Should paediatricians initiate orthopaedic hip dysplasia referrals for infants with isolated asymmetric skin folds?

PURPOSE

Asymmetric skin folds (ASFs) have been linked to developmental dysplasia of the hip (DDH) in select studies, leading to their inclusion in paediatric practice guidelines regarding orthopaedic referral for hip evaluation. The purpose of this study was to investigate the utility of isolated ASFs as a screening tool for DDH in a series of patient referrals evaluated at a single institution.

METHODS

We performed a retrospective review of consecutive patients between 0 and 12 months of age referred to orthopaedic clinics for isolated ASFs. We recorded radiographic findings (acetabular inclination or alpha angle), diagnosis rendered and treatment administered.

RESULTS

A total of 66 patients were included (mean age 6.4 months; 2.47 to 10.76). All patients received pelvic radiographs or ultrasound. In all, 36 patients (55%) were considered normal by their treating physician and 25 (38%) were considered dysplastic and underwent brace treatment. One hip with an isolated ASF was found to have a dislocated hip on radiograph prior to their initial orthopaedic visit. None of the patients in this study have required surgery to date.

CONCLUSION

Using ASFs as a reason for referral led to increased diagnosis of mild dysplasia resulting in orthotic treatment. Thus, in our particular clinical environment, isolated ASFs can be an indicator of mild dysplasia and warrant further workup or referral. Because treatment philosophies regarding recognition and treatment of mild dysplasia vary amongst centres, the value of screening with ASFs likewise depends on the treating orthopaedic surgeon's threshold for treatment of mild dysplasia.

LEVEL OF EVIDENCE

Level IV- Retrospective.

Comparing the Pemberton osteotomy and modified San Diego acetabuloplasty in developmental dysplasia of the hip

PURPOSE

Patients with developmental dysplasia of the hip (DDH) may require a pelvic osteotomy to treat acetabular dysplasia. The Pemberton osteotomy and modified San Diego acetabuloplasty are two options available when surgically treating DDH. The purpose of this study was to compare outcomes following the Pemberton and modified San Diego when treating patients with acetabular dysplasia in typical DDH.

METHODS

We included 45 hips in the modified San Diego group and 38 hips in the Pemberton group. Hips with less than two years follow-up and patients with a neuromuscular diagnosis were excluded. Clinical outcomes were rated using the modified McKay criteria with radiographic outcomes graded using the Severin score. Avascular necrosis (AVN) was assessed using the Kalamchi and MacEwen criteria.

RESULTS

Mean follow-up was 4.9 years (2.1 to 11.2). Both procedures produced similar decreases in the acetabular index (modified San Diego: 17.0˚ versus Pemberton: 15.2˚; p = 0.846). Most hips had good/excellent results using the modified McKay criteria (modified San Diego: 78%, Pemberton: 94%; p = 0.055). Most hips were rated as good/excellent on the Severin scale (modified San Diego: 100%, Pemberton: 97%, p = 0.485). The proportion of hips with AVN grade 2 or higher were similar between groups (modified San Diego: 0%, Pemberton: 3%; p = 0.458).

CONCLUSION

The modified San Diego acetabuloplasty is a safe and effective alternative to treat acetabular dysplasia in patients with typical DDH. By maintaining an intact medial cortex, acetabular reshaping can be customized to address each patient's specific acetabular deficiency.

LEVEL OF EVIDENCE

Level III retrospective comparison.

The aetiology of the non-ossifying fibroma of the distal femur and its relationship to the surrounding soft tissues

PURPOSE

We aim to retrospectively evaluate patients with non-ossifying fibroma (NOF) of the distal femur by radiographs, CT and MRI, and to provide a theory describing the reasoning for the distal femur NOF's location and aetiology.

METHODS

Charts of patients with NOFs between 2003 and 2014 were retrospectively reviewed. Inclusion criteria encompassed a diagnosis of NOF of the distal femur by imaging, and histologically, if available. Radiographs, CT and MRI were used to characterise the relationship of the NOF lesions with the surrounding soft tissues.

RESULTS

The 68 NOFs from 60 patients were included. By radiograph, 41 (60.3%) of the 68 lesions appeared at the medial and 25 (36.7%) at the lateral aspect of the distal femur. In total, 41 lesions had CT scans, showing 22 NOFs (53.7%) attached to the origin of the medial gastrocnemius, 12 (29.3%) to the origin of the lateral gastrocnemius and four (9.8%) at the attachment of the adductor magnus. Of the CT scans, 93% identified the NOF's relationship with an adjoining tendon of the distal femur. Six had MRIs, all of which showed attachment at the medial gastrocnemius.

CONCLUSION

The study reveals a relationship between tendinous structures and NOFs. NOFs of the distal femur occur most commonly at the origin of the medial and lateral gastrocnemius. They may originate from the physis/metaphysis but they do not always attach to the physis, as we observe them 'migrating' as patients grow. More research is required to understand the exact aetiology of NOFs.

Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis

We describe six patients aged from 10 to 15 years who, after injury to the distal tibial physis, presented with the following clinical findings: 1) severe pain and swelling of the ankle; 2) hypoaesthesia or anaesthesia in the web space of the great toe; 3) weakness of extensor hallucis longus and extensor digitorum communis; and 4) pain on passive flexion of the toes, especially the great toe.

In four patients, the fractures were not reduced for more than 24 hours. The intramuscular pressure beneath the superior extensor retinaculum of the ankle was greater than 40 mmHg in all cases (40 to 130 mmHg), and less than 20 mmHg in the anterior compartment. Treatment consisted of release of the superior extensor retinaculum and stabilisation of the fracture. All patients had prompt relief of pain and improved strength and sensation within 24 hours, although two had some residual numbness in the web space of the great toe.

Extensor retinaculum syndrome of the ankle after injury to the distal tibial physis

We describe six patients aged from 10 to 15 years who, after injury to the distal tibial physis, presented with the following clinical findings: 1) severe pain and swelling of the ankle; 2) hypoaesthesia or anaesthesia in the web space of the great toe; 3) weakness of extensor hallucis longus and extensor digitorum communis; and 4) pain on passive flexion of the toes, especially the great toe. In four patients, the fractures were not reduced for more than 24 hours. The intramuscular pressure beneath the superior extensor retinaculum of the ankle was greater than 40 mmHg in all cases (40 to 130 mmHg), and less than 20 mmHg in the anterior compartment. Treatment consisted of release of the superior extensor retinaculum and stabilisation of the fracture. All patients had prompt relief of pain and improved strength and sensation within 24 hours, although two had some residual numbness in the web space of the great toe.

Compartment syndromes

The compartment syndrome is defined as a condition in which high pressure within a closed fascial space (muscle compartment) reduces capillary blood perfusion below the level necessary for tissue viability'. This condition occurs in acute and chronic (exertional) forms, and may be secondary to a variety of causes. The end-result of an extended period of elevated intramuscular pressure may be the development of irreversible tissue injury and Volkmann's contracture. The goal of treatment of the compartment syndrome is the reduction of intracompartmental pressure thus facilitating reperfusion of ischaemic tissue and this goal may be achieved by decompressive fasciotomy. Controversy exists regarding the critical pressure-time thresholds for surgical decompression and the optimal diagnostic methods of measuring intracompartmental pressures. This paper will update and review some current knowledge regarding the pathophysiology, aetiology, diagnosis, and treatment of the acute compartment syndrome.

Preossified longitudinal epiphyseal bracket of the foot: treatment by partial bracket excision before ossification

The longitudinal epiphyseal bracket is a rare ossification defect of tubular bones in the hand and foot. This deformity contains an abnormal secondary ossification center, which may lead to progressive shortening and angular deformity of involved bones. This article describes the results from early treatment of this deformity before the secondary ossification center ossifies. Four patients with seven involved bones (5 metatarsals and 2 phalanges) were treated with surgical excision of the longitudinal epiphyseal brackets, without corrective osteotomy. The average age at surgery was 16 months (range, 6-20 months), and the average follow-up period was 55 months (range, 31-80 months). All five metatarsal patients demonstrated progressive improvement in the deformity. Of the two phalanx patients, one improved and the other did not. Early treatment of the longitudinal epiphyseal bracket before ossification of the secondary center with excision is effective in correcting this deformity. Long-term follow-up assessment until skeletal maturity is necessary to assess the final results of surgery because corrective osteotomy may be necessary for patients who do not have adequate correction.

Altered fibular growth patterns after tibiofibular synostosis in children

BACKGROUND

Iatrogenic synostosis of the tibia and fibula following an operation on the leg in a child has been reported rarely in the literature, and the effects of this complication on future growth, alignment, and function are not known. This is a retrospective case series, from one institution, of crossunions of the distal parts of the tibia and fibula complicating operations on the leg in children. The purpose is to alert surgeons to this possible complication.

METHODS

The senior author identified eight cases of iatrogenic tibiofibular synostosis seen in children since 1985. The patients had various diagnoses and were from the practices of four pediatric orthopaedic surgeons. Synostosis developed in six patients after osteotomies of the distal parts of the tibia and fibula, in one after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision, and in one after posterior transfer of the anterior tibialis tendon through the interosseous membrane combined with peroneus brevis transfer to the calcaneus. Medical records were reviewed, and preoperative and follow-up radiographs were analyzed for changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle.

RESULTS

Five patients were symptomatic after crossunion; they presented with prominence of the proximal part of the fibula, ankle deformity, or ankle pain. Three patients were asymptomatic, and a synostosis was identified on routine follow-up radiographs. Intraoperative technical errors caused two of the crossunions; the cause of the others was unknown. Following tibiofibular synostosis, growth disturbances were noted radiographically in every patient. The normal growth pattern of distal migration of the fibula relative to the tibia was reversed, resulting in a decreased distance between the proximal physes of the tibia and fibula as well as proximal migration of the distal fibular physis relative to the distal part of the tibia. Shortening of the lateral malleolus led to greater valgus alignment of the ankle.

