Showing papers in "Journal of Pediatric Orthopaedics in 1988"

Current techniques of limb lengthening.

Abstract: Limb lengthening is still a major procedure with potentially serious complications. It does not, however, deserve the reputation it gained over the last few years. With a proper understanding of the biology, biomechanics, and strategies of lengthening, excellent results can be consistently obtained with relatively few complications.

Analysis of 429 fractures in 189 battered children.

Abstract: To assess empirically the radiologic appearance of fractures among victims of child abuse, the charts and radiographs of 189 battered children exhibiting fractures (n = 429 total fractures) were studied. Approximately one-half of the patients had a single fracture. Bones most commonly fractured were the humerus, femur, and tibia; transverse fractures were the most common type. Of long bone fractures, the middle third (50%) and distal third (41%) locations were most prominent. Age, race, and gender were not associated with any particular long bone fracture type. Skull fractures were the only type more likely to be present in children aged less than 1 year than in older children (p less than 0.05, one-tailed). In the past, emphasis has been placed on corner fractures, fractures at different stages of healing, and injuries at several sites. Our results suggest that fresh single diaphyseal fractures are more common.

The Pavlik harness in the treatment of congenital dislocating hip: report on a multicenter study of the European Paediatric Orthopaedic Society.

Abstract: The results of functional treatment using the Pavlik harness in congenital dislocation and congenital dysplasia of the hip in children aged less than 11 months were examined by an EPOS study group. This study was conducted on 3,611 hips in 2,636 patients for a period of 1-9 years after treatment. The reduction rate was 92% in grade Tonnis 2 and 3; the healing rate was 80%. In children with dysplastic hips, the healing rate was 95.35%. Avascular necrosis of the femoral head was observed in 2.38%. The Pavlik harness is designed for outpatient treatment if the parents are compliant.

Mechanical factors in slipped capital femoral epiphysis.

Abstract: We performed three-dimensional force analyses on the hips of 50 normal patients and 50 patients with slipped capital femoral epiphysis to determine if mechanical factors alone could account for slips. We found that slipped epiphysis patients have reduced resistance to shear because of increased body weight and a decreased neck shaft-plate shaft angle. Slipped epiphysis patients have relative retroversion, and this generates increased sagittal plane shear stress at the proximal femoral growth plate. We suggest that, during running, these mechanical factors cause shear failure of the growth plate in obese adolescents.

Lateral humeral condylar fractures in children: a report of 47 cases.

Abstract: Forty-seven children with fractures of the lateral condyle were reviewed, 4 of whom were treated after a five month delay. The roentgenographic study revealed 4 different types of fractures according to the degree of displacement. Each type corresponded to precise anatomical lesions. In the treatment of recent fractures, we must distinguish between strictly undisplaced fractures, which can be immobilized in a cast, and other fractures, which require open reduction and internal fixation.

Tibial fractures in children: follow-up study.

Abstract: One hundred seventeen children with tibial shaft fractures were treated by above knee cast with or without traction depending on stability. All fractures united in an average period of 37 days. Reevaluation after 3-10 years showed that initial shortening, fracture type, fracture location, and age of the patient affected growth acceleration, whereas the initial angular magnitude, direction, and planes, as well as the type of the fracture, the age of the patient, and length of follow-up period, affected correction of angulation. We concluded that: shortening can be compensated by growth acceleration; varus deformities can undergo spontaneous correlation whereas valgus deformity and posterior angulation partially persist and rotational deformities persist. Language: en

Radial head and neck fractures in children.

Abstract: This report is a review of long-term results of 42 consecutive fractures of the neck of the radius in children. More than half the patients were followed for greater than 4 years. The results were assessed clinically and radiologically at 6 months and at review. Twenty-seven children (64%) had a good result, 2 (5%) had a fair result, and 13 (31%) had a poor result. Primary angulation was the most important factor affecting the results. Periarticular ossification, avascular necrosis, enlargement of the radial head and of the proximal end of the radius were the most important causes of poor results. Unlike other fractures with unpredictable results, more accurate reduction is mandatory to improve the final outcome.

