A study of normal foot abduction across various age groups in children.

INTRODUCTION: The relapse rate after Ponseti method of correction has reduced in recent years which is attributable to the better appreciation of the need to achieve the correct degree of abduction. Ponseti recommended clinical 'overcorrection' of the foot to 700 of abduction. However, no scientific basis for this figure was found in literature. As the indications of Ponseti method extend to older children, we conducted a study to find out the amount of foot abduction to be achieved before applying a foot abduction brace in various age groups. METHODS: The normal 197 feet of children up to eight years of age were considered for study. The measurements included foot-bimalleolar angle in neutral and maximum possible abduction, thigh foot angle and leg foot angle. RESULTS AND DISCUSSION: The foot bimalleolar angle in neutral had a mean of 82.6 degrees and in maximum abduction a mean of 99.0 degrees. The mean leg foot angle was 66.4 degrees and the mean thigh foot angle was 60.5 degrees. It was found that these variables do not change with age. From the study we concluded that achieved abduction should be about 60-70 degrees before applying foot abduction brace in all children till age eight years with clubfeet treated with Ponseti technique, keeping the leg foot angle or the thigh foot angle as a guideline. This is against the common perception of keeping the abduction at 70 degrees for infants and reducing the abduction to 30 to 40 degrees for older children. Both the leg foot angle and thigh foot angles are reliable indicators of correction.

Pediatric displaced radial neck fractures: retrospective results of a modified Metaizeau technique.

Treatment of displaced radial neck fractures is challenging and controversial, as the risk of unsatisfactory outcome increases after operative as well non-operative treatment. Between 2004 and 2012, we treated 14 children with type IV fracture of radial neck with mean angulation of 72.8°, using the modified Metaizeau technique. The average follow-up was 39 months. Heterotrophic ossification and transient posterior interosseous nerve palsy were the only complication seen in two patients who had to undergo open reduction. We feel that the inability to achieve closed reduction can be attributed to loss of periosteal hinge. We obtained 100 % excellent clinical outcome and 79 % excellent radiological outcome at final follow-up. The modified closed intramedullary pin reduction technique proved to be minimal invasive technique for displaced radial neck fractures by allowing stable anatomic reconstruction while avoiding all the complications of classical Metaizeau technique.

Nonunion of paediatric talar neck fracture.

Fractures of the paediatric talus are infrequent injuries, most complicated by posttraumatic arthrosis and avascular necrosis in the course of treatment. Nonunion in children has not been reported before in literature. We report a case of a 12-year-old boy who had a nonunion of Hawkins type II fracture of talar neck. The nonunion was treated surgically with a good clinical outcome. The goals of management in nonunion of paediatric talar neck fracture are different from those in fresh fractures. A suboptimal reduction should be acceptable without trying a radical surgery which may cause further impairment.

A new method of measuring acetabular cup anteversion on simulated radiographs.

PURPOSE: Optimal positioning of acetabular components is crucial for maintaining stability of THA. Postoperative assessment of acetabular anteversion is a vital but difficult task. Various methods have been devised with good results for measuring anteversion on plain radiographs but these methods are either too complicated or require special objects like scientific calculators, special protectors, tables, etc. A new simplified method of measuring anteversion on plain radiographs was created based on basic geometry. METHODS: Anteversion of acetabular components was estimated on computer generated images of the acetabular cup by our method and compared with two previously established methods of Liaw and Pradhan. Measurement was done at 400 different positions of acetabular cup and compared with actual values. Another analysis was done after adding the femoral head to the acetabular component, thus obscuring some of the acetabular rim. RESULTS: Mean and standard deviation of error for our method was 0.77° ± 0.75° as compared to 0.93° ± 0.86° and 0.72° ± 0.68° for the methods of Liaw and Pardhan, respectively, with no significant differences from actual values. Maximal errors for our method, Liaw's and Pradhan's method were 3°, 4°, and 2.91°, respectively. On analysis, after the adding femoral head, there was a significant error of measurement with Liaw's method, while our method as well as Pardhan's remained accurate. All methods showed high inter- and intraobserver reliability. CONCLUSION: Our new simplified method of measuring acetabular anteversion on plain radiographs is acceptable in comparision to other established methods and requires only routinely used goniometer and calliper.

