Management of scoliosis due to syringomyelia in childhood and adolescence

To determine the effect of syringomyelia treatment (drainage) on the efficacy of orthotic management and safety of operative management of an associated scoliosis, the records of four boys with scoliosis due to syringomyelia were reviewed. The average follow-up was 8 years. On presentation, all had an abnormal neurologic examination. Each syrinx was treated by laminectomy and insertion of a syringosubarachnoid shunt. After drainage, three of four improved neurologically. Two older patients underwent uneventful posterior spinal fusion with Harrington distraction instrumentation after their drainage procedures. One boy developed kyphosis at the site of his laminectomy. Two young patients, whose curves were initially well controlled with bracing, developed continued curve progression over time. Drainage of the syrinx delayed but did not prevent curve progression in immature patients, but did allow use of distraction instrumentation without complication for operative management of the associated scoliosis.

Digital radiography in pediatric orthopaedics: a prospective, controlled, and randomized trial

A prospective, controlled, and randomized trial of digital radiography was conducted to evaluate its advantages in children. Matched pairs of radiographs of the feet were taken in 20 children, and pelvic radiographs were taken in another 20 children. Each pair comprised a digital and conventional film. Half of the digital films were made with a 50% radiation dose reduction. The films were scored for quality. Statistically significant advantages were seen for the digital radiographs as compared with the conventional technique. Visualization of soft tissue and bony detail was enhanced in both foot and pelvic radiographs. This was true even with a 50% dose reduction in many of the parameters scored. We conclude that digital radiography offers advantages over conventional radiography, and recommend its use.

Ulnar nerve palsy following rotational osteotomy of congenital radioulnar synostosis

Two successive cases of ulnar nerve palsy following rotational osteotomy through a congenital radioulnar synostosis are described. Entrapment of the ulnar nerve by the fascia connecting the two heads of the flexor carpi ulnaris was documented in one patient. Recommendations to avoid this complication include shortening of the forearm at the osteotomy site and the release of unyielding soft tissue restraints. Rotational osteotomy at the distal radial metaphysis may provide a safe, alternative approach in the surgical management of this difficult problem.

Heel reconstruction with flexor digitorum brevis musculocutaneous flap

A 4-year-old girl with an extensive soft tissue loss of the left heel is presented. Management by debridement followed by coverage with an innervated flexor digitorum superficialis musculocutaneous flap resulted in primary healing. Full weight-bearing ambulation was resumed 8 weeks postoperatively. The patient has been ambulating on the reconstructed heel for 18 months without difficulty. Technical aspects of the reconstruction are presented as well as a discussion of treatment alternatives.

Cuneiform osteotomy of the femoral neck in severe slipped capital femoral epiphysis

From 1978 through 1988, 27 severe slipped epiphyses (Grade III) in 23 adolescent patients were treated with a cuneiform osteotomy of the proximal neck of the femur. Average time of followup was 8 years 5 months. The results were graded by the criteria of Southwick, with emphasis on pain, function, range of motion, and radiographic appearance. Arbitrarily, no hips were rated excellent, because the authors thought that this rating should be reserved for normal hips that have not had any disease process nor surgical procedure. There were 19 good, 4 fair, and 4 poor results. The 4 poor results were in patients with avascular necrosis. The avascular necrosis rate was 15%. Eight hips had some joint space narrowing during the postoperative followup period. All joint space narrowing was resolved by 20 months postoperatively. All patients, including those with avascular necrosis, improved in joint flexion and joint internal rotation. Although the avascular necrosis rate of 15% is significant, the authors believe that the potential for restoring hip anatomy and providing a normally functioning hip in the adolescent patient makes this procedure a viable treatment option.

Developmental dysplasia of the hip

OBJECTIVE

The definition and early treatment of congenital dysplasia of the hip are controversial. The purpose of this study was to discuss the reasons for changing the acronym to developmental dysplasia of the hip (DDH) and to address its early detection and treatment.