CONCLUSIONS

Tibiofibular synostosis can complicate an operation on the leg in a child. After crossunion, the normal distal movement of the fibula relative to the tibia is disrupted, resulting in shortening of the lateral malleolus and ankle valgus as well as prominence of the fibular head at the knee. The synostosis also interferes with the normal motion that occurs between the tibia and fibula with weight-bearing, potentially leading to ankle pain.

Congenital coxa vara: computed tomographic analysis of femoral retroversion and the triangular metaphyseal fragment

Three patients with congenital coxa vara studied with two- and three-dimensional computed tomographic (2DCT and 3DCT) methods are reported. In all cases, the femoral retroversion was documented and subsequently corrected by proximal femoral osteotomy. In two patients with isolated coxa vara, the physeal-femoral neck angle was decreased as seen in slipped capital femoral epiphysis in adolescents. Our studies suggest that the triangular metaphyseal fragment reflects a Salter-Harris type II separation pattern through the defective femoral neck. The epiphysis and attached triangular fragment slip from the normal superoanterior portion of the neck in an inferior-posterior direction. The treating surgeon should be aware of the often marked femoral retroversion component present in severe congenital coxa vara. This knowledge allows surgical planning for corrective osteotomies that will better normalize hip mechanics. A combination of marked valgus and flexion with internal rotation of the distal fragment are required to fully correct the deformity.

One-stage correction of the dysplastic hip in cerebral palsy with the San Diego acetabuloplasty: results and complications in 104 hips

Ninety-two patients with cerebral palsy underwent a special type of pericapsular acetabuloplasty designed to correct the hip dysplasia that occurs in cerebral palsy. The osteotomy was performed as part of a combined procedure (including femoral osteotomy and soft-tissue releases). Retrospective analysis was performed on 75 of the children (104 hips from 1982 through 1995) with a mean follow-up of 6.9 years. Ninety-nine (95%) of the 104 hips remained well reduced at follow-up. There were no redislocations. If the preoperative migration percentage was >70% (severe subluxation), improved results were noted in hips that had an open reduction with capsulorrhaphy. There were 13 complications including intraarticular extension of the acetabuloplasty (one) and avascular necrosis of the femoral head (eight hips, 8%). Indications for addition of a pericapsular acetabuloplasty include an open triradiate cartilage, acetabular dysplasia (acetabular index >25 degrees), and subluxation or dislocation with a migration percentage of >40%. Even hips with relative incongruity and some deformity of the femoral head can be successfully treated with this combined approach.

The effect of valproic acid on blood loss in patients with cerebral palsy

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Double-blind study of botulinum A toxin injections into the gastrocnemius muscle in patients with cerebral palsy

The purpose of this study was to quantify the gait of subjects receiving two injections of either botulinum A toxin or saline vehicle into the gastrocnemius muscle(s). The study group consisted of cerebral palsy patients who walked with an equinus gait pattern. This study was a randomized, double-blinded, parallel clinical trial of 20 subjects. All were studied by gait analysis before and after the injections. There were no adverse effects. Peak ankle dorsiflexion in stance and swing significantly improved in subjects who received the drug and not in controls. Results of this double blind study give support to the short term efficacy of botulinum toxin A to improve gait in selected patients with cerebral palsy.

Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children

This retrospective review evaluates the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of open or unstable diaphyseal forearm fractures in 32 children with a mean follow-up of 13 months. Thirty-one patients had an excellent result, and one patient had a good result. Average time to bridging cortex was 3 months. Four patients lacked full pronation and supination, with none lacking >20 degrees, and no patients had evidence of growth-plate arrest. Nine complications occurred in eight patients: lost reduction after K-wire removal (three), refracture (two), deep infection (one), pin-site infection (one), transient anterior interosseous nerve palsy (one), and skin ulcer over buried K-wire (one). Both infections occurred in cases in which the K-wire ends were left outside the skin. Each case of lost reduction occurred in single-bone fixation cases when the K-wires were removed before 4 weeks. In children, intramedullary fixation by using standard K-wires plus cast immobilization provides effective treatment for the problematic open or unstable diaphyseal forearm fracture when closed management has failed. Refinement of the technique may help to avoid complications. We now recommend burying the K-wires under the skin for 3-5 months and stabilizing both the radius and ulna with an intramedullary K-wire.