GeoGebra: A reliable and free software for measuring acetabular cup anteversion on digitalized plain radiographs.

OBJECTIVE: Although accurate measurement of cup anteversion in hip replacement requires CT scans, however, its routine application, especially during follow-up, remains economically and ethically unreasonable. Thus, several methods have been devised for making this measurement on plain radiographs. In recent years, several ways have been adopted using software on digital radiographs. We present one such method which uses open access mathematical software GeoGebra. METHODS: Anteversion was measured on 72 radiographs (36 cemented; 36 uncemented) by three different observers using this software. One observer repeated measurements at three weeks interval. RESULTS: The intraclass correlation coefficient for interobserver variability and intraobserver variability was 0.982 (0.973-0.989) and 0.986 (0.978-0.991) respectively. There was a significant difference in the reliability of the method for cemented and uncemented cups with higher reliability for cemented cups (p < 0.001). CONCLUSION: GeoGebra software can be used as a reliable alternative for measuring acetabular cup anteversion on good quality well centred digital radiographs of the pelvis.

Acetabular fractures labelled poor surgical choices: Analysis of operative outcome.

PURPOSE: We report the surgical outcome in 52 patients with acetabular otherwise considered as poor surgical choices. METHODS: 43 male and 9 female patients were operated at a mean age of 43 years and followed up for a mean duration of 60.3 months. There were 22 elementary fractures and 31 associated ones according to Letournal and Judet classification. Osteosynthesis was attempted in 48 patients whereas a primary total hip arthroplasty was performed in 4 patients. Outcome was assessed radiologically and functionally employing Harris Hip Score (HHS). RESULTS: Average HHS in osteosynthesis group was 82.56 ± 12.4 with excellent to good results in 59.6% of the cases. Symptomatic osteoarthritis occurred in 13.5% of cases, avascular necrosis and severe heterotopic ossification in 7.7% each, infection and nerve palsy in 11.5% each. CONCLUSION: Although the complication rates in this series is marginally more than that reported in literature, we recommend that the indications of surgical fixation in acetabular fractures need to be extended to those which were considered poor surgical choices.

Neglected post burns contracture of hand in children: Analysis of contributory socio-cultural factors and the impact of neglect on outcome.

BACKGROUND: No study has ever evaluated the causes and effect of neglect on the outcome of post burns contractures of hand in children. METHODS: 66 hands in 61 children (mean age 12.22 years) with a mean neglect of 11.6 years (range 5-17 years) were assessed for the causes of neglect and the outcome of surgery. Average follow up was 6.6 years. The results were assessed in two groups of 5-10 years neglect as group I and >10 years neglect as group II. RESULTS: In a total number of 134 contracted rays in 66 hands, the surgical procedures included local Z/V-Y flap (51 rays), cross finger flap (48 rays), full thickness graft (35 rays). Additional external fixator with a distracter was used in 3 patients treated at a delay of 14, 16 and 17 years. 50 (81.96%) patients belonged to rural and slum areas. The reasons for delayed treatment included poverty - 33 patients, lack of awareness of surgical treatment - 16 patients; and indifference of parents - 12 patients. 44 (72.13%) children were illiterates. With treatment the average DASH score improved from 65.10 to 36.90 (p < .000) and from 68.14 to 45.93 (p < .000) in group I and II respectively. The results were significantly superior in group I (p < .000). CONCLUSION: The main factors for neglect in treatment of post burns contracture include poverty, lack of awareness and illiteracy. All the patients showed significant improvement in function after the surgery. Contractures with higher neglect had significantly inferior outcome.