DESIGN

This multicenter study was designed to provide an updated assessment of the definition, pathologic anatomy, prevalence, etiology, natural history, early detection, and treatment of DDH.

RESULTS

DDH more accurately describes the condition previously termed congenital dysplasia of the hip. The disorder is not always present at birth (congenital) and an infant may have a normal neonatal hip screening examination and subsequently develop a dysplastic or dislocated hip. Developmental dysplasia encompasses the wide spectrum of hip problems seen in infants and children. Physicians should understand that a normal neonatal screening examination does not assure normal hip development. The diagnosis of developmental dysplasia is made by physical examination. The Ortolani and Barlow maneuvers were designed to detect a subluxatable, dislocatable, or dislocated hip in the neonatal period. In the older child, limited abduction becomes a more reliable sign. The examination is variable depending on the type of dysplasia and changes with growth. The ultrasound is proving to be a sensitive tool in confirming the diagnosis in newborns and infants from birth to 4 months of age. The ultrasound is also valuable in older infants in terms of documenting that the dysplasia is responding to treatment. However, the ultrasound depends on an experienced sonographer and, in some cases, may be too sensitive, resulting in overtreatment. After 3 to 4 months of age, an anteroposterior pelvis radiograph can confirm the diagnosis.

CONCLUSIONS

All newborns should have a neonatal hip screening physical examination. After screening, the hips should be re-examined during health examination visits at 2 weeks, 2 months, 4 months, 6 months, 9 months, and 1 year of age. If any question arises during these visits or if there are associated risk factors, we recommend an ultrasound if the infant is < 4 months of age or an anteroposterior pelvis radiograph if > 4 months of age.

The radiographic anatomy of the thoracic pedicle

A cadaveric study of the radiographic characteristics of the thoracic pedicle was performed. Dried vertebrae at T6 and T7 were mounted and x-rayed at varying angles. The relationship of the pedicles to wire markers, methyl methacrylate cores, and Cotrel Dubousset hooks was analyzed. The oval image of the pedicle on radiographs is its waist. This image narrows with axial rotation of the x-ray beam. The relationship of a correctly placed pedicle hook to its pedicle is radiographically unchanged by rotation. Conversely, an incorrectly placed hook cannot be made to appear in position by rotating the x-ray beam.

Digital radiography can reduce scoliosis x-ray exposure

Digital radiology is a new computerized system of acquiring x-rays in a digital (electronic) format. It possesses a greatly expanded dose response curve that allows a very broad range of x-ray dose to produce a diagnostic image. Potential advantages include significantly reduced radiation exposure without loss of image quality, acquisition of images of constant density irrespective of under or over exposure, and reduced repeat rates for unsatisfactory films. The authors prospectively studied 30 adolescents with scoliosis who had both conventional (full dose) and digital (full, one-half, or one-third dose) x-rays. They found digital made AP and lateral image with all anatomic areas clearly depicted at full and one-half dose. Digital laterals were better at full dose and equal to conventional at one-half dose. Cobb angles were easily measured on all one-third dose AP and on 8 of 10 one-third dose digital laterals. Digital clearly depicted the Risser sign at one-half and one-third dose and the repeat rate was nil in this study, indicating digital compensates well for exposure errors. The study indicates that digital does allow radiation dose to be reduced by at least one-half in scoliosis patients and that it does have improved image quality with good contrast over a wide range of x-ray exposure.

Operative treatment of ankle fractures in children

Fractures of the ankle (distal tibia) that involve the physis or the articular surface are one of the more common injuries for which operative treatment is indicated in children. It should be considered if accurate reduction of the articular surface, the physis, or both cannot be achieved by closed means. Operative treatment often will be required in Salter-Harris type III and IV fractures, juvenile Tillaux, and triplane fractures.

