Normative Femoral and Tibial Lengths in a Modern Population of Twenty-First-Century U.S. Children

BACKGROUND

The Green-Anderson (GA) leg-length data remain the gold standard for the age-based assessment of leg lengths in children despite their methodologic weaknesses. We aimed to summarize current growth trends among a cross-sectional cohort of modern U.S. children using quantile regression methods and to compare the median femoral and tibial lengths of the modern U.S. children with those of the GA cohort.

METHODS

A retrospective review of scanograms and upright slot-scanning radiographs obtained in otherwise healthy children between 2008 and 2020 was completed. A search of a radiology registry revealed 3,508 unique patients between the ages of 2 and 18 years for whom a standard-of-care scanogram or slot-scanning radiograph had been made. All patients with systemic illness, genetic conditions, or generalized diseases that may affect height were excluded. Measurements from a single leg at a single time point per subject were included, and the latest available time point was used for children who had multiple scanograms made. Quantile regression analysis was used to fit the lengths of the tibia and femur and overall leg length separately for male patients and female patients.

RESULTS

Seven hundred patients (328 female and 372 male) met the inclusion criteria. On average, the reported 50th percentile tibial lengths from the GA study at each time point were shorter than the lengths in this study by 2.2 cm (range, 1.4 to 3.3 cm) for boys and 2 cm (range, 1.1 to 3.1 cm) for girls. The reported 50th percentile femoral lengths from the GA study at each time point were shorter than the lengths in this study by 1.8 cm (range, 1.1 to 2.5 cm) for boys and 1.7 cm (range, 0.8 to 2.3 cm) shorter for girls.

CONCLUSIONS

This study developed new growth charts for femoral and tibial lengths in a modern U.S. population of children. The new femoral and tibial lengths at nearly all time points are 1 to 3 cm longer than traditional GA data. The use of GA data for epiphysiodesis could result in underestimation of expected childhood growth.

LEVEL OF EVIDENCE

Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Metallic implant removal in children

The indications for removing metal that was implanted in children and the practice of removing it have changed dramatically during the past century, but this subject is rarely discussed in publications, oral presentations, or resident training curricula. Thus, during their training, residents learn about the topic only sporadically from evaluating patients. This article presents the cases for and against metallic implant removal and identifies situations in which removal is appropriate and situations in which it is not.

Physeal arrest due to laser beam damage in a growing child

A laser beam applied directly to epiphyseal cartilage may damage the cartilage selectively without affecting adjacent bone. The damaged physis is replaced by bone, which forms a bone bridge between the metaphysis and epiphysis, similar to the bone bridges that follow fracture of any long bone. This case report documents damage to two distal phalangeal epiphyseal plates as a sequela of laser beam injury. This resulted in premature partial physeal closure (physeal bars), which in turn caused progressive angular deformity and relative shortening of the digits, requiring multiple osteotomies for correction. This report suggests that special care must be exercised when using laser therapy near physes in growing children.

Surgical treatment of Scheuermann's disease with segmental compression instrumentation

Twenty-one patients with Scheuermann's kyphosis had surgery for progressive kyphotic deformity of 50 degrees or greater. There were six adolescents, with a mean age of 15.6 years (range, 13-17 years) and 15 young adults, with a mean age of 25.4 years (range, 18-40 years). All patients had posterior spine arthrodesis with segmental compression instrumentation. Seven patients with rigid kyphosis had combined anterior and posterior spine arthrodesis. One patient died of superior mesenteric artery syndrome. In the group of 13 patients with posterior arthrodesis only, followup was 4.5 years. The mean preoperative thoracic kyphotic curve of 68.5 degrees improved to 40 degrees at latest review, with an average loss of correction of 5.75 degrees. Junctional kyphosis occurred in two patients with a short arthrodesis: one at the cephalad end and one at the caudal end of the fused kyphotic curve. In the second group of seven patients with combined anterior and posterior arthrodesis, followup was 6 years. The mean preoperative thoracic kyphotic curve of 86.3 degrees improved to 46.4 degrees at latest review, with an average loss of correction of 4.4 degrees. Overall, there was no postoperative neurologic deficit and no pseudarthrosis. Thus, posterior arthrodesis and segmental compression instrumentation seems to be effective for correcting and stabilizing kyphotic deformity in Scheuermann's disease. Despite a long operating time, this technique provided significant correction, avoiding the development of any secondary deformity in most patients. Combined anterior and posterior spine arthrodesis is recommended for rigid, more severe kyphotic deformities.