Subtalar staple arthroereisis for planovalgus foot deformity in children with neuromuscular disease

Twenty-two patients (34 feet) with severe, flexible, planovalgus feet due to neuromuscular conditions were treated with subtalar staple arthroereisis. Patients were followed up for an average of 5 years (range, 2.5-9 years). Of the 34 feet, 18 did not require revision surgery; however, the remaining 16 feet required revision at an average of 39 months after surgery (range, 9-63 months). Revision procedures consisted of hardware removal in four cases, repeated subtalar stapling in one, triple arthrodesis in two, and calcaneal with or without cuboid and cuneiform osteotomy in nine feet. The long-term results of subtalar staple arthroereisis were unpredictable, and although it was effective in approximately half of our patients, we no longer recommend this procedure for the correction of the neuromuscular planovalgus foot deformity.

Clinical implications of clubfoot histopathology

Ipsilateral peroneus brevis muscle histopathology was studied in 64 children with idiopathic rigid equinovarus at the setting of initial posteromedial-lateral release. Fifty percent of biopsies demonstrated abnormal muscle fiber morphology, classified as congenital fiber-type disproportion or fiber-size variation. Forty-one infants (59 feet) underwent initial surgical intervention within the first year of life with a minimum 2-year follow-up. Feet with abnormal muscle histology had a significantly greater incidence of recurrent equinovarus deformity requiring reoperation; the relative risk of clubfoot recurrence in children with fiber abnormalities was 5.6. Male patients with bilateral deformity and abnormal peroneus brevis histology had a particularly high incidence of recurrent equinovarus. Developmental internal tibial torsion requiring surgical intervention was also greater in the abnormal-fiber histology group. The incidence of postoperative metatarsus adductus/varus necessitating surgery was comparable despite histologic findings. Thus muscle-fiber abnormalities are prevalent in idiopathic equinovarus. Such fiber-type anomalies may predict recurrent limb deformities.

Calcaneal-cuboid-cuneiform osteotomy for the correction of valgus foot deformities in children

We performed combination calcaneal-cuboid-cuneiform osteotomies in 18 patients (26 feet) with severe valgus foot deformity. The operation consists of a sliding calcaneal osteotomy, an opening-wedge cuboid osteotomy, and a pronation, plantar flexion closing-wedge osteotomy of the medial cuneiform in addition to appropriate soft-tissue releases. The preoperative goals of restoring the axis of the foot parallel to the axis of progression and relieving pain, as well as shoe, brace, and skin problems, were met in 23 of the 24 feet available for review at an average of 18 months after surgery. This procedure has the advantage of localized correction of deformity without the problems associated with arthrodesis.

Current concepts in the pathophysiology, evaluation, and diagnosis of compartment syndrome

This article reviews present knowledge of the pathophysiology and diagnosis of acute compartment syndromes. Recent results using compression of legs in normal volunteers provide objective data concerning local pressure thresholds for neuromuscular dysfunction in the anterior compartment. Results with this model indicate that a progression of neuromuscular deficits occurs when IMP increases to within 35 to 40 mm Hg of diastolic blood pressure. These findings provide useful information on the diagnosis and compression thresholds for acute compartment syndromes. Time factors are also important, however, and usually are incompletely known in most cases of acute compartment syndrome. Although the slit catheter is a very good technique for monitoring IMP during rest, these catheters and their associated extracorporeal transducer systems are not ideal. Recently developed miniature transducer-tipped catheters and, perhaps, future development of noninvasive techniques may provide accurate recordings of IMP in patients with acute compartment syndromes.

Ice-cream truck-related injuries to children

Few studies exist on the cause and nature of injuries to children from ice-cream truck-related accidents. We reviewed the medical records of 11 children with orthopedic injuries treated at Children's Hospital-San Diego from 1985 to 1995 for injuries in such accidents. Of nine children on their way to or from an ice-cream truck who were struck by an oncoming vehicle, all were girls; eight had pelvic or lower-extremity fractures. When ice-cream trucks park on the street, they pose a danger to children, because children are drawn to them, and the trucks' large size blocks the vision of oncoming drivers.

Etiology of supracondylar humerus fractures

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Children's Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Anterior release and fusion in pediatric spinal deformity. A comparison of early outcome and cost of thoracoscopic and open thoracotomy approaches

STUDY DESIGN

A consecutive series of patients undergoing thoracoscopic anterior spinal release and fusion for scoliosis or kyphosis was compared with a consecutive series of patients treated with an open thoracotomy approach.

OBJECTIVES

To compare the early clinical results, costs, and charges of performing an anterior thoracic spinal release and fusion with the two approaches.

SUMMARY OF BACKGROUND DATA

The thoracoscopic approach to the spine is gaining acceptance, yet there are little data comparing the technique with standard open methods for the treatment of spinal deformity.

METHODS

The first 14 thoracoscopic cases performed at the authors' hospital were compared with 18 open thoracotomy cases treated during the previous 12-month period. In each case the discs were excised and bone grafted before performing a posterior fusion. The early clinical outcomes and the hospital charges/costs were analyzed.