The effect of trimethaphan-induced hypotension on canine spinal cord blood flow. Measurement at different cord levels using radiolabelled microspheres

Controlled hypotension which is used during scoliosis surgery to improve operating conditions and minimize transfusion requirements may decrease spinal cord blood flow (SCBF). Previous studies using hydrogen washout, an invasive technique, have shown that trimethaphan-induced hypotension is associated with a decrease in SCBF, whereas hypotension induced with sodium nitroprusside or nitroglycerin is not. To determine whether the decrease seen with trimethaphan represented a generalized rather than regional spinal cord phenomenon, SCBF was measured at three separate cord levels (T2-3, 7-8, L2-3) using a noninvasive radionuclide-labelled microsphere technique. When the mean arterial pressure was reduced by 50%, SCBF decreased 35 to 45% at all levels of the cord examined, and remained at this reduced level during the period of hypotension. The results confirm that trimethaphan-induced hypotension is associated with a significant reduction in SCBF and that this occurs throughout the spinal cord during the period of hypotension.

Undetected posttraumatic instability of "stable" thoracolumbar fractures

A review of 106 consecutive patients who had operative stabilization of thoracolumbar fractures revealed that 16 patients had surgery 4 months to 13 years after injury, for chronic instability. In these 16 patients, there were 8 wedge-compression fractures, 6 flexion-distraction injuries, 1 burst fracture, and 1 fracture-dislocation. All six patients with flexion-distraction injuries and the two patients with either a burst fracture or a fracture-dislocation had good results. Only two of the eight patients with wedge-compression fractures had good results. We concluded from this study that: (a) instability that presents without a progressive spinal deformity may go unrecognized; (b) all types of spine fractures can produce chronic, painful instability; and (c) poor results predominate in wedge-compression fractures operated more than 13 months after injury, regardless of the type of surgical treatment rendered.

Foot deformity in hereditary onycho-osteodysplasia

A 30-year-old woman with hereditary onycho-osteodysplasia was examined. In addition to the classic tetrad of fingernail and toenail dysplasia, patellar aplasia, iliac horns, and radial head hypoplasia and dislocation, she also had scoliosis, proteinuria, and distinctive bilateral foot anomalies. The foot deformity consisted of a ball-and-socket ankle joint, valgus ankle, forefoot supination, and lateral subluxation at the tarsal-metatarsal joints. The literature showed that the radiographic findings of foot deformity in this dysplasia have never been reported in detail before. Evidence suggests that this distinctive pattern of deformity may be more common than previously appreciated.

Angular deformities of the lower limbs in children

Bowlegs and knock-knees are common concerns in the early years of life. For the majority of children, these problems represent normal physiologic development and they correct spontaneously. A few children will have pathologic malalignment, which may lead to functional or cosmetic problems that may require treatment, usually bracing and occasionally surgery. Physiologic varus and valgus and the common causes of pathologic malalignment, including Blount's disease, rickets, hereditary conditions, infection, and trauma are discussed.

Heel reconstruction with the deep circumflex iliac artery osteocutaneous flap

A patient with extensive loss of bone and soft tissue from the right heel is presented. The defect was reconstructed using an osteocutaneous flap based on the deep circumflex iliac vessels. Indications for this procedure include extensive loss of bone and soft tissue precluding the use of local flaps. A 30-month period has elapsed since her reconstruction. A single ulcer developed 13 months postoperatively that healed after flap revision. We feel that tailoring the flap to minimize redundancy at the initial operation, subsequent tissue excision if necessary, and reinnervation augment durability of the flap.

Arthrography in evaluation of birth injuries of the shoulder

Birth injuries of the shoulder and proximal humerus of infants can be difficult to evaluate on plain radiographs because of lack of ossification in the proximal humeral epiphysis. We here describe arthrography of the infant shoulder and advocate it as a useful diagnostic procedure in the evaluation of humeral fractures and brachial palsies. Two infants with birth injuries of the shoulder are described. The value of dynamic fluoroscopic evaluation of the injured joint in conjunction with arthrography is illustrated in evaluation of a brachial plexus palsy.

