Cervical spondylolysis in children: is it posttraumatic?

Cervical spondylolysis is a rare defect of unknown etiology. Five cases of cervical spondylolysis as well as two cases of fractures of the pedicles of C2 in infants are presented. Comparison of the cases suggests that a fracture at birth or in infancy may be the cause of some cases of cervical spondylolysis.

Semitendinosus tenodesis for repair of recurrent dislocation of the patella in children.

Recurrent dislocation of the patella is more common in girls than in boys. Although several predisposing factors may exist, patellar dislocation is most commonly associated with familial ligamentous laxity. Many surgical repairs have been described to stabilize the patella. We have found the semitendinosus transfer to the patella to result in a predictable, stable patellofemoral joint without risk of injury to the proximal tibial physis. Between January 1990 and December 1997, 29 children have been treated at the Children's Hospital of Eastern Ontario with a semitendinosus transfer for recurrent dislocation of the patella. Seven children were excluded from the study because of insufficient follow-up; consequently this series consisted of 22 children. Four children underwent bilateral repairs, hence 26 knees that have been operated on with this procedure were included in this study. There were three boys and 19 girls, with an average age at surgery of 14 years and 4 months, ranging from 8 years and 11 months to 17 years and 10 months. The average length of follow-up was 3 years and 2 months, ranging between 2 years and 7 years and 4 months. All children had experienced greater than three episodes of recurrent dislocation of the patella. Pain consistent with patellofemoral syndrome or chondromalacia was present in 17 of 26 knees. On clinical examination, 10 knees exhibited marked ligamentous laxity. There were nine positive patellar apprehension tests, and eight patellae were hypermobile. All children were treated with a semitendinosus transfer to the patella with concomitant tightening of the medial retinaculum and a lateral retinacular release. On long-term follow-up, 23 of the 26 knees (88%) were asymptomatic, and the child had returned to regular activities. Each child completed the Lysholm and the subjective component of the Zarins-Rowe questionnaire to determine the subjective results of the repair procedure. Three children complained of patellofemoral symptoms. One child experienced recurrence of the patellar dislocation, and one child developed medical patellar subluxation.

Musculoskeletal manifestations of the Antley-Bixler syndrome.

The Antley-Bixler syndrome is a rare disorder with many musculoskeletal anomalies that demand orthopedic assessment. The syndrome includes skeletal, craniofacial, and urogenital anomalies. The most common skeletal deformities are radiohumeral synostosis, craniosynostosis, multiple joint contractures, and arachnodactyly. Other orthopedic manifestations that may occur are femoral bowing, ulnar bowing, camptodactyly, synostoses of carpal and tarsal bones, clubfoot, vertebral body anomalies, perinatal fractures, and advanced skeletal age. The inheritance pattern is thought to be autosomal recessive. A patient with this syndrome is described, which is the 18th of 24 reports published in the world literature. This case is compared with the other reported cases.

Infantile hemangiopericytoma of the musculoskeletal system: case report and literature review.

Infantile hemangiopericytoma is an uncommon cause of a soft-tissue mass in the neonatal period. Only 86 of these tumors have been reported in the literature. Thirty of these were located in the extremities. This review presents a case of infantile hemangiopericytoma localized to the knee in an 8-month-old infant. Current literature suggests that the majority of these lesions are benign, and surgical excision is curative. Recurrence and metastatic disease rarely occur. Because 30-50% of infantile hemangiopericytomas occur in the extremities, orthopaedic surgeons should be aware of and familiar with this tumor.

Anterior cruciate ligament tears in children: an analysis of operative versus nonoperative treatment.

A 12-year retrospective analysis of 42 children with arthroscopically confirmed anterior cruciate ligament disruption was undertaken to determine (a) the subjective efficacy of treatment, (b) the clinical and biomechanical results of operative and nonoperative management, and (c) the most appropriate long-term outcome measurements. Patients were followed up for a mean of 5.3 years from the time of initial treatment and were between the ages of 5 and 17 years (mean, 14.4) at the time of treatment. The children were treated nonoperatively by primary ligament repair or by intraarticular anterior cruciate ligament reconstruction. In the child, a complete tear of the anterior cruciate ligament was best managed by intraarticular surgical reconstruction. This was confirmed by clinical examination (p < 0.01), by a composite knee score involving a clinical examination and patient questionnaire (p < 0.0005), and by testing with the KT-1000 arthrometer. No significant differences in outcome could be attributed to the patient age or the maturity of the growth plates. In the active child, anterior cruciate reconstruction for complete tears resulted in a more stable and functional knee.