RESULTS

The percent curve correction was similar between the thoracoscopic and open methods: scoliosis 56% and 60%, respectively; kyphosis, 88% and 94%, respectively. The blood loss and complication rates were similar between the two groups; however, the chest tube output was greater in the thoracoscopic group. The length of hospital stay was not reduced, and the cost of the open procedure is 29% less than the thoracoscopic approach. The minimally invasive thoracoscopic approach avoids cutting the chest/shoulder musculature, greatly decreasing the morbidity of anterior spinal surgery.

CONCLUSIONS

The thoracoscopic technique is a safe and effective alternative to open thoracotomy in the approach to the anterior thoracic spine for the treatment of pediatric and adolescent spinal deformity.

Genu valgum in children with coxa vara resulting from hip disease

Three patients with chronic hip disease and progressive coxa vera deformity also had an unrecognized compensatory ipsilateral genu valgum until the primary hip deformity had been corrected operatively. This unrecognized genu valgum may become subtly worse in a growing child because of lateralization of the mechanical axis of the lower extremity with respect to the knee joint. Operative correction of coxa vara acutely moves the mechanical axis farther laterally, causing the occult genu valgum to become clinically apparent. The genu valgum may subtly worsen over time in a growing child because of lateralization of the lower extremity mechanical axis with respect to the knee joint, with the resulting abnormal Hueter-Volkmann forces across the physis causing progressive genu valgum. Recognition of occult genu valgum before correcting coxa vara in children allows the surgeon the better to advise the family about the need for possible subsequent operations on the knee.

The use of modified Neufeld's skeletal traction in children and adolescents

A modified form of Neufeld's skeletal traction is described. This technique is a useful method of treating children and adolescents with femoral or pelvic fractures. The advantage over standard femoral skeletal traction is early mobilization of the patient to a sitting position. Additionally, the patient can be placed in this form of traction at home, allowing earlier discharge from the hospital.

Ultrasonography and developmental dysplasia of the hip: a cost-benefit analysis of three delivery systems

The role of ultrasound (US) in the diagnosis and management of infants with developmental dysplasia of the hips (DDH) is becoming widely accepted. In our community, there exist three delivery systems for US-DDH: the radiology based, the combined radiology/orthopaedic based, and the orthopaedic office based. This study reviewed the costs and benefits of each delivery system and found that once expertise had been gained and start-up costs were met, the orthopaedic office-based system was the most convenient, efficient, and cost effective for the patient/family and treating physicians. This mirrors the experience of cardiologists, obstetricians, and family practitioners, fields in which the utility of office-based ultrasonography is widely recognized and has become the standard.

Single-incision combination biopsy (muscle and nerve) in the diagnosis of neuromuscular disease in children

The diagnosis of specific neuromuscular diseases in infants and children is often suspected clinically and confirmed histologically by muscle biopsy. In relatively few cases, the differential diagnosis includes hereditary or acquired peripheral neuropathies, and nerve biopsy is required for diagnosis. Historically, children who needed both muscle and nerve biopsies have had two separate incisions at the thigh (muscle) and ankle (nerve) to obtain the specimens. A procedure has been developed that employs a single incision on the posterior aspect of the calf, which allows for simultaneous muscle (soleus or peroneals) and nerve (sural) biopsies. A retrospective study of 22 patients who underwent single-incision combination biopsy was performed. Age at time of biopsy ranged from 2 months to 14 years. Adequate specimens for histologic analysis were obtained in all but one case. Histologic diagnoses were made in 32% of the muscle biopsies and 29% of the nerve biopsies. Mean follow-up after biopsy was 3 years 6 months. Potentially significant complications of nerve biopsy were not seen in this cohort. Single-incision combination biopsy is the preferred technique when simultaneous muscle and nerve biopsies are required. Knowledge of the location of the sural nerve in the calf is essential. This technique is relatively less invasive than separate muscle and nerve biopsies, allows for the harvest of adequate muscle and nerve specimens, is minimally morbid, and can be performed on very young infants.

"Isolated" traumatic radial-head dislocation

A delay in diagnosis of a traumatic radial-head dislocation in the absence of a concurrent ulnar fracture is common. Published reports of this injury imply an isolated injury to the radius without involvement of the ulna. This hypothesis is challenged by a retrospective study of all cases over an 8-year period that demonstrates an identifiable injury to the ulna in every case. A new radiographic sign, the "ulnar bow sign," is described to assist in the proper recognition of this injury pattern. A radial-head dislocation or subluxation should be suspected if the posterior border of the ulna on a true lateral radiograph deviates > 0.01 mm from a straight line.