Effect of nitroglycerine-induced hypotension on canine spinal cord blood flow

Twenty-four mongrel dogs were anaesthetized with pentobarbitone and morphine sulphate. Neuromuscular blockade was achieved using pancuronium. Spinal cord blood flow was measured using the radionuclide microsphere and hydrogen washout methods before, during, and following nitroglycerine-induced hypotension. Heart rate, mean arterial pressure, cardiac output, pulmonary capillary wedge pressure, and acid-base balance were determined with each measurement. Mean arterial pressure was reduced by 50%. Spinal cord blood flow, as measured by the microsphere method, increased during the period of hypotension, whereas values obtained using the hydrogen washout method were not significantly different from those at normotension. No significant change in spinal cord blood flow was detected by either method after the application of spinal distraction. Nitroglycerine acts predominantly on venous capacitance vessels and it is postulated that perfusion pressure, and therefore flow, is maintained despite a reduction in arterial pressure.

Bilateral fracture of the pedicle of the second cervical vertebra in the young child

We report the cases of five children, six to eighteen months old, who had bilateral fracture of the pedicles of the second cervical vertebra. The children were treated with gentle cervical traction in mild extension or were maintained in near-anatomical reduction in a Minerva jacket or halo cast. The fractures united in four patients. One patient underwent fusion to stabilize the spine.

Autoimmunity to articular collagen in patients with osteoarticular syndromes

We studied the occurrence of autoimmunity to articular antigens in 39 patients with noninflammatory osteoarticular syndromes and 60 controls. Cell mediated immunity (CMI) was measured by assaying for leukocyte inhibitory factor (LIF) in supernates of mononuclear leukocytes cultured with native human collagen (types I, II, or III) or proteoglycan monomer. After stimulation with type II collagen, but not other antigens, 27/39 patients and 13/60 controls had positive LIF assays (p less than 0.001). In controls, but not in patients, CMI was associated with positivity for the HLA antigen DR4. No patient had antibodies to native type II collagen. These findings may reflect normal responses to articular injury or suggest that CMI contributes to the pathogenesis of osteoarticular syndromes. But they also emphasize that peripheral blood reactivity is not a certain reflection of synovial immunopathology.

The influence of trimethaphan (Arfonad)-induced hypotension with and without spine distraction on canine spinal cord blood flow

Controlled hypotension is used in scoliosis surgery to reduce the need for transfusion and to improve operating conditions, but there is concern that deliberate hypotension may decrease spinal cord blood flow (SCBF) and predispose the spinal cord to injury, particularly when it is distracted during Harrington instrumentation. To study the effect of deliberate hypotension on SCBF, the mean arterial pressure (MAP) was reduced to 50% of its normotensive value with trimethaphan (Arfonad) in dogs and the SCBF measured using the hydrogen washout technique with and without spine distraction. The SCBF was significantly reduced to half its normotensive value of 23.2 ml/min/100 gm to 11.4 ml/min/100 gm after hypotension was established. The SCBF remained significantly decreased compared with controls when measured at 30, 45, and 60 minutes following the induction of hypotension and also when hypotension was terminated. SCBF was not further reduced when 2 cm of spine distraction was added. These results show that induction of hypotension with trimethaphan is associated with a similar decrease in SCBF, which is maintained as long as the drug is used and that this effect continues after the drug is terminated and the MAP increases. Cautiously extrapolating these findings clinically would suggest that trimethaphan may not be the drug of choice for controlled hypotension during scoliosis surgery, despite its apparently favorable hemodynamic and hormonal responses.

