence during infancy. Recent advances in the understanding and management of septic arthritis include: (1) demonstration of beneficial effects of continuous passive motion in rabbits; (2) identification of inflammatory mediators of cartilage destruction and their respective sources; (3) recognition of changing patterns of pathologic organisms; (4) evolution of new antibiotics and standards for oral and home intravenous therapy; (5) development of arthroscopic debridement of septic knees; and (6) further refinement of indications for aspiration-irrigation versus open surgical drainage of septic joints. Permanent sequelae from septic arthritis can only be prevented by early diagnosis and aggressive treatment.

Physeal bar resections after growth arrest about the knee

Localized growth arrest about the knee can be treated with excision when less than 50% of the physis is involved and when at least 2.5 cm of growth remains. Simultaneous corrective osteotomy should be performed when the angular deformity exceeds 20 degrees. The superiority of the various interposition materials remains controversial, but the alternatives are fat, cartilage, elastomer, and methylmethacrylate.

Management of vascular injuries in displaced supracondylar humerus fractures without arteriography

One hundred forty-three displaced (type III) supracondylar fractures of the humerus in children were treated over a 5.5-year period with 17 (11.9%) having signs of vascular impairment at the time of presentation. Rapid reduction and Kirschner wire stabilization without arteriogram was performed in each case. In three cases in which satisfactory blood supply to the hand was not present after reduction, circulation was restored after exploration of the brachial artery revealed two intimal tears and one arterial entrapment. The remaining 14 patients were normal at follow-up with no late vascular compromise. Based on these findings, we feel prereduction arteriography is not indicated in this injury.

Self-administered nitrous oxide for fracture reduction in children in an emergency room setting

Analgesia using a self-administered mixture of 50% nitrous oxide and 50% oxygen (Nitronox) was evaluated prospectively in 22 children undergoing closed reduction of fractures in the emergency room. The majority of these patients underwent reduction of forearm fractures. When the children were asked about pain after the procedures, 12 (60%) recalled no pain, 7 (35%) minimal pain, and 1 (5%) moderate pain. None recalled severe pain. Eleven (52%) of the patients had minimal pain, 8 (38%) had moderate pain, and 2 (10%) had no pain, as judged by an emergency room physician. None had severe pain. There were no complications and the ease of administration was remarkable. We conclude that N2O:O2 in a 50:50 mixture provides very effective, safe analgesia for fracture reduction in the emergency room setting.

The triceps-dividing approach to open reduction of complex distal humeral fractures in adolescents: a Cybex evaluation of triceps function and motion

Triceps function and elbow motion were evaluated in nine elbows after open reduction of complex distal humeral fractures through a triceps dividing approach. At 3-year 6-month follow-up, the patients had an average flexion/extension of 136 degrees to -6 degrees. Triceps peak torque decreased slightly, measured by Cybex testing with a 6% deficit at 60 degrees/s, 3% deficit at 120 degrees/s, and 3% deficit at 180 degrees/s. We recommend triceps division rather than olecranon osteotomy in children who require open reduction of complex distal humeral fractures.

Physeal arrest about the knee associated with non-physeal fractures in the lower extremity

The cases of seven patients who had a physeal arrest about the knee in association with nonphyseal fractures in the lower extremity were reviewed. The patients were between ten and twelve and one-half years old at the time of injury, and the physeal arrest involved either the posterolateral part of the distal femoral physis or the anterior part of the proximal tibial physis. There was no evidence of iatrogenic trauma to the physis. Recognition of the physeal injury was delayed for an average of one year and ten months until a gross angular deformity appeared. Adolescents who have fractures of the lower extremities that do not appear to involve a physeal plate should nevertheless be evaluated and followed for possible physeal injury about the knee that can be detected only after additional growth has taken place.

Chronic recurrent multifocal osteomyelitis. Association with vertebra plana

In seven children who had chronic recurrent multifocal osteomyelitis, the radiographic and histological findings were consistent with those of osteomyelitis, but the results of cultures were negative. We studied the clinical, radiographic, histological, and microbiological findings in these patients, who had a total of thirty-nine lesions. The lesions occurred most frequently in the spine, tibia, and femur; three patients had vertebra plana. The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of the osseous lesions without specific treatment. The diagnosis is one of exclusion. Biopsy is recommended, and results of cultures must be negative before therapy with antibiotics can be withheld.