Lateral condylar fracture of the humerus following posttraumatic cubitus varus

Posttraumatic cubitus varus is widely regarded as just a cosmetic deformity. Six cases of lateral condylar fracture of the humerus in children with preexisting cubitus varus due to prior elbow fracture are presented. Five occurred following malunited extension-type supracondylar fractures of the humerus; the other occurred following a lateral condylar fracture complicated by lateral overgrowth. All cases were treated by anatomic reduction (two closed, four open) and percutaneous pinning of the lateral condylar fracture. Three of the six cases subsequently underwent supracondylar osteotomy of the distal humerus to correct the underlying varus malalignment. Biomechanical analysis suggests that both the torsional moment and the shear force generated across the capitellar physis by a routine fall are increased by varus malalignment. Posttraumatic cubitus varus may predispose a child to subsequent lateral condylar fracture and should be viewed as more than just a cosmetic deformity.

Financial aspects of femoral shaft fracture treatment in children and adolescents

The billing records of 58 children and adolescents with femoral shaft fractures treated during 1990 were analyzed. The treatment groups included early spica casting, skin traction, skeletal traction, home traction, and intramedullary rodding. The medical charges included both the hospital and physician (orthopedist, radiologist, and anesthesiologist) components. The total charges were lowest for the early spica group ($5,494) and highest for the skeletal traction and intramedullary rodding groups ($21,093 and $21,359, respectively). Both skin traction and home Neufeld traction were associated with significant savings over in-hospital skeletal traction and intramedullary rodding. With the continually rising cost of health care, it is the responsibility of the physician to know the charges for various treatment options.

Quantitative analysis of hip dysplasia in cerebral palsy: a study of radiographs and 3-D reformatted images

Cerebral palsy patients (31 hips) were evaluated using radiographic and three-dimensional (3-D) images to quantify hip anatomy. The 3-D images overcome distortions caused by joint contractures. Changes were more pronounced in the non-ambulators and characterized by shallow sockets with increased neck-shaft angles. These hips tended to subluxate in a posterior-superior direction and most had defects in the femoral heads. Ambulators had increased femoral anterversion but other hip parameters tended to improve with age. The 3-D measures of roof steepness and socket depth were found to correlate strongly with radiographic parameters of subluxation.

Evaluation of CT scans and 3-D reformatted images for quantitative assessment of the hip

Hip measurements using three-dimensional (3-D) images and computed tomography (CT) scans were evaluated. The 3-D measurements proved more accurate than CT measurements of femoral and acetabular anteversion. Additionally, accurate 3-D measurements (> 99%) of the femoral neck-shaft angle were provided. Acetabular anteversion determinations by CT scans were systematically decreased as pelvic flexion increased, whereas accuracy was > 96% with 3-D images. The 3-D software allows image rotation in all three reference planes, which minimizes positional errors. A case study is provided to exemplify the shortcomings of conventional imaging techniques and the utility of the quantitative 3-D protocol.

Spinal fusion in Duchenne muscular dystrophy--fixation and fusion to the sacropelvis?

Twenty-two wheelchair-bound patients with Duchenne muscular dystrophy (DMD) underwent Luque segmental instrumentation and fusion. Twelve patients were instrumented to the sacropelvis, and 10 were instrumented to L5. Mean preoperative and postoperative curves were nearly identical in both groups. The mild degree of trunk shift and pelvic obliquity was similar between the two groups. The recommendation for operation in such patients should be made when their curve is > 20 degrees and if their forced vital capacity is > 40%. If treatment is initiated early, Luque instrumentation and fusion from high thoracic (T2 or T3) to the fifth lumbar vertebra should be sufficient.

Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome

The etiology of congenital muscular torticollis remains a mystery despite intensive investigation. Magnetic resonance imaging (MRI) scans of 10 infants with this condition showed signals in the sternocleidomastoid muscle similar to those observed in the forearm and leg after compartment syndrome. Cadaver dissections and injection studies defined the sternocleidomastoid muscle compartment. Injection studies and pressure measurements performed at the time of bipolar release in three patients with congenital muscular torticollis confirmed the existence of this compartment in vivo. Clinical review of 48 children with congenital muscular torticollis showed a relation between birth position and the side affected by the contracture. Because of the association of congenital muscular torticollis with other intrauterine positioning disorders, we postulate that head positioning in utero can selectively injure the sternocleidomastoid muscle, leading to development of a compartment syndrome. Congenital muscular torticollis may represent the sequela of an intrauterine or perinatal compartment syndrome.

Metatarsal epiphyseal bracket: treatment by central physiolysis

Longitudinal epiphyseal bracket (LEB) is a rare ossification anomaly in which an epiphysis brackets the diaphysis of a phalanx, metacarpal, or metatarsal. This abnormal epiphysis tethers longitudinal growth, resulting in a shortened and oval-shaped bone. Four patients with five LEBs were treated by central physiolysis and followed for a mean of 6 years. The patients had significant hallux varus deformity. Three patients had duplicated great toes, and two had tibia hemimelia significant enough to require epiphysiodesis as they neared adolescence. Resection of the LEB allowed the proximal and distal epiphysis to resume untethered growth. Silastic or methyl methacrylate was placed over the resected physis to prevent bony rebridging. The associated hallux varus deformity was corrected by capsulorrhaphy and K-wire fixation. In all patients, the metatarsal resumed longitudinal growth and correction of the hallux varus was maintained.

