Fractures of the odontoid process: a report of 15 cases in children younger than 6 years.

Fractures of the odontoid process are rare in children. We retrospectively reviewed 15 cases in children younger than 6 years, with an average follow-up of 4 years and 3 months. Eight of these patients had neurologic involvement; magnetic resonance imaging (MRI) changes were seen in the spinal cord at the cervicothoracic junction in six. This neurologic injury was thought to be due to the major anterior displacement of the upper spine, causing spinal cord stretch at the spinal apex of the cervical and thoracic spine. Eight patients secured in forward-facing car seats were injured as the result of motor vehicle accident. Conservatively treated fractures fused without problem. By contrast, the three cases operated on as the initial management of the fracture had complications postoperatively.

Callus response to micromovement during elongation in the rabbit.

The purpose of this investigation was to determine whether induced micromovement during the elongation period could improve the consolidation of diaphyseal elongation obtained by callus distraction. Two series of paired rabbit hindlimbs were studied. The surgical procedure and the waiting period were identical. During elongation, one hindlimb was stimulated, and the other was the control. The consolidation period was 2 days. Reproducible tibial osteotomy and lengthening of the two tibiae was confirmed radiographically. The mineralized callus was quantified by dual-beam x-ray absorptiometry. The callus diameters were measured. Bones were axially compressed to failure. Callus volume, mineral quantity, mineral density, and resistance to failure were not different on the stimulated side compared with the unstimulated side, so micromovement applied during elongation had no effect on bone consolidation. For all tibiae, resistance to failure of the callus was significantly correlated to callus volume, to callus mineral content, and to callus mineral density.

Bone growth after lengthening of the lower limb in children.

Femoral and tibial growth was studied in 6 children undergoing a femoral lengthening and 28 children a tibial lengthening. Growth of both femurs and tibiae was evaluated for 3 years both before and after the procedure. No significant growth disturbance was noted in femoral lengthenings of 14%. However, growth variations were constant after tibial lengthening of 18% on the average and could be correlated to the amount of lengthening. The consequences of these changes are limited in terms of final limb length because overgrowth of the femur often compensates for growth retardation of the tibia when tibial lengthening is less than 18%. Experimental and clinical studies assert that lengthenings of more than 30% can result in significant and definite growth retardation of the lengthened bone.

The too-long anterior process calcaneus: a report of 39 cases in 25 children and adolescents.

We observed 39 feet with a "too-long" anteromedial process of the calcaneus (TLAP) in 25 children and adolescents. The abnormality was diagnosed from symptoms (ankle sprains or persistent ankle or foot pain) in 33 cases. Six cases of TLAP were noted on radiographs taken of the patient's opposite, asymptomatic foot. Initial treatment by 3 weeks of strapping failed in seven of seven cases, and 3-6 weeks of primary plaster immobilization failed in 10 of 25 feet. Primary immobilization treatment failed in 17 of 33 symptomatic feet. Resection of the TLAP provided good results in 14 of 15 feet when used as a secondary procedure after failure of immobilization treatment and in one foot in which it was used as primary treatment. We believe that this abnormality is an anatomic variant that becomes symptomatic because of inversion stress with impingement of the abnormally long process between talus and cuboid.

Bilateral congenital pseudarthrosis of the olecranon.

A case of bilateral congenital pseudarthrosis of the olecranon is reported in a 15-month-old boy. This abnormality was noted at birth because of a fixed flexion deformity of both elbows. The left side was operated on at the age of 16 months and the right side at 21 months. Surgical exploration showed a mobile pseudarthrosis with a 2-cm gap between the tip of the olecranon and the nucleus, each one covered with cartilage. This cartilage was excised, the triceps tendon was lengthened to allow the lowering of the nucleus, and both fragments were fixed with nylon threads. The elbow was kept extended for 30 days in a plaster cast. Fusion was obtained shortly. At the 2-year follow-up, the function was nearly normal as was the radiological appearance. This abnormality is very rarely reported in the literature, and we emphasize the necessity of an early operation.

The outcome of walking in stable neuromuscular deficiencies.

In some patients with stable or very gradually worsening neuromuscular disorders, walking performance nevertheless decreases with increasing hip flexion and spinal deformity as the patient grows. The relations between muscular deficiency, pelvic and spinal deformity, head stability, gravity parameters and walking performance were studied in 43 patients aged 18 months to 38 years with a view to finding out how these parameters are related, whether progressive spinal deformity and loss of walking can be avoided or delayed, and whether specific therapy for each of these parameters can help. Early combating of hip flexion deformity by physiotherapy, accompanied by limbering-up exercises of the spine to counteract lumbar and thoracic lordosis are useful, as are orthoses to correct pelvic tilt anteversion, spinal lordosis and head instability. If physiotherapy is ineffectual or too late, tenoctomy of the rectus femoris may help.

