Recurrence of a primary xanthoma of the humerus in a 9-year-old normolipidemic child.

Xanthomas are rare bone tumors that occur more often in patients with hyperlipidemia or metabolic disorders. We report the case of a 9-year-old child presenting with right shoulder pain after a trauma. A benign osteolytic lesion was found in the proximal humeral metaphysis. Curettage of the lesion was performed. Histologic findings confirmed intraosseous xanthoma. Although there was no evidence of dyslipidemia or metabolic disease, the patient suffered local recurrence at the 8-month follow-up, requiring a second surgery with bone grafting. This difficult and rare diagnosis must be kept in mind with osteolytic lesions.

[Sleeve fracture of the patella: A diagnosis not to be underestimated]. / Un diagnostic à ne pas méconnaître : la fracture avulsion de la patella.

Fracture of the patella is quite rare in children. However, sleeve fractures of the patella are specific to the child. We report on the case of a 12-year-old boy who suffered complete functional incapacity with hemarthrosis and symptoms that suggested rupture of the extensor apparatus. It occurred after abrupt extension of the knee during a high jump. The x-ray showed an ascended patella. The diagnosis was made and emergency surgical exploration showed a sleeve fracture. Surgical repair provided a good result, with a 2-year follow-up. A literature review found 59 cases in 20 studies with a majority of case reports with only two series over ten cases. The ages and mechanisms are identical to those observed in our study. Diagnosis is difficult and must be clearly determined. The two important signs are the ascension of the patella and the depression to its lower extremity. The prognosis is most often conditioned by rapid surgical repair.

[Osteoid osteoma on distal phalanx tip of second toe, without scintigraphy fixation]. / Ostéome ostéoïde de la phalange distale sans hyperfixation scintigraphique.

Osteoid osteoma is a very small painful, benign tumor, located preferentially on long bones. Cases on the phalanxes of the toes are very rare. Pain takes up nearly all the clinical presentation. Poor clinical signs and atypical location make diagnosis difficult and delayed. Sometimes, it can be confused with local infection. Various additional tests are described to help diagnosis. Technetium 99-m scintigraphy coupled with CT is the key exam with high sensitivity and morphological accuracy. We report on the case of a 10-year-old boy with an atypical location of osteoid osteoma on the distal phalanx tip of the second toe, without scintigraphy fixation and obvious nidus on X-ray and CT scan.

ACL reconstruction in children: a transphyseal technique.

The annual incidence of ACL tears is increasing steadily in pediatric patients. Chronic anterior instability causes meniscal lesions at a frequency that increases significantly with the injury-to-surgery interval. Conservative therapy, simple suturing, and isolated extra-articular tendon reconstruction are associated with high failure rates. Intra-articular arthroscopy-assisted tendon reconstruction is a good treatment method, although several different techniques have been described. We used a transphyseal technique with a hamstring tendon graft to treat 14 knees in 13 patients with a mean age of 13 years and 7 months. Mean injury-to-surgery interval was 6 months. Strict compliance with technical rules is required when using this technique. Bone tunnel diameter must not exceed 8 mm. Bone tunnels must be as vertical and central as possible. The fixation material must not bridge the physis (at the femur, cortical fixation; and at the tibia, fixation using a resorbable screw no longer than 25 mm combined with a staple). Meniscal lesions were present in half the knees and meniscal preservation considered mandatory. Conservative treatment of concomitant lesions was performed routinely. After a mean follow-up of 15 months, no recurrent tears or revision procedures for meniscectomy had been recorded. The IKDC grade was A or B in 93% of knees. The mean subjective IKDC score was 83.3 and the Lysholm score was in the excellent or good range in 93% of knees. Of the 14 knees, 2 exhibited signs suggesting femoral epiphysiodesis, with 4° of valgus deformity compared to the contra-lateral knee and no clinical consequences. Transphyseal reconstruction with open physes conducted in strict compliance with technical rules can be performed to control the instability and preserve the menisci. Nevertheless, this technique carries a risk of epiphysiodesis, chiefly at the femur.

[Epidemiological survey of wrist fractures in children]. / Les fractures du poignet de l'enfant: étude épidémiologique.