Managing complications of posterior spinal instrumentation and fusion

Complications of posterior spinal instrumentation for adolescent idiopathic scoliosis are often preventable. Preoperative planning helps to minimize intraoperative and postoperative problems. Late recurrence of rotational deformity (crankshaft) in skeletally immature patients can be prevented by adding anterior surgery. Intraoperative complications are minimized by controlled hypotensive anesthesia and sequencing of surgical steps to allow for autocoagulation, reducing blood loss. Use of spinal cord monitoring, Stagnara wakeup test, and careful distraction decreases the risk of neurologic deficit. Good hook-site preparation helps avoid dural tears. The incidence of postoperative pneumothorax and hemothorax is decreased by careful hook attachment, avoiding pleural penetration, judicious use of rib excision thoracoplasty, and roentgenographic verification of central venous pressure line position. Postoperative recommendations include bed position at 30 degrees, frequent log rolling, incentive spirometry, early sitting and standing, early Foley catheter and nasogastric tube removal, prophylactic antibiotics, and prompt attention to wound infections. Postoperative orthotic wear, prescribed exercise, and activity restriction decrease the risk of early instrumentation failure and help correct early postoperative trunk imbalance. The late complications include suspected pseudarthrosis; this should be surgically treated again if there is persistent pain or marked loss of curve correction.

One-stage correction of the spastic dislocated hip. Use of pericapsular acetabuloplasty to improve coverage

We performed a combined one-stage approach for the treatment of eighteen spastic subluxated or dislocated hips in eleven children who had cerebral palsy. All patients were between five and thirteen years old and had spastic subluxation or dislocation of the hip and severe acetabular dysplasia. The operation consisted of release of the adductors, psoas, and proximal hamstrings; a femoral-shortening varusderotation osteotomy; and a pericapsular pelvic osteotomy. The pelvic osteotomy was designed to increase superolateral coverage of the femoral head in the elongated acetabulum, which had erosion of the superior and lateral aspects. At the latest follow-up (mean duration, six years and ten months), seventeen of the eighteen hips remained anatomically reduced.

Proximal hamstring lengthening in the sitting cerebral palsy patient

We retrospectively studied 62 nonambulatory children with spastic quadriplegic cerebral palsy who underwent proximal hamstring lengthening to improve hip and spine positioning. Preoperatively, all had hamstring contracture, with difficulty sitting due to hip extensor thrust and increased kyphosis. Thirty-five patients with follow-up greater than or equal to 2 years were studied using a modified Reimer scale to assess sitting ability. Sitting ability improved significantly (p less than 0.01) postoperatively, along with popliteal angle (p less than 0.001) and straight leg raising (p less than 0.001). Proximal hamstring lengthening is effective in treating severe hamstring contractures in the wheelchair-bound child with cerebral palsy.

Percutaneous muscle biopsy in the diagnosis of neuromuscular disease

Open biopsy of affected muscle is traditionally used to obtain tissue samples for histologic, histochemical, and biochemical analysis in patients with suspected myopathies. Percutaneous muscle biopsy offers certain advantages over the open technique: it can be performed in an outpatient clinic or as day surgery, usually with a local anesthetic for children greater than 12 years of age, and thus is less costly, more efficient, and less risky. There is also a significant difference in the residual scar. We reviewed the charts of 379 children and adults who had undergone percutaneous muscle biopsy to determine the usefulness of this alternative technique. The analysis could be accurately performed even though the muscle tissue was not at resting length and not oriented in any particular manner, and in nearly all patients sufficient tissue could be obtained for analysis without open biopsy.

Complications of posterior arthrodesis of the cervical spine in patients who have Down syndrome

Ten patients who had Down syndrome and had had a posterior arthrodesis of the upper cervical spine were studied. The mean age at the time of the operation was 8.9 years, and the patients had been followed for three days to forty-nine months. Complications related to the operation occurred in all patients. They included infection and dehiscence at the site of the wound, incomplete reduction of the atlanto-axial joint, instability of the adjacent motion segment, neurological sequelae, resorption of the autogenous bone graft, and death in the postoperative period. Resorption of the bone graft, which occurred in six of the patients, has not previously been reported in patients who have Down syndrome, to our knowledge. Several theoretical mechanisms for this complication are proposed. We recommend non-operative management for patients who have Down syndrome and atlanto-axial instability without neurological signs or symptoms. If the severity of symptoms necessitates a posterior arthrodesis, a high rate of complications must be anticipated.