The management of spinal metastasis in children.

OBJECTIVE: To seek an optimal treatment plan from the results of treatment for metastatic disease of the spine in children. DESIGN: An 8-year retrospective study of children with metastatic disease of the spine. Imaging studies were reviewed and treatment modalities analysed. SETTING: The divisions of pediatric orthopedics and pediatric neurosurgery at the Children's Hospital of Eastern Ontario, Ottawa. PATIENTS: All children seen between April 1980 and December 1987 who had lesions metastatic to the spine by hematogenous or direct extension. There were 20 children (15 boys, 5 girls) with a mean age at the time of diagnosis of 9.5 years. Follow-up ranged from 2 weeks to 108 months. One child was lost to follow-up. INTERVENTIONS: Eleven children underwent laminectomy and decompression. Of the 14 neurologically compromised children, 5 received chemotherapy and radiotherapy and 9 received chemotherapy, radiotherapy and surgery. MAIN OUTCOME MEASURES: Type of metastatic lesion, vertebrae involved and response to therapy. RESULTS: Vertebrae involved with metastases were as follows: cervical (3), thoracic (5), lumbar (8) and multilevel (2). Meninges were involved in 2 cases. The most common causes of metastatic spinal involvement were neuroblastoma (4 cases) and astrocytoma (6 cases). Pathologic fractures occurred in 4 children and kyphoscoliosis in 4. Spinal cord paresis developed in 14 of the 20 children. Of the 6 children who survived from 48 to 108 months, 5 had tumours of neural origin, 4 being astrocytomas. Children with neuroblastoma or leukemic infiltration had a good initial response to chemotherapy. Five of the 6 surviving children had astrocytomas, and 5 were treated by surgical decompression. CONCLUSIONS: Metastatic disease of the spine in children secondary to astrocytoma should be treated aggressively, but from the experience gained from this study it is impossible to devise a rigid treatment plan for each type of metastatic tumour. The choice of chemotherapy, radiotherapy or surgery depends on the type of tumour, the age of the child and whether or not the spinal cord is compromised.

Isolated fractures of the tibia with intact fibula in children: a review of 95 patients.

Isolated tibial fractures with an intact fibula are the most common tibial fracture pattern in children. When displaced, this fracture can be difficult to reduce and retain in the position because of the splinting of the intact fibula. A 4-year review of 95 children with fracture of the tibia with an intact fibula was performed at the Children's Hospital of Eastern Ontario. Eighty-one percent of the fractures were caused by an indirect rotational twisting force. Seventy-three percent of fractures were localized at the distal third of the tibial shaft. Varus angulation deformity occurred most commonly when the fracture line started distally on the anteromedial side of the tibia and progressed in an oblique or spiral manner to the proximal posterolateral aspect of the tibia. This was postulated to be caused by the posterior flexor muscle forces being more concentrated medially, whereas laterally, the intact fibula acts like a splint, thus producing a bending moment resulting in varus angulation. Close follow-up and monitoring of the isolated tibial fractures with weekly radiographs for the first 3 weeks is recommended.

Pediatric Chance fractures: association with intra-abdominal injuries and seatbelt use.

Seven cases of Chance fractures of the spine in children are presented, with their association to intra-abdominal injuries secondary to seatbelt use. A discussion and review of the literature suggest an increasing frequency of this particular injury with a high association given the clinical sign known as the "seatbelt sign." Also reviewed is the association of intra-abdominal injuries secondary to seatbelt restraints, and particular attention is paid to the concurrence of intra-abdominal injury with Chance fractures of the spine. The unique features of the pediatric anatomy in relation to the design of the adult seat restraint as it relates to the vertebral fracture and intra-abdominal injuries are noted. A review of the literature discusses the development of a classification for this flexion-distraction type of vertebral injury, and supports our experience of the increasing frequency of these particular injuries with increasing seatbelt use.