Brachymetatarsia of the first metatarsal treated by surgical lengthening

The first metatarsal of six feet in four patients was surgically lengthened. Brachymetatarsia was caused by a congenital defect in two patients, nonunion after metatarsal osteotomy in one patient, and premature physeal closure associated with pin placement across the physis in one patient. In each patient, middiaphyseal osteotomy was performed, pins were placed into the proximal and distal metatarsal fragments, and an external distracting device was attached. After distraction, a fibular graft was inserted and the device was removed. The percentage of metatarsal length gained from the lengthening averaged 36% (range 12-68%). The fibular graft healed in the lengthened position in all patients.

Fracture of the distal radial physis complicated by compartment syndrome and premature physeal closure

Complications after injury to the epiphyseal growth plate of the distal radius are uncommon. An 11-year-8-month-old boy developed two complications--compartment syndrome of the forearm and premature closure of the physis--after a Salter-Harris Type I injury. Treatment included closed reduction, decompression, skin grafting, excision of the physeal bar, and epiphysiodesis of the distal ulna and the remaining open physis of the distal radius.

Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988

All children in Olmsted County, Minnesota, who had a physeal fracture in the 10-year period 1979 through 1988 were identified in this population based study. Children with acute fractures from surrounding areas of Olmsted County and children with subacute, chronic fractures or complications of fractures among referral patients were not included. Eight-hundred fifty children sustained 951 physeal fractures; 561 boys (66%) sustained 637 fractures, and 289 girls (34%) experienced 314 fractures. The male:female ratio was 2:1 and incidence rates were greatest among 11-12 year-old girls and 14-year-old boys. The overall age- and sex-adjusted incidence of physeal fractures was 279.2 per 100,000 person-years (95% confidence interval, 261.4-296.9). The most common site was the phalanges of fingers, which accounted for 37% of all physeal fractures. Salter-Harris type II was the most common type of fracture (54%), but 149 fractures (16%) did not fit into this classification. Therefore, two new, previously unclassified fracture types were added and are reported in detail (see Physeal Fractures: Part 2. Two Previously Unclassified Types, pp. 431-38). This led to a review of existing classifications and creation of a new one (see Physeal Fractures: Part 3. Classification, pp. 439-48).

Fishtail deformity following fracture of the distal humerus in children: historical review, case presentations, discussion of etiology, and thoughts on treatment

Fishtail deformity is an uncommon complication of distal humeral fractures in children. This article reports four cases accompanied by premature closure of a portion of the distal humeral physis with resultant deformity, length retardation, decreased elbow motion, and functional impairment. The ages of the patients at time of injury ranged from 4 years 2 months to 6 years 1 month (average 5 years 4 months). The average length of follow-up was 9 years 9 months (range, 3 years 5 months to 18 years 10 months). The cause of the arrest is multifactorial and may be due to a gap in reduction of an intracondylar fracture, avascular necrosis of the epiphysis, or central premature physeal arrest (bar formation) without a fracture gap or avascular necrosis. If identified in a young child, surgical closure of the medial and lateral portion of the physis may prevent the deformity from progressing and would not cause significant additional humeral length discrepancy.

Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage

This is a review of 116 children who had a fracture of the proximal radial head or neck over a 15-year period. Of 33 teenagers with closed physes, 17 (52%) had intraarticular involvement. Of 83 younger children with an open proximal radial physis, six (7%) had an intraarticular fracture (Salter-Harris type III or IV). Of the 17 patients with closed physes and intraarticular fracture, 13 had adequate follow-up. There were eight excellent, three good, one fair, and one poor results. Of the six children with open physes and intraarticular fracture, there were one good and five poor results. This study confirms that intraarticular fracture of the radial head is much more common if the proximal radial physis is closed. In addition, this review indicates that the prognosis is extremely poor for children who have a radial head intraarticular fracture that also involves an open physis (Salter-Harris types III and IV), particularly when the fracture is treated initially nonoperatively. Displaced proximal radial fractures that involve both physeal and articular cartilage may be occult, and as with all physeal and intraarticular fractures, anatomic reduction (open if necessary) is mandatory.