Acute compartment syndrome. Effect of dermotomy on fascial decompression in the leg

Prompt surgical decompression is the only means of preventing the late sequelae of ischaemic contracture in post-traumatic compartment syndromes. However, controversy exists regarding the length of dermotomy required for adequate decompression in the lower extremity. This study investigated the skin envelope as a potential contributing factor. Wide fascial releases were performed through limited 8 cm incisions in eight cases of post-traumatic lower extremity compartment syndrome. In nine of 29 compartments the pressure remained greater than 30 mmHg. Lengthening the skin incisions to an average of 16 cm decreased intracompartmental pressures significantly. This study documents the skin envelope as a contributing factor in acute compartment syndromes of the leg. The use of generous skin incisions is supported and the need for intra-operative compartment pressure measurements in the treatment of this condition is emphasised.

A new "transducer-tipped" fiber optic catheter for measuring intramuscular pressures

Laboratory and clinical tests were used to determine the efficacy of a new fiber optic "transducer-tipped" catheter for measuring intramuscular pressures. When pressures ranging from 0 to 250 mm Hg were applied by a mercury manometer, the fiber optic system accurately recorded the pressures. In addition, the fiber optic system showed long-term stability by accurately recording the manometer pressure over a 3 day period. The Slit system showed a higher magnitude of hydrostatic pressure artifacts with catheter tip movement as compared to the fiber optic system. The two catheters showed no difference when measuring pressures in pig muscle at rest or when being compressed throughout a range of 0 to 250 mm Hg. In human volunteers, both catheters measured essentially equal pressures at rest, during venous stasis, and during a combination of venous stasis and compression. For long-term assessment, the Slit system required as many as three saline flushes, whereas the fiber optic system measured pressures continuously without manipulation. We conclude that the fiber optic system is as accurate as the Slit catheter for measuring tissue fluid pressures at rest. In addition, the fiber optic system offers distinct advantages over conventional fluid-filled systems for measuring intramuscular pressures due to a lack of hydrostatic pressure artifacts caused by limb position and to the lack of flushing for long-term measurements.

Brainstem evoked potentials for scoliosis surgery: a reliable method allowing use of halogenated anesthetic agents

A predictable and accurate method of monitoring cord function during scoliosis surgery using somatosensory brainstem evoked potentials (SBEP) is described. This method allows the use of halogenated anesthetic agents, which are ideal for neuromuscular patients, but easily disrupt traditional cortical monitoring. Fifty-eight children with idiopathic, neuromuscular, and syndrome related scoliosis were monitored with 51 true negative, one false negative, four true positive and two false positive results. The SBEP method is sensitive and effective for all types of scoliosis surgery, especially neuromuscular scoliosis.

Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg

One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty-five patients were diagnosed as having a chronic compartment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found between the two groups on history and physical examination was a 45.9% incidence of muscle herniae in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preexercise pressure greater than or equal to 15 mm Hg, 2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or 3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.

Halo application in the infant

The technique for halo application in very young children is described, with case presentations of three children aged less than 2 years who underwent successful cervical fusion with halo immobilization. Our multiple pin technique for very small children diverges significantly from previously accepted recommendations. With multiple pins, significantly less torque is required to provide stability, allowing a greater range of pin placement sites in areas where the infant skull might otherwise be considered too thin. This technique of halo application provides a safe and effective method of cervical immobilization for infants.

Kappa Delta Award paper. Tissue fluid pressures: from basic research tools to clinical applications

The two basic research tools developed to measure tissue fluid pressure (wick catheter) and osmotic pressure (colloid osmometer) have undergone extensive validation and refinement over the past 20 years. Using these techniques, basic science investigations were undertaken of edema in Amazon reptiles, pressure-volume relations in animals and plants, adaptive physiology of Antarctic penguins and fishes, edema in spawning salmon, tissue fluid balance in humans under normal conditions and during simulated weightlessness, and orthostatic adaptation in a mammal with high and variable blood pressures--the giraffe. Following and sometimes paralleling this basic research have been several clinical applications related to use of our colloid osmometer and wick technique. Applications of the osmometer have included insights into (a) reduced osmotic pressure of sickle-cell hemoglobin with deoxygenation and (b) reduced swelling pressure of human nucleus pulposus with hydration or certain enzymes. Clinical uses of the wick technique have included (a) improvement of diagnosis and treatment of acute and chronic compartment syndromes, (b) elucidation of tissue pressure thresholds for neuromuscular dysfunction, and (c) development of a better tourniquet design for orthopaedics. This article demonstrates that basic research tools open up areas of basic, applied, and clinical research.

Arthroscopic treatment of septic knees in children

Twenty patients were treated for septic arthritis of the knee with arthroscopic lavage (15 patients) or arthrotomy (five patients). Parenteral antibiotics were used in both groups, and both groups did well at follow-up. The advantages of arthroscopic debridement and irrigation over arthrotomy include low morbidity, minimal scarring and much earlier functional recovery (mean 10 days). The advantages over needle aspiration include complete joint visualization, lavage, and easy drain placement allowing suction-irrigation over several days, thus avoiding multiple aspirations. Arthroscopic treatment of knee sepsis in children is simple to perform, is associated with minimal morbidity, and affords excellent long-term results.