Vertebral growth after thoracic or lumbar fracture of the spine in children.

We studied vertebral growth after thoracic or lumbar fractures in 52 children followed up from the time of fracture until skeletal maturity. We identified pure anterior compression in 32, combined anterior and lateral compression in 11, and total vertical compression in nine. Six patients had no treatment, 42 had a conservative treatment, and four were operated on. In fractures with anterior compression < 10 degrees, no significant difference could be found between the group without treatment and the group with conservative treatment when the Risser sign was 0 or 1 at the time of injury. In such fractures with angles > 10 degrees, conservative treatment gave better results when the Risser sign at injury was < or = 2. Prolonged conservative treatment was not effective in children with a Risser sign of 3. The evolution of lateral compression seems to be related to the initial injury rather than to treatment. Vertical compression injuries were positively influenced by a conservative treatment when the Risser sign was < or = 2.

[Too long antero-medial process of the calcaneus. A study of 59 cases in 37 children and adolescents]. / Processus antéro-interne du calcanéum trop long. Expérience de 59 cas chez 37 enfants et adolescents.

PURPOSE OF THE STUDY: In 1983, we reported 5 cases of a type of tarsal abnormality which often went unrecognized in children and adolescents, the so-called "too long antero-medial process of the calcaneus" (TLAP). This report analyzes 59 such abnormalities observed in 37 children and adolescents. Treatment of the 48 symptomatic cases is presented. MATERIAL: A retrospective study was done on the files of all patients in whom oblique foot radiographs, CT scan or MRI of the foot showed an abnormal antero-medial process of the calcaneus. Of this group, patients were re-examined and radiographs of both feet (AP, lateral and oblique views) were obtained. METHODS: Gender, age at occurrence of symptoms, diagnosis and follow-up, patient complaints and successive treatment were assessed. Final clinical results were graded according to patient's complaints of pain and functional limitation as well as clinical evaluation of subtalar motion. RESULTS: Fifty-nine TLAPs have been found in 37 patients, 30 girls and 7 boys of 11.6 years on average at the first symptoms. Delay of diagnosis from onset of symptoms to final diagnosis averaged 2 years. First symptoms were so-called ankle sprains in 19 patients, ankle instability with tarsal pain in 17, pain and tarsal stiffness in 11, spastic flat foot in 1. In 11 patients, the abnormality was found on the opposite foot. In 2 patients, the TLAP was combined to a calcaneo-navicular bridge of the other foot. Eleven strapping managements resulted in 11 failures, 36 plaster immobilizations led to 12 good, 2 fair and 22 poor results; 25 resections gave 23 good, 1 fair and 1 poor result at a 4.6 years follow-up on average. DISCUSSION: In some people, the antero-medial process of the calcaneus is elongated and becomes interposed between the head of the talus and the cuboïd, far enough to cause impingement on the navicular. Because of the elongation, supination produces a "nutcracker" phenomenon with compression of the process between the talus and the cuboïd; this may result in a chondral injury of the talus head at its inferior and lateral part which faced the TLAP. Authors suggest that calcaneo-navicular coalition and TLAP represent a spectrum of types of errors in embryologie mesenchymal formation with lack of normal joint formation of the tarsal ossicles during fetal life. Immobilization treatment as primary management was particularly unsuccessful in the group with recurrent ankle sprains and persistent pain. Process resection proved a highly successful technique in management of those patients who failed to achieve good results with plaster immobilization. CONCLUSION: The "too long antero-medial process of the calcaneus" should be considered when assessing possible causes of recurrent ankle sprain or persistent tarsal pain in adolescents. An oblique X-ray is usually satisfactory for diagnosis. In patients who failed a conservative management, resection of the process produced good results and painless, supple feet.

Callus response to micromovement after elongation in the rabbit.

The purpose of this investigation was to determine whether induced micromovement could improve the consolidation of diaphyseal elongation by callus distraction. Two series of paired rabbit hindlimbs were studied. The surgical procedure, waiting period, and elongation period were identical. One hindlimb was then left under neutralization conditions, but the other limb was stimulated by axial micromovements. Reproducible tibial osteotomy and lengthening of the two tibiae were confirmed radiographically. The mineralized callus was quantified by dual-beam x-ray absorptiometry. The anteroposterior and lateral diameters of the callus were measured. A semiquantitative histologic study allowed the ratio between fibrous or cartilaginous callus or both and mineralized callus to be determined. Bones were axially compressed to failure. Callus volume, callus mineral content, callus mineral density, and mechanical forces required to failure were significantly superior on the stimulated side compared with the neutralized side, so micromovements applied after the end of elongation were beneficial for bone healing. Mechanical forces required to failure were significantly correlated to callus volume and callus mineral density.