Management of chronic posttraumatic radial head dislocation in children

We describe a new procedure for the management of chronic posttraumatic radial head dislocation, which uses two drill holes in the proximal ulna. The holes are placed at the original attachments of the annular ligament and thereby allow repair of the annular ligament (frequently avulsed from one attachment and impinged within the joint) or reconstruction of the annular ligament with whatever tissue or material desired (triceps tendon is convenient). It secures the radial head in its normal position from any dislocated position. It also allows for osteotomy of any accompanying deformity of the ulna or radius. This operation developed gradually between 1967 and 1995 while we treated seven female patients. The average age at time of injury was 5 years 10 months (range, 3 years 4 months to 8 years 11 months). The interval between injury and operation averaged 30 months (range, 3 months to 7 years). The age at time of surgery averaged 8 years 4 months (range, 5 years 4 months to 13 years 5 months). The only criterion for surgery was a normal concave proximal radial articular surface. Follow-up averaged 48 months. At final follow-up, all patients were fully active and had no elbow pain or instability. Analysis of these cases suggests that the criteria for surgical repair should be based on two features: (a) normal concave radial head articular surface, and (b) normal shape and contour of the ulna and radius (deformity of either should be corrected by osteotomy). The age of the patient and duration of the dislocation are unimportant.

Transiliac exposure of the sacrum: a new surgical approach

Biopsy or surgical approach of the midsacrum is difficult from the anterior, posterior, or superior approaches. I describe a lateral approach removing a piece of posterior ilium and entering the midsacrum through the sacroiliac joint. The approach was successfully used in an 8-year 7-month-old girl for the removal of an osteoid osteoma. The patient was monitored for 9 years 6 months until skeletally mature (age 18 years 1 month). This approach is applicable for biopsy or removal of benign tumors in the midsacrum in adults. Some developmental asymmetry of the pelvis may develop if it is used in children.

Isolated closed diaphyseal fractures of the femur in children: comparison of effectiveness and cost of several treatment methods

The effectiveness of several treatment modalities for isolated closed femur fractures in children ages 4 through 16 years is compared based on outcome (clinical results, morbidity, and parents' satisfaction) and cost. Between 1986 and 1993, 30 patients were treated. Treatment methods included immediate hip spica cast application, distal femoral skeletal traction pin to align the fracture followed by early hip spica cast incorporating the pin (6th day), in-hospital traction, primary external fixation, and primary intramedullary nailing. Average follow up was 4.1 years. Overall results were excellent with minimal morbidity for all treatment methods. Early application of hip spica cast with or without incorporation of the distal femoral traction pin required the fewest hospital days, the shortest time to union, and had the lowest overall cost. Complications, mainly malunion and femoral length discrepancy, however, were greater. Skeletal traction resulted in the longest hospital stay and was equal in cost to external fixation and intramedullary nailing. Primary external fixation appears most applicable in patients who are unlikely to tolerate early casting and who are at increased risk of avascular necrosis with femoral nailing. Patients treated with an intramedullary nail had the fewest complications. Age, size, and gender of patient, location and type of fracture, as well as social circumstances are all significant factors in choosing the optimal method of treatment.

Metatarsal lengthening: case report and review of literature

Shortening of one or more metatarsals may be a cause of metatarsalgia and painful toe deformity. Usually, symptoms are limited and may be successfully addressed with nonoperative treatment. Rarely, operation indicated. This report reviews the surgical techniques, results, and complications. These operations include osteotomy and one-stage distraction with bone grafting, osteotomy and one-stage distraction without bone grafting, osteotomy with gradual distraction and bone grafting, and osteotomy with gradual distraction without bone grafting.