PURPOSE OF THE STUDY: The incidence of wrist fractures is increasing in children. We undertook an epidemiological survey in western France to determine characteristic features. MATERIAL AND METHODS: A prospective multicentric study was conducted over one year in five university hospital centers in western France. The survey included 839 wrist fractures in children aged 6 to 16 years. The following criteria were recorded: age and gender, date and energy of the trauma, side and description of the fracture. Displacement was measured on the AP and lateral radiographs. RESULTS: The boys were older than the girls at the time of the wrist fractures, generally during the summer season (May to October). The left wrist was involved in 55% of the fractures; 83% were metaphyseal fractures. Fractures with epiphyseal detachment were more frequent in adolescents and occurred after high-energy trauma. Metaphyseal fractures were more common in girls than in boys. Displacement was greater in older children, particularly in case of epiphyseal detachment. DISCUSSION: We did not observe the male predominance often reported in our country. The girls probably practice sports as much as boys.

[Angiomatoid fibrous histiocytoma: a rare pathologic entity]. / Histiocytome fibreux angiomatoïde: une entité rare.

Angiomatoid fibrous histiocytoma is an unusual tumor, affecting primarily young adults who develop local disease with favorable prognosis. This contrasts with the aggressive natural history of malignant fibrohistiocytoma. We report case of a 9-year-old girl who presented with a tumor mass of soft tissues with an unusual deep location, thereby with non distinctive clinical features. Surgical treatment was performed.

[Foot deformities in longitudinal ectromelia of the lower limbs]. / Les anomalies du pied dans les ectromélies longitudinales des membres inférieurs.

We have studied 204 feet in 181 children with congenital limb shortening. There were 17 short femurs in 11 children in whom it was impossible to lengthen the leg. Thirteen feet were abnormal. It was necessary to adapt the foot to fit the chosen prosthesis. In 34 children it was possible to correct the length of the short femur. In 21 the feet were normal. 13 had abnormal feet associated with fibular aplasia and deformities included equinovalgus, hind foot synostosis, and deficient rays. In 72 children with congenital hypoplasia or aplasia of the fibula, 76 feet were affected. The function of the foot depends on attaining a stable position beneath the tibia. In 34 children (35 feet), the feet were in a stable position. There were 22 ball and socket ankle joints. Before carrying out leg lengthening, operation was necessary on 9 feet, and a further 13 required operation after lengthening had been carried out. In 34 children (41 feet) there was fibular aplasia. The feet lay in equinovalgus and were often narrow. Only 5 did not have a degree of synostosis. Twenty-three feet in twenty two children were operated on with early soft tissue release, tendon transfer and tibiotalar arthrodesis. This is our treatment of choice. Twenty-seven children had tibial dysplasia which affected 37 feet. The feet lay in equinovarus and in 5 there was partial diplopodia. In the absence of a tibia (19 feet) disarticulation of the knee was carried out. In 12 there was proximal shortening of the tibia which in 9 cases was treated by tibiofibular union. It was possible to retain only 2 feet in a proper position in a lengthened leg. In 30 children (33 feet) both fibular and tibial hypoplasia was present. The feet functioned well. There were 22 ball and socket ankles, 28 narrow feet and numerous synostoses. In limbs with atypical dysplasia 7 abnormal feet were noted. If it is possible to preserve or lengthen the limb it is vital that the foot is retained in a stable position beneath the tibia in order that satisfactory function be obtained. If limb lengthening is impossible, the foot must be adapted to match the prosthesis.

Desepiphysiodesis--elimination of partial premature epiphyseal closure. Experience of 17 cases.

Between 1975 and 1990, 17 growth plates have been operated on by epiphyseal bridge resection. The children were from 4 years and 10 months to 13 years and 10 months old. The etiology of partial closure was traumatic (10 times), caused by therapeutic mistakes (3 times), septic osteomyelitis (1 case), purpura fulminans (1 case), unknown (2 cases). There was always length discrepancy or deformity of bone. The regions that have been subjected to treatment were distal femur, proximal tibia, distal tibia, distal radius. Evaluation of the bone bridge was made by tomoscintigraphies and recently by MR imaging and computed tomoscintigraphy. The bone bridge size was from 2.5% to 60% of the growth plate surface; surgical technique consists of resection of bone bridge connecting epiphysis and metaphysis which is replaced by methyl metacrylate. In 16 cases simultaneous corrective osteotomy was performed. Results are poor, there were only two good results and 8 failures; seven results were medium. The failures can all be explained by mistakes in technique or indication, except one. Indications are post-traumatic narrow bridges in young children. It would be useful to know the vitality of the residual growth plate.