Chronic recurrent multifocal osteomyelitis: a follow-up study.

Abstract: Thirteen children/adolescents and two young adults with unifocal or multifocal nonpyogenic inflammatory bony lesions with a prolonged, fluctuating course are reported. The lesions were most often located at the metaphyseal region of tubular bones and the clavicle, but also at the spine, ischiopubic bone, and the sacroiliac joint. Progressive sclerosis and hyperostosis occurred mostly in the clavicle and occasionally in the tibia, femur, metatarsal, and ischiopubic bone, linking the changes to those described under the name Garre osteomyelitis. Seven patients had pustulosis palmoplantaris, and the skeletal disorder may be regarded a form of pustulotic arthroosteitis.

Congenital constriction band syndrome

Abstract: A retrospective study of 55 patients with congenital constriction band syndrome was performed. Multiple extremity involvement was found to be the most common clinical feature associated with the disease, and 34% of the patients studied were premature at birth. Malformations included constriction bands, clubfoot, intrauterine amputation, syndactyly, and acrosyndactyly (fenestrated syndactyly). The extremities were most often affected distally, involving the longer central fingers and medial two toes. More proximal involvement with constriction bands was associated with a higher frequency of neurologic deficit. Significant leg-length discrepancy exceeding 2.5 cm was seen in 9 of 38 patients (24%) with lower extremity involvement, a condition that has not been previously reported.

Convex growth arrest for progressive congenital scoliosis due to hemivertebrae.

Abstract: Thirteen patients with progressive congenital scoliosis due to hemivertebrae or hemivertebrae associated with other spinal anomalies were treated by convex anterior and posterior hemiarthrodesis and hemiepiphysiodesis. The average curve prior to operation was 46 degrees, average age was 3 years 6 months, and average followup was 6 years 6 months. One patient failed because of an inadequate length of anterior surgery which was successfully salvaged by further surgery. Twelve patients were successes: Seven had only cessation of the progressive curve, and five had progressive curve improvement greater than or equal to 5 degrees due to the arrested convex and persistent concave growth. This procedure is a valuable treatment modality for selected patients with congenital scoliosis.

The evolving slope of the proximal femoral growth plate relationship to slipped capital femoral epiphysis.

Abstract: We measured the physeal angle (slope) of the proximal femoral physis on the standard anteroposterior (AP) radiographs. Controls consisted of 307 hips in children aged 1-18 years. Similar measurements were made on the affected (slip) and unaffected (nonslip) sides of 107 children with manifest unilateral slipped capital femoral epiphysis. An age-related increase of 14 degrees occurs in the slope of the proximal femoral physis between ages 1 and 18 years, with maximal increase between ages 9 and 12 years. Increasing obliquity of the proximal femoral physis may be yet another factor contributing to slipped capital femoral epiphysis.

Differentiation of idiopathic toe-walking and cerebral palsy.

Abstract: Kinematic data were collected on two groups of children with diagnoses of idiopathic toe-walking and mild spastic diplegia. Although both groups lacked a heel strike at initial contact, two distinct gait patterns were found. The toe-walkers displayed a variable pattern of ankle motion with moderate to severe plantarflexion at stance. The cerebral palsy patients showed a repeatable gait pattern with only minimal deviation from normal. The absence of a heel strike in this group is due to the sustained knee flexion at terminal swing and initial contact, which was significantly greater than in the toe-walkers.

Mechanical induction of osteogenesis: the importance of pin rigidity.

Abstract: Eight dogs, divided into two groups of four by varying pin rigidity, underwent 15% left tibial lengthening by the Ilizarov method. In group I, "tensioned" 1.6-mm wires maintained a rigidity approaching that of 4.0-mm pins. In group II, the wires, maintained at half the tension, averaged 45% of the rigidity measured in group I. All dogs in group I filled the experimental gap with de novo osteogenesis, whereas all of the dogs in group II prematurely bridged the gap, arresting the process of osteogenesis. From these experimental results, clinical trials have been started using commercially available external fixation devices utilizing pins with equivalent rigidity.