A validity study of an implicit phonological awareness paradigm

The purpose of this investigation was to examine the validity of a nonsense-word-pairs paradigm as an implicit phonological awareness task. For this task one member of each nonsense-word-pair violated the rules of consonant combination in English (e.g., /integral kib/), and the other did not (e.g., /integral rib/). The subjects were required to choose the member of the pair that contained permissible consonant sequence(s). Eighty-one normally developing first- and second-graders were given the implicit phonological awareness task, 3 explicit phonological awareness tasks, 2 reading tasks, and a multisyllabic word production task. There were significant correlations between the implicit phonological awareness task and all of the experimental tasks, with the exception of one. Additionally, the implicit phonological awareness task was sensitive to developmental differences between the first- and second-grade readers.

Spinal column deformity and instability after lumbar or thoracolumbar laminectomy for intraspinal tumors in children and young adults

STUDY DESIGN

A retrospective study about the occurrence of spinal column deformity or instability after multilevel lumbar or thoracolumbar total laminectomy for removal of benign intraspinal tumors in children and young adults.

OBJECTIVES

To analyze the long-term clinical and radiographic outcome of these patients, and to specify factors that affect the occurrence of postlaminectomy spinal column deformity and instability.

SUMMARY OF BACKGROUND DATA

Spinal column deformity is not uncommon after multilevel cervical or thoracic laminectomies for removal of intraspinal tumors in children. Its incidence in the lumbar and thoracolumbar spine reportedly is low.

METHODS

Thirty-six consecutive patients (23 male, 13 female) underwent multilevel lumbar or thoracolumbar total laminectomy for removal of benign intraspinal tumors from 1966 to 1989. Twelve patients were aged 17 years or younger ("children and adolescents"; mean age, 11 years), and 24 were aged 18-30 years ("young adults"; mean age, 24 years). All patients had preoperative, immediate postoperative, and follow-up clinical and radiographic examinations.

RESULTS

At a mean follow-up period of 14 years (range, 4-28 years), six patients (16.6%) had spinal deformity (lordosis or thoracolumbar kyphosis associated with scoliosis), and four (11%) had spondylolisthesis. Spinal column deformity occurred in 33% of children and adolescents and in 8% of young adults. Spondylolisthesis occurred in 16.6% of children and adolescents and in 8% of young adults. Three patients had fusion for spinal column deformity. Pain was present in eight patients, and other neurologic signs and symptoms were found in 18. There was an increased incidence of postoperative spinal deformity in patients who had more than two laminae removed (P < 0.01) or a facetectomy performed at the time of the initial operation (P < 0.05). There was no association between the occurrence of the deformity and sex, neurologic condition after laminectomy, or length of follow-up period.

CONCLUSIONS

Spinal deformity or instability after multilevel lumbar or thoracolumbar total laminectomy is not uncommon in children and adolescents. Limiting laminae removal and facet destruction may decrease this incidence. Fusion may be required to correct post-laminectomy deformity and to stabilize the spine.

Radial opening wedge osteotomy in Madelung's deformity

Radiopalmar opening wedge osteotomy was used in 11 female patients (12 wrists) with Madelung's deformity who ranged in age from 9 to 31 years. Five patients met the radiographic criteria for generalized dyschondrosteosis. Clinically, there was dissatisfaction with the appearance of the wrist. The principal motion deficits were in radiocarpal extension and forearm pronosupination associated with varying degrees of discomfort with sustained activity. All had a decreased radioulnar angle, lunate subluxation shown radiographically, and various degrees of dorsal subluxation of the ulnar head. Indications for surgery were pain, limited motion, cosmetic appearance, and progressive deformity in two immature patients. Biplanar corrective opening wedge osteotomy of the radius was performed with iliac crest graft. Three patients had an added ulnar recession. Fixation was with a plate or Kirschner wire. Supplementary distracting external fixation was used in six cases. The follow-up period averaged 48 months. Pain relief in all patients was satisfactory. Range of motion and grip strength were not influenced. The radioulnar angle improved by 11 degrees, but lunate subluxation was minimally changed. Length of the forearm and bowed appearance of the forearm were improved. Reduction of the radioulnar joints was improved but remained incongruous.