Femoral lengthening using the callotasis method: study of the complications in a series of 70 cases in children and adolescents.

The authors reviewed 70 femoral lengthenings performed for limb-length discrepancy in 66 children and adolescents using gradual incremental distraction. Nine were performed using the Judet lengthener and 61, the Orthofix external fixator. Etiology of the femoral shortening was congenital in 22, posttraumatic in 17, postinfection in 13, neurologic in 12, and miscellaneous in six. There were 83 complications, which were assessed as to their relation to the etiology of shortening, amount of lengthening, and age. The incidence of joint complications did not seem to be less than that previously encountered with rapid distraction methods of lengthening. Bony consolidation was achieved without additional surgery in 88% of cases. Delayed consolidation was most commonly encountered in children younger than 8 years old with congenitally short femora. The authors believe that good results can be obtained by incremental distraction by using uniplanar fixation by aggressive physical therapy, proper fixator application, and appropriate dynamization of the fixator.

[Femoral lengthening by callotasis. A study of a series of 79 cases in children and adolescents]. / Alongement de fémur par callotasis. Etude d'une série de 79 cas chez l'enfant et l'adolescent.

PURPOSE OF THE STUDY: Results of femoral lengthening using callotasis method, with particular attention to the complications are presented. MATERIAL AND METHODS: 79 femoral lengthenings performed for limb length discrepancy in 75 children and adolescents were studied. Etiology of the femoral shortening was congenital in 23 cases, post-traumatic in 20, post-infection in 14, neurologic in 13, and miscellaneous in 9. Nine lengthenings were performed using the Judet lengthener and 70 using the Orthofix external fixator. We used gradual incremental distraction (callotasis). RESULTS: Average lengthening achieved was 52 mm (range: 35 to 85), which represented a 17.7 per cent increase in femoral length (range 7.6 per cent to 64 per cent). There were 87 complications, i.e. 110 per cent. Several complications were often encountered during one lengthening, thus, 23 lengthenings (30 per cent) were performed without any complication and 49 (62 per cent) without additional unpredicted operations or anesthesia. All these complications were studied according to the stage (intraoperative, elongation, consolidation and delayed) in which they occurred and to their severity. They were assessed to establish their relationship to etiology of shortening, amount of lengthening and age. Intraoperative complications were rare (2 cases). In the distraction period, joint complications are the most frequent (33 complications), involving the hip 22 times and the knee 11 times; 28 healed without any problems, 14 needed reoperation and 1 dislocation of the hip led to an avascular necrosis. DISCUSSION: The incidence of joint complications did not seem to be less than that encountered with previous methods of lengthening. The author believes that systematic tenotomies performed in order to avoid such complications in congenital short femurs are abusive and have to be discussed case-by-case. Bony consolidation was achieved without additional surgery in 90 per cent of cases. Eight patients had delayed consolidation but did not require surgery. Complicated consolidation was most commonly encountered in children less than 8 years old with congenitally short femurs. The author compared healing time according to the type of dynamization. A significant improvement was found when using a silastic collar (33.3 days/cm) in place of classical dynamization (46.6 days/cm). CONCLUSION: The author believes that good results can be obtained by incremental distraction using uniplanar fixation. Results could be improved by proper fixator application, aggressive physical therapy and well-thought dynamization of the fixator.

Prostaglandins in PUVA-treated psoriasis.

The biosynthesis of prostaglandins (PG) in biopsies from 9 patients with recalcitrant psoriasis was studied before, during, and after treatment with 8-methoxy-psoralen and long-wave ultraviolet light (UVA). No statistical difference was found between the results obtained before, during, and after the treatment. In PGE1-equivalents, the concentration in involved psoriatic skin was 2.16 +/- 0.31 ng (mean +/- S.E.M.) before, 2.01 +/- 0.33 ng during, and 2.85 +/- 0.31 ng per g wet weight after PUVA. In uninvolved skin the concentrations were 2.38 +/- 0.26 ng, 2.23 +/- 0.15 ng and 3.29 +/- 0.24 ng per g wet weight, respectively. In the presence of exogenous arachidonic acid in the incubation medium the activity formed was higher, but no statistical difference was found between pretreatment values and those obtained during and after PUVA treatment. The hypothesis that PUVA treatment stimulates PG biosynthesis, thus accounting for the beneficial therapeutic antipsoriatic effect, could not be confirmed.