Brace-wear compliance in patients with adolescent idiopathic scoliosis.

Abstract: Thirty-eight full-time and 38 part-time unselected brace wearers treated during a 7-year period were interviewed in a retrospective study to determine actual brace-wear compliance. Actual compliance was found to be lower than reported by patients during clinic visits and was much lower than reported in previous series. Only 15% of patients were highly compliant. On average, patients wore their braces 65% of the time they were instructed to do so. The reasons for low compliance in brace wear are unclear.

Complications of intramedullary rods in osteogenesis imperfecta: Bailey-Dubow rods versus nonelongating rods.

Abstract: Twenty-nine patients with osteogenesis imperfecta underwent 108 intramedullary roddings with 42 Bailey-Dubow rods and 66 nonelongating rods. The average age at insertion of the first rod was 5 years; average follow-up was 3.1 years (range 1-9 years). The overall complication rate was 60%-69% for Bailey-Dubow rods and 55% for nonelongating rods. Forty-seven percent of bones receiving rods required reoperation. Nonelongating rods had a 29% reoperation rate and a 24% replacement rate; Bailey-Dubow rods had a 19% reoperation rate and a 12% replacement rate.

Pulmonary function and scoliosis in Duchenne dystrophy.

Abstract: Summary: Pulmonary function data were evaluated in 68 Duchenne muscular dystrophy patients to determine the rate of decline of the percentage of normal forced vital capacity (FVC). The percentage of normal FVC declined most rapidly during the adolescent growth spurt, which demonstrated a need for an accurate and reliable means for determining height in these patients. The age at 35% of normal FVC was 14.9 ± 3.6 years (2 SD), and survival for the 28 patients who died was 3.2 (range 0.2-5.7) years. Pulmonary function tests were performed 10-74 months after spinal stabilization on 21 Duchenne dystrophy patients and compared with 46 nonfused scoliotic Duchenne patients. No difference was found in the rate of deterioration of the percentage of normal FVC.

Skeletal age estimation in leg length discrepancy.

Abstract: Sixty hand radiographs of children with known leg length discrepancy were reported independently in a "blind" manner by four radiologists using the Greulich and Pyle Atlas. Significant variation was found. Fifty percent of the children were assigned a skeletal age that differed by more than 1 year between radiologists; 10% varied by more than 2 years (p less than 0.05). Female skeletal age was considerably underestimated by an average of 11 months. Skeletal age estimation is one source of error in the timing of surgery for leg length equalization, especially when a single estimate is used. Skeletal age also appears to be more variable in children with leg length discrepancy.

Neuromuscular: atlantoaxial instability in individuals with down syndrome, a fresh look at the evidence

Abstract: In 1984, the Committee on Sports Medicine of the American Academy of Pediatrics published in this journal a statement on the remarkably high incidence of atlantoaxial instability among individuals with Down syndrome. On the assumption that this instability, demonstrable through a specified series of lateral x-ray films of the neck, constituted a predisposition to cervical spine dislocation with subsequent spinal cord compression, the Academy supported and made more specific a series of recommendations that had originated from the Kennedy Foundation a year previously. In essence, for those persons who are found to have the radiographic sign of instability, participation in sports should be restricted. Because the implementation of these recommendations could deprive tens of thousands of individuals with Down syndrome of activities that are emotionally and physically beneficial and because of the rarity of reported cervical dislocations associated with injury, a case review was done. Included were those cases cited as support for the recommendations along with additional reports that had been omitted and a few cases reported subsequently. Little support for the hypothesis that atlantoaxial \"instability\" is a predisposing factor to \"dislocation\" was found, although much was found to indicate an urgent need for carefully designed longitudinal studies. Because nearly all of the cases of actual dislocation were preceded by at least several weeks of readily detectable physical signs, a physical examination with careful attention to neurologic signs prior to participation in sports is more predictive of potential or impending dislocation than the radiologic criteria currently recommended.