Pediatric update #7. The orthopaedic manifestations of head injury in children.

The incidence of significant head injury has been estimated at 220/100,000 children. Over 90% of these will recover with little residual disability. The purpose of this study is to re-examine the small but significant percentage of head injured children with permanent total body involvement to identify patterns of deformity and temporal sequences and to develop preventive treatment regimens. Sixteen head injured children with residual spastic quadriplegia were examined. All exhibited musculoskeletal abnormalities. Hip adduction contractures were most common leading to hip subluxation in eight children, followed by pes equinus, scoliosis, pelvic obliquity, and knee flexion contracture. The average time to onset of permanent foot deformity was 11 months after head injury, for scoliosis an average of 22 months postinjury, and for hip subluxation an average of 31 months postinjury. Hamstring contractures occurred later, at an average of 37 months, but caused the most interference with good seating. The physical problems of the head injured child have some similarities to those of the child with cerebral palsy, but with distinct differences. An aggressive surgical approach to prevention and treatment of fixed deformity in these children is recommended at an early stage with postoperative orthotic management and stable seating in abduction.

1-Desamino-8-D-arginine vasopressin (desmopressin) decreases operative blood loss in patients having Harrington rod spinal fusion surgery. A randomized, double-blinded, controlled trial.

To evaluate the effect of 1-desamino-8-D-arginine vasopressin (desmopressin) on blood loss in surgery, we conducted a randomized, double-blind trial of the drug in 35 patients with normal hemostatic function who were having spinal fusion with Harrington rod instrumentation. Seventeen patients were designated to receive 10 micrograms/m2 of desmopressin, and 18, to receive a placebo. Preoperative testing showed that desmopressin increased factor VIII coagulant activity, von Willebrand antigen concentrations, glass bead platelet retention, and prothrombin consumption and decreased the partial thromboplastin and bleeding times (p less than or equal to 0.0003). During surgery, desmopressin reduced blood loss by 32.5% (547 mL; 95% confidence interval [CI], 19 to 1075; p = 0.015) and reduced the need for concentrated erythrocyte transfusions by 25.6% (0.86 units; 95% CI, 0.08 to 1.65; p = 0.022). After surgery, desmopressin reduced the duration of treatment with analgesic agents by 13.1% (34.0 hours; 95% CI, -5.2 to 72.7; p = 0.105), presumably by decreasing bleeding in the surgical wound. When adjusted for the origin of the scoliosis by two-way analysis of variance, this effect was even more evident (p = 0.014). Multiple regression analysis showed that the best three predictors of blood loss in surgery and transfusion requirements were the bleeding time, glass bead platelet retention, and the use of desmopressin.

Computer corner #16. Computer as an aid in orthopaedic slide production.

The state of the art in the field of graphics presentation is increasing almost monthly. At the present time, however, there is the software capability to allow orthopaedic surgeons to become quite competent in the production of quality graphic material, especially the production of 35-mm slides of a quality that can be presented at any orthopaedic meeting for a modest cost and minimal production time.

Computer corner #15. The AAOS: request for computer system proposal.

The Committee on Computer Science and Practice Management of the American Academy of Orthopaedic Surgeons has provided an excellent format to ensure a happy relationship between the vendor and the orthopaedic office using this package. Problems in communication and understanding between the vendor and the orthopaedic surgeon will undoubtedly be significantly reduced. How the system will work is the vendor's problem, but what you want it to do for you is your problem, and both of these issues are addressed in these questionnaires. It is recommended in the computer package that three vendor proposals be invited. Since the most frequent cause of computer problems is improper evaluation of what functions the computer system must perform in order to meet the needs of the orthopaedic office, this series of questionnaires is important. In addition to recommending this computer package, I would also emphasize that if at all possible--in spite of what may appear to be an excellent system on paper--try to visit an office in which the system has been in use over the past six to 12 months.

Computer corner #13. Computerized examinations in orthopaedics.