Sports injury pattern in school going children in Union Territory of Chandigarh.

OBJECTIVE: To determine incidence of various types of sport injuries and other associated factors, among competitive sports playing school children of Chandigarh. DESIGN: This study is a survey based study, and spanned for a period of one year. School going students in age group 11-18 years of Chandigarh (Union Territory) India, who were in competitive sports, were included for this survey after taking informed consent from concerned school authorities. 33 schools consisting of 36.165 students were analysed in the study, 7230 students were found to participate in 40 different categories of sports. RESULTS: Total of 246 filled questionnaires were analyzed making it an injury frequency of 3.40% among 7230 participating young athletes in 12 months study duration. Estimated incidence rate, considering hours of exposure in practice, came out to be 48.07 injuries per 1000 h of exposure in practice among 246 injured cases. 40.2% of the injured children (99/246) attributed their injury to poor ground condition while other 30.5% (75/246) to faulty techniques. Rest attributed their injuries to poor fitness levels, improper use of equipment and other reasons. Of the 33 schools surveyed, 27.3% (9/33) had a doctor as health professional, 9.1% (2/33) had a physiotherapist while 66.6% of the schools (22/33) had no health care professional. CONCLUSION: The incidence of sports injuries in the region is high as compared to the global data. The findings has highlighted the need for a nationwide surveillance system and then taking appropriate measures for future injury prevention and appropriate management.

Fracture arising of Steinmann pin cortical defect 3 years after insertion: A case report and review of literature.

A plethora of complications have been reported after insertion of a Steinmann pin amongst which the commonest ones are infection and pin loosening. We present a literature review on pathological fractures arising out of cortical defects left behind by pin insertion and report a unique case where a Steinmann pin insertion in proximal tibia has given rise to a fracture as late as 3 years after insertion.

Pucker sign in proximal humeral fractures: implications on management.

Fracture of the surgical neck of humerus in young patients is a relatively rare injury. We reviewed the available material on the topic and identified puckering at the shoulder in high-energy fracture of the surgical neck as a finding which has been reported infrequently but signifies a need for open reduction. We present a review of the literature on the subject and our similar experience in two young males who had puckering and ecchymosis at the shoulder.

Comparison of short term results of single injection of autologous blood and steroid injection in tennis elbow: a prospective study.

BACKGROUND: It has been recently reported that local injection of autologous blood in tennis elbow offers a significant benefit by virtue of various growth factors contained therein. The objective of our study was assessment of efficacy of autologous blood injection versus local corticosteroid injection in the treatment of tennis elbow. METHODS AND TRIAL DESIGN: A single blinded, prospective parallel group trial was undertaken. 50 consecutive patients of untreated lateral epicondylitis were enrolled. Randomisation was done on alternate basis and two groups were constituted, first one receiving steroid injection and second one injection of autologous blood. Both groups were evaluated at 2 and 6 weeks for pain relief and stage of disease. RESULTS: Baseline evaluation showed no difference between the two groups (chi square test, P > 0.05). Between group analysis at 2 weeks showed no difference in pain relief and Nirschl stage (unpaired t test, P > 0.05). Evaluation at 6 weeks demonstrated a significant decrease in pain levels and stage of disease in blood group (unpaired t test, p < 0.05). CONCLUSIONS: Autologous blood injection was more effective than steroid injection in the short term follow up in tennis elbow.

Superior dislocation hip with anterior column acetabular fracture - open reduction and internal fixation using a twin incision technique.

Superior variety of anterior dislocation of the hip is a rare injury. Its occurrence with acetabular fractures has been documented infrequently. We report a case of superior dislocation of the hip with anterior column acetabular fracture. Open reduction of the hip and internal fixation of the fracture was carried out using a twin incision technique. The course to recovery has been uneventful.

Sprengel's shoulder treated by the Woodward procedure: analysis of factors affecting functional and cosmetic outcome.