MR imaging of physeal bars

PURPOSE

To determine if three-dimensional (3D) rendered and projection images derived from magnetic resonance (MR) imaging data are advantageous for the preoperative assessment of physeal bars.

MATERIALS AND METHODS

Fifteen patients with suspected physeal bars were examined with MR imaging. Gradient-echo sequences were used with both two-dimensional and 3D MR imaging techniques. The 3D rendered and projection images were then derived from the MR imaging data. Patients were categorized on the basis of the effect of MR images on the decision to perform physeal bar excision.

RESULTS

MR findings had either a moderate (n = 7) or a major (n = 6) effect on the surgical treatment of 13 patients (87%). They had no effect in two patients (13%) and were misleading in none.

CONCLUSION

MR imaging is an excellent modality for imaging physeal bars. Imaging data can be processed to yield both 3D rendered and projection physeal maps that are particularly useful in preoperative planning.

Triplane fracture of the distal radius: case report

A 14-year 4-month-old boy sustained a triplane fracture of the distal radius. Reduction and maintenance of reduction were achieved by closed manipulation and cast. The triplane fracture can occur in areas other than the distal tibia and distal humerus and can be successfully treated nonoperatively.

Osteochondritis dissecans of the femoral head in children and adolescents: a report of 17 cases

Osteochondritis dissecans of the femoral capital epiphysis is uncommon and is usually reported as a case report or in association with other diseases. This study reports 17 cases with the primary underlying diagnosis of Legg-Calvé-Perthes disease in seven, idiopathic in six, avascular necrosis following trauma in three, and avascular necrosis with previous infection in one. Twelve cases had long-term follow-up. Two cases in which no surgery was performed were followed for an average of 12.5 years; 10 cases in which surgery was performed were followed for an average of 16.1 years. Excision of the osteochondritis fragment was performed in six cases. It was necessary only to dislocate the hip to excise the lesion in five cases. No morbidity resulted from temporary surgical dislocation. Excision of the osteochondritis dissecans fragment allowed these six patients to return to fairly normal living during the time of follow-up.

Spontaneous fusion in scoliosis after instrumentation without arthrodesis

The technique of subcutaneous rod insertion without exposure of the curve has been proposed as a method of controlling the progression of scoliosis while allowing the spine to grow. We review the literature and present three patients whose spines spontaneously fused unexpectedly while undergoing this form of treatment. The fusion occurred posteriorly, and continued anterior growth led to increased deformity from the crankshaft phenomenon. Based on this experience, the authors recommend careful follow-up and early anterior fusion when the crankshaft phenomenon is observed.

Operative hysteroscopy: American Association of Gynecologic Laparoscopists' 1993 membership survey

The 1993 American Association of Gynecologic Laparoscopists' membership survey on operative hysteroscopy had 713 respondents reporting 14,707 procedures. Directed biopsy and endometrial ablation were the most commonly reported. The majority of operative hysteroscopies were performed for a complaint of abnormal bleeding (78%). The most frequent reported complication was uterine perforation not requiring transfusion (14.2/1000 procedures). The rates of water intoxication and pulmonary edema stayed essentially unchanged from 1991: 2/1000 in 1993 compared with 1.4/1000 in 1991. No deaths were reported this year. The consistency in rates of procedures performed and complications within the three surveys conducted in 1988, 1991, and 1993 add credibility to the data from these retrospective studies.

Physeal fractures: Part 2. Two previously unclassified types

This article describes two physeal fractures not previously classified. The first is a fracture completely across the metaphysis with extension to the physis. There is usually no extension of the fracture along the physis, as is seen with the Salter-Harris type II fractures. It is a common fracture, occurring in 15.5% of the Olmsted County study. The second previous unclassified fracture is one in which a portion of the physis is missing. This is always an open fracture, and, thus, always requires initial surgery. It almost always develops premature physeal closure and almost always requires late reconstructive surgery.

Physeal fractures: Part 3. Classification

Over the past 100 years, several attempts to classify physeal fractures have been made. Each new classification has made changes to the previously existing classifications. After review of these classifications and of data collected from a population-based study (see Physeal Fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988, pp. 423-30), a new classification was constructed. This classification includes two new fractures (see Physeal Fractures: Part 2. Two Previously Unclassified Types, pp. 431-38). This classification has sound anatomic, epidemiologic, and prognostic bases.