MRI and CT evaluation of primary bone and soft-tissue tumors

Twenty-six patients with primary tumors of bone or somatic soft tissues underwent both magnetic resonance imaging (MRI) and computed tomography (CT); 15 of the patients had radionuclide bone scans as well. Only in a minority of cases did these tomographic methods provide information needed for diagnosis that could not be derived from the plain radiographs alone; however, for assessing the extent of the disease, both CT and MRI proved very valuable, particularly MRI. Specifically, MRI was superior to CT in delineating the extent of the neoplasms and their relation to surrounding structures in 21 of the patients, equal in four, and inferior in only one. Furthermore, in the 13 patients with tumors of long bone, MRI was judged superior to CT in visualizing marrow abnormality in 12 cases, and equal in only one case. Radionuclide scans demonstrated the lesions in 14 of the 15 cases; its primary utility was in excluding additional lesions. It is concluded that for these patients, MRI was the imaging method of choice in assessing the extent of bone and soft-tissue tumors.

The role of arthrography in the management of dysplasia epiphysealis hemimelica

Dysplasia epiphysealis hemimelica can be diagnosed on plain radiographs of the affected areas. However, double contrast arthrography in three new cases provided additional information. The cartilaginous portions of the lesion at the articular surface of the bone were precisely demonstrated, aiding the orthopedic surgeon in deciding which patients should have surgery and planning the extent of operation necessary.

The influence of induced hypotension and spine distraction on canine spinal cord blood flow

Deliberate hypotension is used in scoliosis surgery to reduce the need for blood transfusion and to improve operating conditions. There are concerns, however, that hypotension may decrease spinal cord blood flow (SCBF) and thereby predispose the spinal cord to ischemic injury, particularly when it is distracted during Harrington instrumentation. In a canine model, the mean arterial pressure (MAP) was reduced to 50% of the normotensive value with sodium nitroprusside and halothane to study its effects, with and without spinal distraction, on spinal cord blood flow measured by the hydrogen clearance technique. The induction of systemic hypotension resulted in a significant decrease in spinal cord blood flow from 15.7 +/- 1.1 ml/min/100 g (control) to 10.7 +/- 4.7 ml/min/100 g. This initial decrease in spinal cord blood flow returned to normotensive values by 35 minutes following the induction of hypotension, suggesting an autoregulatory effect. This indicates that the induction of deliberate hypotension to half its normotensive mean arterial pressure is associated with a significant decrease in spinal cord blood flow that returns to normotensive levels by 35 minutes. One and two centimeters of longitudinal distraction applied during systemic hypotension did not reduce spinal cord blood flow when it was applied at least 45 minutes after the hypotension was induced. Thus, when longitudinal stretch of a magnitude approximating that used clinically during Harrington instrumentation is applied in the presence of systemic hypotension, the normal SCBF is not reduced when the autoregulating system is functioning.(ABSTRACT TRUNCATED AT 250 WORDS)

Split posterior tibial-tendon transfers in children with cerebral spastic paralysis and equinovarus deformity

In the treatment of equinovarus deformity of the foot in children with cerebral spastic paralysis, to supplement heel-cord lengthening, we split the posterior tibial tendon and transferred its posterior half laterally into the peroneus brevis tendon. Thirty-seven operations were performed on thirty-one hemiplegic, quadriplegic, and diplegic children who were followed for a mean of eight years postoperatively (range, four to fourteen years), at which time twenty-six of the thirty-one children were skeletally mature. There were thirty excellent, four good, and three poor results. The results did not deteriorate with time. Thirty-two of thirty-four children with good or excellent results had functioning dorsiflexors of the foot and were brace-free postoperatively. The children who had a poor result had recurrent deformity, but none had development of a calcaneal or calcaneovalgus deformity.

Arthrography in the posttraumatic elbow in children

Radiographic interpretation of children's elbows after trauma can be perplexing because of the large proportion of unossified cartilage relative to bone. The numbers of ossification centers appearing at different ages also complicate the interpretation. This study summarizes arthrographic experience in 10 children who sustained elbow trauma. Nine children had arthrography performed 5-24 months after injury. Seven patients had supracondylar or condylar fractures, one patient had a proximal radial fracture, and two patients had suspected osteochondritis dissecans. Arthrography was useful in delineating the integrity of the joint surfaces and in identifying healed rotated fracture components, cartilaginous spurs, nonunion of unossified fragments, and the normal physis. A small scarred joint and intraarticular loose bodies also were demonstrated. Elbow arthrography, though clearly not indicated for all pediatric elbow trauma, can contribute valuable information in the complex elbow fracture.