Tibial tubercle apophysitis in cerebral palsy treated with proximal tibial epiphysiodesis: report of two cases with 3-year follow-up

Tibial tubercle apophysitis, or Osgood-Schlatter disease, is a condition not commonly seen in conjunction with cerebral palsy. The reported radiologic incidence of this association is only 3%. The condition usually responds to conservative therapy, consisting of rest, immobilization, and antiinflammatory agents. Occasionally, a child with cerebral palsy and resistant apophysitis requires surgical intervention. We report two patients with bilateral apophysitis who underwent proximal tibial epiphysiodesis with complete relief of symptoms and rapid return to community ambulation.

The association of femoral retroversion with slipped capital femoral epiphysis

We examined twenty-five patients who had a unilateral or bilateral slip of the capital femoral epiphysis and determined the degree of anteversion of the thirty-nine involved hips with computerized axial tomography. Thirteen patients (eighteen hips) were seen at the time of the original diagnosis (Group I), and twelve patients (twenty-one hips) were seen one to seven years after operative treatment (Group II). The mean amount of anteversion for all of the involved hips was +1.0 +/- 8.2 degrees. The mean amount of anteversion for the Group-I hips was -0.7 +/- 7.4 degrees and the mean amount for the Group-II hips was 2.5 +/- 8.7 degrees. The mean amount of anteversion for the hips in both Groups I and II was less than the predicted mean amount for individuals of the same age. The mean amount of anteversion of the unaffected hips of our patients who had a unilateral slip was +6.3 +/- 8.2 degrees. The amount of internal rotation of the hip in extension exceeded the amount when it was in flexion in all of the patients. A decreased angle of femoral anteversion appears to be specifically associated with the development of slipped capital femoral epiphysis. The mechanical forces that act across the proximal femoral physis may be altered by this rotational abnormality, and this may lead to an increased shear stress that ultimately causes failure of the growth plate.

Slipped capital femoral epiphysis: assessment of epiphyseal displacement and angulation

Nineteen hips with slipped capital femoral epiphysis underwent assessment of the severity of epiphyseal displacement on anteroposterior and lateral roentgenograms and by computerized tomography. The head-shaft angle, the percentage of maximal epiphyseal displacement, and the computed tomographic head-neck angle were determined. The head-shaft angle showed great variability when compared with the percentage of epiphyseal displacement and with the head-neck angle. The percentage of epiphyseal displacement showed less variability when compared with the computerized tomographic head-neck angle; however, the range of error was still significant. These data suggest that the computerized tomographic measurement of degree of slip is more accurate than previously described techniques. We believe that the computerized tomographic measurement of head-neck angle achieves greater accuracy and therefore reproducibility by virtue of a decrease in position dependency. This measurement may be indicated as a reproducible standard for assessing slip severity in the horizontal plane.

Varus derotation osteotomy in the treatment of persistent dysplasia in congenital dislocation of the hip

We have attempted to define the indications for and limitations of varus derotation osteotomy in the treatment of persistent dysplasia in congenital dislocation of the hip. We studied the cases of thirty-four patients (forty-four hips) who were divided into three groups according to age at operation, and evaluated the influence of femoral remodeling, age, acetabular response, instability, and pre-existing avascular necrosis with respect to the final results. The length of follow-up ranged from five to twenty-two years. Rapid return to a valgus femoral neck-shaft angle by remodeling was not a cause of failure in any age group. There were consistently good results in the patients who were less than four years old at the time of operation. Acetabular correction by remodeling occurred through the age of eight years, but four of thirteen hips in patients who were between the ages of four and eight showed persistent dysplasia despite the operative procedure. The results were less predictable as the patients approached the age of eight years. There was no benefit from isolated femoral osteotomy in ten of eleven hips in patients who were older than eight. Pre-existing avascular necrosis appeared to compromise the results of the procedure in all age groups.