PURPOSE: To report the functional and cosmetic results of cases with Sprengel's shoulder who underwent the Woodward procedure. MATERIALS AND METHODS: Twelve children were operated at a mean age of 5.58 years and reviewed at an average follow up of 31.83 months. RESULTS: The mean preoperative Cavendish grade for cosmetic evaluation was 3.17, which decreased to 1.25 postoperatively (statistically significant, p < 0.0005, Wilcoxon signed-rank test). Similarly, the range of abduction at the shoulder increased from a mean of 115.83° preoperatively to 153.33° at final review (p < 0.0005). Age had a negative correlation with both functional improvement (r = -0.55, Spearman correlation coefficient) and cosmetic improvement (r = -0.11), although the latter suggested a very weak association, if any. Cavendish grade improvement and increase in abduction had a strong positive association (r = 0.713). However, there was no correlation between the increase in abduction and lowering of the scapula achieved (r = 0.131). The presence of an omovertebral bar did not affect the final functional outcome, nor did the presence of associated congenital anomalies. CONCLUSION: The Woodward procedure is a reliable method for obtaining uniformly predictable results in Sprengel's shoulder. The surgery should be performed at a younger age in order to optimise the functional outcome.

Flexible intramedullary nailing in paediatric femoral fractures. A report of 73 cases.

BACKGROUND: Flexible intramedullary nailing has emerged as an accepted procedure for paediatric femoral fractures. Present indications include all patients with femoral shaft fractures and open physis. Despite its excellent reported results, orthopaedic surgeons remain divided in opinion regarding its usefulness and the best material used for nails. We thus undertook a retrospective study of paediatric femoral fractures treated with titanium or stainless steel flexible nails at our institute with a minimum of 5 years follow up. MATERIAL AND METHODS: We included 73 femoral shaft fractures in 69 patients treated with retrograde flexible intramedullary nailing with a minimum follow up of 5 years. Final limb length discrepancy and any angular or rotational deformities were determined. RESULTS: Mean age at final follow up was 15.5 years (10-21 years). Mean follow up was 7.16 years (5.0-8.6 years). Titanium and stainless steel nails were used in 43 and 30 cases respectively. There were 51 midshaft, 17 proximal, and 5 distal fractures.All fractures united at an average of 11 weeks but asymptomatic malalignment and LLD were seen in 19% and 58% fractures respectively. LLD ranged from -3 cm to 1.5 cm. Other complications included superficial infection(2), proximal migration of nail(3), irritation at nail insertion site(5) and penetration of femoral neck with nail tip(1). There were 59 excellent, 10 satisfactory and 4 poor results. CONCLUSION: Flexible intramedullary nailing is reliable and safe for treating paediatric femoral shaft fractures. It is relatively free of serious complications despite asymptomatic malalignment and LLD in significant percentage of fractures.

Splenic abscess in children: a report of three patients.

Splenic abscess is uncommon in paediatric age group. It usually occurs in conditions of disseminated infective focus. Conventional treatment of abscess is incision and drainage, although splenectomy or splenic conservation is alternative. In this report, we are presenting case summaries of three patients suffering from splenic abscess. A retrospective review of three children was managed for splenic abscess in our institution.All three patients presented with pyrexia, weight loss, and recurrent abdominal pain for more than six weeks. Human immunodeficiency virus (HIV) antibody detection test (ELISA) was nonreactive in all of them. The first patient was managed by splenectomy because of multiple splenic abscesses involving the entire spleen; the second one had exploratory laparotomy and drainage of splenic abscess with preservation of the spleen; and the third patient had successful ultrasonic guided aspiration of abscess. The follow-up ultrasonography done after three and six months in two patients, with splenic conservation, did not reveal any recurrence of abscess. In children with splenic abscess, ultrasound guided aspiration of abscess should be the first line of treatment, when this fails either because of multiple abscesses or dense adhesions around the spleen then splenectomy or open drainage may become necessary.