Premature epiphyseal fusion and degenerative arthritis in chronic recurrent multifocal osteomyelitis.

A 9-year-old boy was diagnosed with chronic recurrent multifocal osteomyelitis affecting multiple sites. During an 8-year follow-up he developed premature closure of a distal radial epiphysis and degenerative changes in the adjacent radiocarpal joint.

The "flatback" cast.

A properly applied above-elbow cast in a child presents difficulties not seen in adults. Because of the differences in anatomy, physiology, and compliance, children can benefit from modification of the standard above-elbow cast. We report on a method of application of the "flatback" cast to address these concerns.

Heterotopic ossification in children after iliopsoas release.

Heterotopic calcification or ossification of the soft tissues adjacent to the lesser trochanter was observed in the radiographs of 4 patients during a retrospective review of the records of 68 patients with Perthes' disease. This abnormality has since been seen in one other patient with Perthes' disease and in five with spastic quadriplegia. All 10 patients are known to have undergone iliopsoas release as part of adductor tenotomy. The authors believe that the heterotopic ossification is related to the surgery.

Traumatic pseudodislocation of the acromioclavicular joint in children. A fifteen year review.

Traumatic acromioclavicular separation in the skeletally immature patient is frequently overdiagnosed and overtreated. Fifty-eight children, aged 5 to 16 years, who presented over a 15 year period with injuries to the distal clavicle, were reviewed retrospectively. The majority showed coracoclavicular widening radiographically, suggesting acromioclavicular separation. In 45 cases, a distal clavicular fracture was identified, while an acromioclavicular separation without fracture was initially diagnosed in 13. Long-term followups of these patients demonstrate excellent results with conservative management. "Pseudodislocation" involves a clavicular fracture of the lateral metaphysis or metaphyseal epiphyseal separation and not an acromioclavicular disruption. This pseudodislocation of the acromioclavicular joint in the skeletally immature patient must be differentiated from the adult counterpart to avoid unnecessary operative intervention.

Orthopaedic manifestations of blastomycosis.

The cases of seventy-two patients who had blastomycosis and were seen between 1926 and 1988 were retrospectively reviewed for involvement of the musculoskeletal system. Most patients were from rural rather than urban areas (almost a 2:1 ratio), and an especially large number were from northwestern Ontario or were native Indians (primarily Ojibwa). Bone was the second most common site of involvement (seventeen patients); in approximately one-half of these patients, the osseous site did not cause symptoms. Metaphyses of long bones and small bones were involved the most; the metaphyseal lesions tended to be eccentric, well circumscribed, and lytic. There were two deaths--the most recent, more than twenty years ago--of patients who had involvement of bones and joints; these patients, by modern standards, had had inadequate treatment. Treatment with amphotericin B and, more recently, with ketoconazole, in conjunction with operative treatment, was very effective.

The toddler's fracture revisited.

The authors have reviewed our experience with 37 cases of toddler's fracture. This fracture of the distal tibia occurs in 1 to 4 year-old-children. History of trauma is usually trivial and the physical findings and radiological appearance are often subtle. The latter consists of a faint oblique lucent line crossing the distal tibia and terminating medially. It is usually seen on the anteroposterior view, poorly seen on the lateral and well seen on the internal oblique. Initial radiographs may be normal. A similar fracture of the midshaft of the tibia was associated with child abuse. Treatment consists of immobilization for a few weeks to protect the limb and to relieve pain. Diagnosis requires a high index of suspicion and is important because it obviates the need for investigations to rule out more sinister etiologies such as tumor or infection. The finding of a midshaft tibial fracture may indicate child abuse.

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.

Orthopaedic injuries in children associated with the use of off-road vehicles.

Two hundred and thirty-three children who had musculoskeletal injuries related to the use of off-road vehicles were admitted to acute-care hospitals in the two largest urban centers in Manitoba between April 1979 and August 1986. There were 190 boys and forty-three girls, and the ages ranged from two to seventeen years. Ninety-three accidents involved the use of a minibike or dirtbike; seventy-two, a snowmobile; fifty-nine, a three-wheeled all-terrain vehicle; and nine, a four-wheeled all-terrain vehicle. The injuries in 73 per cent of the children occurred in a rural setting. The use of alcohol or a drug was recorded for only three children. Loss of control of the vehicle led to the majority of injuries. There were 352 fractures of an extremity or the spine and fifty-one major soft-tissue injuries of the musculoskeletal system; 186 (53 per cent) of the fractures were displaced, 107 (46 per cent) of the patients had more than one fracture, and thirty-four (10 per cent) of the fractures were open. There were sixty growth-plate injuries. A total of 186 associated injuries were present in ninety-one patients. In a separate review of the records of the Chief Medical Examiner, it was noted that twenty-one fatal accidents that were related to the use of off-road vehicles occurred in the Province of Manitoba during the same period of time.

Injuries and deaths associated with off-road recreational vehicles among children in Manitoba.

Injuries and deaths associated with off-road recreational vehicles are of increasing concern in North America. We reviewed all hospital admissions and deaths attributed to these vehicles in Manitoba from April 1979 to April 1985 among children 16 years of age or younger. Of the 693 hospital admissions and deaths 480 were associated with motorbikes, snowmobiles or all-terrain vehicles (ATVs). The incidence of injuries resulting from snowmobile and dirtbike accidents remained stable over the study period; however, there was an almost exponential increase in the number of admissions because of ATV-related injuries. There were 21 deaths during the study period. Preventive measures through legislation are necessary to reduce the numbers of injuries and deaths; these include mandatory registration, licensing and enhanced safety regulations.

Orthopaedic manifestations of leukemia in children.

Acute leukemia of childhood may present with various clinical manifestations that mimic orthopaedic conditions. The osseous radiographic abnormalities of this disease, although well described in the literature, are not pathognomonic, and certain changes may not be as frequent as was previously thought. In a retrospective study, we reviewed the cases of 107 patients, less than eighteen years old, who had been seen at the Winnipeg Children's Hospital. The mean follow-up was 4.6 years for the fifty-eight patients who were still alive and 2.0 years for the forty-nine non-survivors. In twenty-two (20.6 per cent) of the patients, the presenting complaints were pain in the extremities, back pain, osteomyelitis, septic arthritis, or fracture. The radiographic abnormalities, which were present in forty-seven (43.9 per cent) of the children at the time of diagnosis, were osteopenia, lytic lesions, metaphyseal bands, periosteal new bone, and sclerotic lesions. Since the initial symptoms of leukemia commonly involve the musculoskeletal system, a high index of suspicion must be maintained by orthopaedic surgeons.

Butler arthroplasty for correction of the adducted fifth toe: a retrospective study of 36 operations between 1968 and 1982.

This is a retrospective study of 30 children and adolescents who have undergone Butler arthroplasty for correction of an overriding fifth toe. Bilateral operations were performed on six patients, giving a total of 36 operations. Good to excellent results were obtained in 34 of the 36 operations. With attention to detail, this is a simple and safe operation. Full correction is obtainable without postoperative splintage or cast immobilization. This study represents the only reported experience in North America of this little-known procedure.