[Acute infectious arthritis of the knee in children. Prognosis and therapeutic discussion apropos of 51 cases with an average follow-up of 5 years]. / Les arthrites aiguës infectieuses du genou de l'enfant. Pronostic et discussion thérapeutique à propos de 51 cas ayant un recul moyen de 5 ans.

The purpose of this paper was to evaluate the results after acute septic arthritis of the knee in children and to discuss the method of treatment. 51 cases records of septic arthritis of the knee in children were studied with an average follow-up of 5 years. The etiology was hematogenous in 42 cases, penetrating wounds in 7 cases and osteomyelitis in 2 cases. Treatment was chiefly joint washing by arthrotomy 36 times, arthroscopy 4 times, with a needle 8 times; 3 synovectomies were necessary. Patients underwent systematic joint immobilization and parenteral antibiotics. The results were excellent in 35 cases, good in 10 cases, fair in 6 cases. Prognosis was good for hemategenous arthritis, but much less so for arthritis secondary to penetrating wounds and osteomyelitis. The essential factor for a good result was an early diagnosis and treatment. Apart from 2 arthrodeses, functional results were good. One of the noteworthy facts of our series was the great number of negative cultures (68 per cent). Treatment is discussed according to literature. Joint washing by arthroscopy has the double advantage of being simple and innoculous, and enables synovial biopsy. Immobilization at first seems necessary but its duration can be shortened to encourage articular cartilage nutrition. Antibiotics must be given parenterally at first, to be continued by oral administration as soon as their efficiency is proven. To evaluate this, CRP seems to be an efficient test.

[Non-traumatic myositis ossificans in a child. Review of the literature apropos of a case mimicking malignant tumor]. / Myosite ossifiante non traumatique chez l'enfant. Revue de la littérature: à propos d'un cas simulant une tumeur maligne.

A ten year nine month-old girl was admitted to hospital for a painful inflammatory tumour of the right popliteal area. There was a calcification on X-ray and computerised angiography showed a tumour. MRI showed a heterogenous irregular mass. This looked like a malignant tumour. At surgical biopsy: it was a circonscripta myositis ossificans. This benign tumour of soft tissues, rare in children (25 cases in the literature), had a spontaneous favourable evolution. Differential diagnosis with malignant tumour is well known, but is still difficult. Biopsy is necessary in doubtful cases. We had to remove the mass because of acute pain.

[Operations for lengthening the upper limbs in children and adolescents]. / Les opérations d'allongement du membre supérieur chez l'enfant et l'adolescent.

We report 16 cases of lengthening of the upper limb: 4 humerus, 12 ulna from 1976 to 1987. Humerus lengthening are progressive with Wagner apparatus. They gave lengthening from 7.5 to 12 cm. There were no important complication. Ulna lengthening were done in patients with multiple hereditary osteochondromes and hereditary multiple exostoses, to correct the deformities of the forearm, and prevent dislocation of the proximal radial head. Actually progressive lengthenings replace immediate ones with radial osteotomy.

[Orthopedic aspects of congenital insensitivity to pain]. / Les aspects orthopédiques de l'insensibilité congénitale à la douleur.

The congenital insensitivity to pain regroups some rare diseases which are mainly 5: congenital insensitivity to pain; congenital sensitive neuropathies; distal sensitive neuropathies; Riley-Day syndrome or hereditary dysautonomia; at last, miscellaneous troubles. Three different cases are reported in children: true congenital insensitivity to pain; hereditary dysautonomia or Riley-Day syndrome; congenital insensitivity to pain localised to a lower limb joined to amniotic disease and abnormality of this limb. The orthopedic symptoms (osteomyelitis, arthropathies as Charcot type, dislocations, fractures) lead often to diagnosis and they are an important step of the prognosis. Scoliosis seems to be frequent in this disease. The orthopedic and surgical treatment, according to each localization, is difficult and must emphasize the prevention of bones and joints injuries.