Opening-wedge osteotomy for angular deformities of long bones in children

Mild angular deformities associated with a mild limb-length discrepancy of long bones in children can be treated effectively with opening-wedge osteotomy with insertion of a specially prepared autogenous tricortical iliac-crest bone graft and with minimum or no internal fixation. Thirty-one osteotomies in twenty-six children satisfactorily corrected the deformities so that the angulation and length of the bone were comparable with the values on the normal, contralateral side. Physeal arrest or ipsilateral excision of a physeal bar was performed either concomitantly or at a separate operation in twenty-one of the twenty-six patients, to aid in the treatment of the limb-length discrepancy. Opening-wedge osteotomy is applicable for correction when the angular deformity is 25 degrees or less and the limb-length discrepancy is, or will be, twenty-five millimeters or less at maturity.

Deformities and problems of the forearm in children with multiple hereditary osteochondromata

Multiple hereditary osteochondromata is the most common benign bone tumor. Deformities of the forearm are the most frequent cause of functional impairment in these patients. The most common deformity is a combination of relative shortening of the ulna, bowing of the radius and/or ulna, increased ulnar tilt of the distal radial epiphysis, ulnar deviation of the hand, progressive ulnarward translocation of the carpus, and subluxation/dislocation of the proximal radial head. In addition to relative shortening and cosmetic displeasure, these deformities commonly produce limited forearm rotation, limited wrist motion, and, when the radial head dislocates, both elbow pain and loss of motion. This article reviews all surgical procedures currently in use, and attempts to synopsize the current thinking about how best to treat these deformities. Preventing and reducing progression of deformity and functional impairment, particularly radial head dislocation, remain paramount goals, and aggressive management is advocated.

Premature physeal arrest of the distal tibia associated with temporary arterial insufficiency

Premature physeal arrest may occur after various insults to the physis. Its association with diaphyseal fracture without obvious physeal damage is well known, but the cause is obscure. The case reported documents premature closure of the distal tibial physis of an infant after a temporary but significant episode of vascular insufficiency. Direct arterial occlusion or arterial spasm may account for some cases of physeal arrest associated with nonphyseal-related trauma.

Congenital endplate acetylcholinesterase deficiency

Endplate acetylcholinesterase (AChE) consists of globular catalytic subunits attached to the basal lamina by a collagen-like tail. Different genes encode the catalytic subunit and the tail portion of the enzyme. Endplate AChE deficiency was reported previously in a single case (Engel et al., 1977, patient 1). We describe here our observations in four additional patients (patients 2-5). Three cases were sporadic; patients 2 and 3 were sisters. All had generalized weakness increased by exertion but ophthalmoparesis was not a constant feature. All had mild slowing of the pupillary light reflex; other dysautonomic features were absent. None benefited from anticholinesterase therapy. All patients had a decremental electromyogram response; in four of the five patients, single nerve stimuli evoked a repetitive response. Miniature endplate potential amplitude was reduced in patient 5 only. Endplate amplitudes and currents were prolonged but the open-time of the acetylcholine receptor ion channel was normal. In patients 1-4 the quantal content of the endplate potential was reduced due to a reduced number of readily releasable quanta. Quantitative electron microscopy revealed abnormally small nerve terminals, abnormal encasement of the presynaptic membrane by Schwann cells and degeneration of junctional folds and of organelles in the junctional sarcoplasm. Acetylcholinesterase was absent from all endplates of all patients by cytochemical and immunocytochemical criteria. Density gradient ultracentrifugation of muscle extracts from patients 1, 3, 4 and 5 revealed an absence of the collagen-tailed form of the enzyme in patients 1, 3 and 4 but not in patient 5. The kinetic properties of the residual AChE in muscle were normal. Erythrocyte AChE activity and Km values, determined in three patients, were also normal. Studies of the catalytic subunit gene of AChE in patients 2 and 3 revealed no abnormality in those exons that encode the domain to which the tail subunit binds. In patients 1-4 the molecular defect is likely to reside in the gene encoding the tail subunit of AChE, or in a protein necessary to assemble the catalytic and tail subunits. In patient 5, the absence of AChE from the endplate may be due to a faulty tail subunit, a defect in the basal lamina site that binds the tail subunit or failure of transport of the assembled asymmetric enzyme from the cell interior to the basal lamina. The cause of the weakness in these patients is not fully understood but possible mechanisms are discussed.