Ambulation in Patients with Myelomeningocele: A Multivariate Statistical Analysis

Abstract: Factors determining ambulation in 163 patients with myelomeningocele were studied by a multivariate statistical method. Neurological dysfunction unrelated to the plaque was analyzed by magnetic resonance imaging. There were no ambulators at the thoracic or L1-L2 level. At the L3 level, 54% ambulated, and at the L4 level, 67% ambulated. Eighty percent were ambulators at L5 and all at the sacral level. Below L1-L2, one-half of the nonambulators had neurological deficiencies caused by syringohydromyelia or Chiari malformations preventing ambulation. Severe scoliosis was closely, age moderately, and hip flexion contracture slightly related to the inability of the other nonambulators to walk, while pelvic obliquity, hip dislocation, or knee flexion contracture was not.

Shaft forearm fractures in children: intramedullary nailing with immediate motion: a preliminary report.

Abstract: Nailing is a good solution for shaft forearm fractures in children who require surgery. A closed reduction is very often possible owing to the bent tip of the pins. The procedure avoids extensive dissection, unlike epiphyseal plates. When a nailing is performed, the distal approach for both bones is the most convenient, avoiding elbow pain on the proximal ulnar incision. Six children of 57 had unacceptable reduction following conservative treatment and underwent intramedullary fixation. An immediate mobilization was possible in all patients. We observed neither delays in union nor recurrent fractures. The range of motion was normal in the postoperative period and at the 1 year follow-up.

Fractures in premature infants.

Abstract: Fractures not related to birth trauma were diagnosed in 1.2% of preterm infants between the 24th and the 160th day of life. The clinical and radiologic findings as well as the follow-up on 12 preterm infants with one or more fractures were reviewed. Fractures occurred either in the ribs or long bones or both. Their clinical history, the radiographic appearance, and laboratory data suggest that most of the infants may have suffered from bone loss associated with low intake of calcium and phosphorus. Improving the metabolic status and removing the risk factors prevented further fractures and led to good healing.

Treatment of spastic equinus by aponeurosis lengthening.

Abstract: The aponeurosis lengthening described in this study was performed on 156 patients (219 procedures) with spastic equinus deformities. There was only one wound complication and no calcaneus deformities from overlengthening. The recurrence rate requiring relengthening was high (48% of the procedures), particularly if the initial operation was performed before the age of 5 years. The length of postoperative immobilization did not affect the recurrence rate. The aponeurosis lengthening technique described is a simple lengthening of the aponeurosis, leaving the soleus largely intact without the use of internal sutures. It has a negligible complication rate, but a high rate of recurrent equinus.

Clubfoot analysis with three-dimensional computer modeling.

Abstract: Which way are the bones rotated in a clubfoot? This question has long been debated by clubfoot surgeons. Opinions have been based on observations from surgery, radiographs, and autopsies. These methods all have pitfalls and are subject to misinterpretation. We used three-dimensional computer modeling to analyze histologic sections of a newborn clubfoot and a newborn normal foot. Relative to the bimalleolar axis in the axial plane, the normal talus demonstrated 5 degrees of internal rotation of its body and 25 degrees internal rotation of its neck. The clubfoot talus showed 14 degrees of external rotation of its body and 45 degrees of internal rotation of its neck. The calcaneus was externally rotated 5 degrees in the normal foot and internally rotated 22 degrees in the clubfoot.

Maturation factors in slipped capital femoral epiphysis.

Abstract: Several maturation factors relative to growth and epiphyseal development were reviewed retrospectively in 191 patients with slipped capital femoral epiphysis, including bone age, height and weight, thyroid functions, sex hormone levels, and growth hormone levels. Seventy-one percent of 138 patients had weights above the 80th percentile. Active thyroid (T3) was significantly low in 25% of 80 patients studied. Testosterone levels were markedly depressed in 76% of 64 patients tested. In this same group, 87% had low growth hormone levels. The consistently low testosterone and growth hormone levels, along with a tendency toward hypothyroidism, lend support to the biochemical theory of a delicate hormonal imbalance in slipped capital femoral epiphysis.