Distal tibial physeal fractures in children that may require open reduction

Fractures of the distal end of the tibia in children often involve the physis. They are of particular importance because partial growth arrest can occur and result in angular deformity, limb-length discrepancy, or incongruity of the joint surface (or a combination of these). We evaluated the cases of thirty-two children who had a fracture leading to established partial growth arrest of the distal end of the tibia. Most of this group had had a Salter-Harris Type-III or Type-IV fracture. Twenty-eight of the fractures had been treated by gentle closed reduction and immobilization in a plaster cast. We also evaluated the cases of thirty-three children who were seen by us for treatment of an acute fracture; most of these were Salter-Harris Type-III or Type-IV fractures of the distal end of the tibia. Nineteen of the twenty acute Type-III or Type-IV fractures that were treated with accurate open reduction of the physis and internal fixation healed without growth disturbance, while five of the nine fractures that were treated by closed means formed a bone bridge, presaging a disturbance in growth. This study suggests that Salter-Harris Type-III and Type-IV, and perhaps Type-II, fractures of the distal end of the tibia commonly cause disturbance of growth in the tibia, and that anatomical reduction of the physis by closed or open means may decrease the incidence of these disturbances of growth, including shortening and varus angulation of the ankle.

Patency of anastomosed arteries and veins subjected to reapplication of microvascular clamps

One hundred and two rat femoral vessels, both vein and artery, were transected and repaired with a standard technique. After a 30-minute observation period, vessel clamps were reapplied in a standardized manner. The repairs were reexplored at 2 weeks. The results demonstrated no serious reduction in vessel patency in the first period or at the 2 week exploration. Reapplication of vessel clamps after an initial flow period post anastomosis does not have a significant effect on vessel patency.

Angular and torsional deformities of the lower limbs in children

Angular and torsional malalignments of the lower extremity in children are common problems for which parents seek orthopedic advice. Calcaneal valgus of the foot, internal tibial torsion, genu varus, genu valgus, and femoral anteversion are normally observed in infants and usually are corrected with growth. The majority of angular deformities are physiologic; however, it is important to distinguish those requiring further evaluation and treatment. Accurate examination and knowledge of the natural history of rotational and angular deformities allow accurate assessment of the child and sound advice to the parents. There is a trend away from the use of shoe modifications, Denis-Browne-type bars, and twister cables in treating these deformities. Surgical treatment is occasionally required, but the prerequisites in each case should be carefully observed.

Spontaneous ventral spinal epidural hematoma with anterior cord syndrome: report of a case

The authors report a case of spontaneous ventral thoracic epidural hematoma presenting as an anterior cord syndrome. The epidural hematoma ws evacuated through a posterolateral approach to the spinal canal. A disseminated intravascular coagulopathy appeared intraoperatively. By 3 months after operation the neurological deficits had cleared.

Esophagitis complicating scoliosis management with the Boston thoracolumbosacral orthosis

The design of the Boston thoracolumbosacral orthosis for scoliosis treatment may increase intragastric pressure, possibly causing reflux esophagitis. Early recognition and aggressive medical treatment of reflux may avoid esophagitis and the need to either abandon or modify conservative scoliosis management.

Facilitation of exchange transfusions with Scribner shunts in Reye's syndrome

Scribner shunts were placed in nine patients, who had clinical and laboratory evidence of Reye's syndrome and ranged in age from four to fifteen years, to facilitate repeated, rapid exchanges of large volumes of blood. A method of inserting the Scribner shunt is described. Over a period of 30 to 90 minutes, 3 to 8 units of blood were easily exchanged without hemodynamic or mechanical difficulties. There were no infections; all shunts were removed from survivors after four to eight days without permanent sequelae.