Computerized examinations can play an important role in the evaluation and education of trainees in orthopaedics. Several centers in the United States and Canada are currently using these, thus allowing an exchange of examination questions. Once a system is set up, only minimal involvement on the part of the instructor and office staff is required. All participants--trainees and instructors--can benefit from computerized examinations.

Degloving injuries in children.

Degloving injuries are uncommon but serious and are being encountered with increasing frequency in children. A 5-year review of experience with degloving injuries on the Orthopaedic Service at the Winnipeg (Manitoba, Canada) Children's Hospital revealed 16 patients who had sustained this trauma in association with fractures. Twelve of these children had typical anatomical degloving. However, six patients had an associated concealed degloving or so-called "physiological degloving," with disruption of the underlying skin vasculature but no actual disruption of the skin surface. The most common causes of degloving injuries were being run over by a motor vehicle and farm machinery accidents. The diagnosis and proper management of the degloved extremity, especially when accompanied by underlying fracture, are essential in children if morbidity and limb loss are to be minimized.

Conversation in the operating theater as a cause of airborne bacterial contamination.

Using microspheres of human albumin sprayed on the face and in the nostrils under the facemask, we studied the role of conversation in contaminating the operating-room environment in addition to the microbial contamination of the air in an empty and in an occupied operating room. Conversation consistently increased the number of microspheres found in the simulated wound. The spatial relationship between the mask and the hood was important in reducing contamination. A complete hood overlapping the mask, with no gaps at the sides or bottom of the mask, was most efficient. The air contamination was increased by the presence of operating-room personnel and varied in different parts of the theater according to the density of traffic. We concluded that conversation contributes to airborne contamination in the operating theater but that contamination from this source can be lessened by wearing a face-mask that extends underneath an overlapping hood.

The hidden adolescent ankle fracture.

Ankle injuries are common in adolescence, seldom initially seen by orthopaedists, and often treated primarily by emergency department personnel. It is often not appreciated that the distal tibial growth plate fuses in a mediolateral direction, leaving it open and vulnerable to growth plate injuries for a longer period during adolescence. Fractures of the lateral plafond of the tibia are often not appreciated due to overlap of the fibula. A review of the injuries at the Winnipeg Children's Hospital has revealed these are not as uncommon as often supposed. A 3 year experience yielded 26 patients with so-called "Tillaux fractures" of which 9 could be diagnosed only by the oblique view and 5 were initially missed. Knowledge of the anatomical behavior of the fusing tibial growth plate in the ankle-injured adolescent plus mandatory oblique views of the ankle in this age group should enable the casualty officer in a busy emergency department to bring this fracture out of hiding and make the diagnosis in every instance.

Influence of spinal curvature on exercise capacity.

It is well recognized that scoliosis in excess of 65 degrees results in cardiorespiratory impairment. Lesser degrees of spinal curvature have been noted to have near normal respiratory function studies at rest. Because of the great cardiorespiratory reserve, decreases in function secondary to scoliosis may be masked in studies conducted at rest. To study this concept, an investigation of the work capacity of 38 adolescent children with varying degrees of adolescent idiopathic scoliosis was undertaken. The maximal oxygen capacity and endurance time was measured and compared with a group of normal controls. A significant negative correlation between percentile endurance time and degree of spinal curvature was found showing a reduction in endurance time with every 20 degrees increase in spinal curvature (p less than 0.006). The application of "the exercise capacity test" as an investigative tool for scoliosis was found to be practical, since endurance time is a reliable index of the cardio-pulmonary status.

Fractures of the neck of the talus in children.

A review of children with talar injuries treated at the Winnipeg Children's Hospital yielded 12 patients that had been treated for fractures of the neck of the talus between 1960 and 1978, inclusive. Three developed avascular necrosis of the body of the talus; two of these had their fractures recognized only after avascular necrosis had become radiologically evident. The children ranged in age from 1 year 7 months to 13 years 11 months at the time of the injury. Fracture of the neck of the talus does occur in children and may be associated with avascular necrosis of the body. This injury should be considered and the talus should be examined in all children sustaining trauma secondary to falls from a height or motor vehicle trauma.