Adolescent bunion deformity treated with double osteotomy and longitudinal pin fixation of the first ray

Surgical correction of bunion deformity in adolescents is performed infrequently. Double osteotomy and longitudinal pin fixation of the first ray was performed on 15 feet. This procedure is technically easy, provides excellent correction and stability, and has a low rate of recurrence of deformity. Five numerical determinations were obtained from preoperative, intraoperative, and final follow-up radiographs. They included intermetatarsal angle, first-fifth metatarsal angle, and metatarsophalangeal angle, first-second metatarsal distance, and length of the first and second metatarsals. The mean length of follow-up was 32.5 months. The operation is indicated for severe deformities and should be applicable to adults.

Meniscal cyst and magnetic resonance imaging in childhood and adolescence

We retrospectively reviewed 11 cases of meniscal cyst diagnosed at the Mayo Clinic from 1976 through 1990. Patient age ranged from 4 to 18 years (average 13 years). Two cases were diagnosed on clinical findings alone. Arthrograms were available in five cases. Magnetic resonance imaging (MRI) was used in four cases. These cases illustrate the difficulty in making the diagnosis of meniscal cyst. MRI is a useful tool for diagnosing meniscal cyst and aids in surgical planning. Because of the extensive differential diagnosis of the meniscal cyst, we recommend MRI in preoperative evaluation of soft tissue masses about the knee.

Physeal injuries of the distal humerus

Physeal injuries of the distal humerus comprise approximately 10% of all physeal injuries. Diagnosis of these injuries at a young age before the ossification centers have ossified and become visible radiographically is difficult. Poor outcome of distal humeral physeal injuries is not uncommon and can be best prevented by knowledge of anatomy and the use of all appropriate imaging techniques. The focus of this article is to correlate anatomy at different ages with the occurrence of specific injuries.

Premature partial physeal arrest. Diagnosis by magnetic resonance imaging in two cases

The management of premature physeal arrest requires accurate assessment of not only the location but also the extent of the bar. Numerous imaging techniques are available to evaluate the physis. Multiplanar tomography has proven to be the most precise method. The utility of magnetic resonance imaging (MRI) of physeal bars has not been demonstrated. This article presents MRI results in two cases of physeal bars. MRI provides a means of assessing physeal bar formation with an accuracy approaching that of multiplanar tomography. In certain instances, its efficacy may exceed that of tomography, specifically when the physis cannot be properly oriented for tomographic evaluation, when more planes are desired, and when radiation exposure is thought to be excessive. With improvement of its capabilities and availability (which may also reduce cost), it may become the diagnostic imaging technique of choice.

Radial growth plate injury in a female gymnast

Radial growth plate injury is a cause of wrist pain in female gymnasts. The mechanism of injury and its relationship to dowel grips, now standard gymnastic equipment, are considered. An athlete's response to a treatment approach emphasizing moderation and protection is described.

Surgical lengthening of the humerus: case report and review

This article reviews 12 cases of humeral lengthening accomplished by transverse midshaft osteotomy and gradual distraction by an external fixator attached to two half pins in the proximal and two half pins in the distal humeral fragments. Six cases were treated by second-stage (application plate, screws, and bone graft with removal of apparatus) and third-stage (removal of plate and screws) procedures. In the other six cases, the external apparatus was allowed to remain in place until the humerus united. There were few complications. There were no nonunions, delayed unions, malunions, or late fractures.