Macrodactyly of the hands and feet.

Abstract: Fifteen new cases of macrodactyly of the hands and feet are presented. These cases were combined with those already reported in the literature to determine if lesions of the upper extremity are clinically the same as those in the lower extremity. Similarities were found in the incidence, specific digits involved, multiplicity of digital involvement, and sex ratio. Differences were found in growth behavior, extent of bony involvement, and presence of neural involvement. These findings suggest that this rare, usually isolated, congenital anomaly may be two distinct entities.

Relationship of iliac crest maturation to skeletal and chronologic age.

Abstract: Risser's sign, a measure of the excursion of the iliac crest apophysis, has been used to estimate remaining skeletal growth. We used the Brush-Bolton Collection to correlate iliac crest excursion with other roentgenographic standards of skeletal age. Iliac crest excursion was measured using Risser's technique. We were able to determine mean chronologic and skeletal ages for each Risser stage for boys and girls. The state of maturation of the iliac crest apophysis, together with clinical observations of secondary sexual maturation, permit an accurate assessment of skeletal maturation without the need for wrist and hand roentgenograms.

Grice subtalar arthrodesis followed to skeletal maturity

Abstract: A retrospective review of 45 patients (62 feet) who had undergone a Grice subtalar arthrodesis and who had reached skeletal maturity was undertaken. Preoperative deformities were due to flaccid and spastic paralysis, as well as congenital abnormalities. There were failures in 32% and poor results in 61%. Unrecognized ankle valgus, overcorrection of the hindfoot into varus, uncorrected calcaneus deformity, and anterior graft orientation largely contributed to the poor results. Weight-bearing radiographs of the feet and ankles are necessary to distinguish ankle valgus from hindfoot valgus. A subtalar arthrodesis cannot be used to compensate for ankle valgus, nor can it be used to correct the calcaneus component of a deformity without appropriate muscle-balancing procedures or osteotomies.

Oblique tibial osteotomy for Blount's disease (tibia vara)

Abstract: Nine oblique proximal tibial osteotomies were performed on six children with genu varum, all but one of whom had Blount's disease. The osteotomy was a single-plane cut allowing simultaneous correction of varus and internal rotation and permitting postoperative cast wedging if necessary to improve position. All osteotomies healed within 10 weeks. The major complications were three episodes of weakness of the extensor hallucis longus, two of which resolved in 4 days and one of which resolved only partially. We were able to combine the osteotomy with other procedures, such as epiphyseal bar resection. All nine osteotomies achieved the desired correction of deformity.

Sports medicine: hip and pelvic injuries in the young athlete

Abstract: Hip and pelvic injuries are relatively rare in the young athlete. Contusions and musculotendinous sprains are the most common injuries about the hip and pelvis. Apophyseal avulsion fractures and stress fractures are the most frequently encountered skeletal injuries. Each of these entities can be successfully treated with guided physical therapy following conservative management with rest, anti-inflammatory medications, and ice massage until the patient is pain free. Epiphyseal, diaphyseal, or pathologic fractures are rare entities that are secondary to violent trauma. These injuries are severe and often require operative intervention. Femoral neck fractures have a high rate of complications from avascular necrosis, nonunion, or malunion. Pelvic fractures have frequent associated genitourinary, abdominal, neurologic, and musculoskeletal injuries. Pathologic fractures are most commonly secondary to benign lesions, such as unicameral bone cysts, and less likely owing to malignancy. Finally, in children with hip pain during athletic activities, even with antecedent trauma, the sports clinician must screen for slipped capital femoral epiphysis, Perthes' disease, congenital subluxation of the hip, toxic synovitis, systemic neoplasia, or infectious process.