Management of ankle deformities in multiple hereditary osteochondromata

Nine patients with multiple hereditary osteochondromata underwent ankle surgery for valgus deformity. The indications for operation included pain from trauma of the prominent masses, pain in the ankle joint associated with the deformity, limited ankle motion, and undesirable cosmesis. The procedures included excision of osteochondromata, fibular lengthening, and medial tibial hemiepiphyseal retardation by inserting staples. Excision of osteochondromata as an isolated procedure relieved pain and improved cosmesis but did not alter the tibiofibular length discrepancy or the ankle valgus. Lengthening of the fibula and medial tibial hemiepiphyseal stapling, alone or in combination, corrected the valgus deformity of the ankle. At final follow-up (mean 43 months), no patient had pain or functional impairment.

Multiple hereditary osteochondromata

Multiple hereditary osteochondromata is a disorder consisting of multiple projections of bone (exostoses) capped by cartilage. The lesions are most numerous in the metaphyses of long bones but may appear on diaphyses of long bones and on flat bones and vertebrae. The transmission is autosomal dominant. Sarcomatous transformation is uncommon and probably occurs in fewer than 1% of patients. The more common indications for surgical excision of lesions are pain, growth disturbance, compromised joint motion, cosmesis, and secondary impingement of tendon, nerve, or vessel. Excision of the lesions is effective in relieving pain, improving cosmesis and joint motion, and removing secondary impingement of tendon, nerve, or vessel, and may retard or prevent progressive disturbance of osseous growth. Wrist and ankle deformities are often associated with relative shortening and bowing of the ulna and fibula, respectively; tilt and tapering of the distal radial and tibial epiphyses; and distal radioulnar and tibio-fibular diastasis. These deformities can be effectively treated by ulnar and fibular lengthening combined with hemiphyseal stapling of the distal radius and tibia. Progressive genu valgum is well corrected by placement of staples over the medial side of the physis of the distal femur or proximal tibia or both.

Dowel bone graft technique for triple arthrodesis in talocalcaneal coalition--report of a case with 12-year follow-up

Symptomatic talocalcaneal coalition can be treated surgically by either excision of the coalition or arthrodesis. The arthrodesis may be talocalcaneal, talonavicular and calcaneocuboid, or include all three joints (triple arthrodesis). Arthrodesis is indicated in talocalcaneal coalition when there is persistent pain, particularly if it is associated with deformity or degenerative changes. Arthrodesis that maintains normal contours of the foot, including its length and height, can be accomplished by the dowel technique described in this article.

Magnetic resonance imaging in early diagnosis of Legg-Calvé-Perthes disease

Two male patients, aged 6 and 9 years, were suspected of having unilateral Perthes disease because of typical symptoms and clinical signs. Roentgenograms, including scintigraphy, were normal. Magnetic resonance imaging (MRI) showed definite avascular necrosis in the affected hip. Roentgenograms subsequently also became positive for Perthes disease. These two cases document the advantages of MRI in early diagnosis of Perthes disease prior to development of typical radiologic changes.

Blount disease: a review of the English literature

A review of the English literature on Blount disease (osteochondrosis deformans tibiae; tibia vara) revealed that two forms of the disease, infantile and adolescent, are recognized. The cause of Blount disease is probably multifactorial. Most recent evidence on the pathogenesis implicates mechanical factors. The diagnosis can be difficult in very young children and must be based on history, physical examination, and radiographic findings. A proximal tibial metaphyseal-diaphyseal angle of greater than 11 degrees should be observed carefully for the development of Blount disease. Both nonoperative and operative treatment has been used successfully.

Skewfoot (forefoot adduction with heel valgus)

Skewfoot, a malalignment of tarsal and metatarsal bones, is recognized clinically by forefoot adduction and heel valgus. Synonyms include S-shaped foot, serpentine foot, and Z-foot deformity. Skewfoot must be differentiated from metatarsus adductus, metatarsus varus, and metatarsus adductovarus. Only 50 cases have been reported, and only two primary articles have been published in the English literature. Four patients who were treated at the Mayo Clinic are described. The ages of the patients at the time of presentation ranged from 6 months to 3 years. Three patients underwent operation. Because the natural history of skewfoot is unknown and pain is infrequent, treatment alternatives must be carefully considered. If operation is undertaken, realignment of the tarsal bones should be supplemented with hindfoot bone stabilization.