Displaced femoral neck fractures at the bone-screw interface after in situ fixation of slipped capital femoral epiphysis.

Two patients had displaced femoral neck fractures at the bone-screw interface after in situ fixation of slipped capital femoral epiphysis. Both fractures required closed reduction and internal fixation. Inadvertent derotation of the femur occurred in both patients and allowed fixation of the fracture through the intramedullary canal of the femoral neck without anterior penetration of the pins into the joint; a nonunion occurred in this patient. The other patient developed chondrolysis and avascular necrosis. Because the femoral neck is vulnerable to stress fractures in young adults, there is some question whether pins placed anteriorly through the femoral neck cortex should be removed.

Chondrolysis after slipped capital femoral epiphysis.

Chondrolysis, or acute cartilage necrosis, is a controversial and perplexing complication of slipped capital femoral epiphysis (SCFE) in adolescents. It usually leads to deformity, pain, limping, and limitation of motion in the affected extremity. Although several theories have been proposed, no agreement has been reached as to the etiology or the pathogenesis of chondrolysis. Furthermore, no treatment program has been completely successful, and the general prognosis and natural history of this condition are not clear. An overview of the latest knowledge of the matter is presented.

Subtrochanteric fracture after fixation of slipped capital femoral epiphysis: a complication of unused drill holes.

Subtrochanteric fracture of the femur has been infrequently reported after in situ fixation of slipped capital femoral epiphysis, and this occurred in only 1.4% of our patients over a 10-year period. As this technique is used more frequently, however, the incidence of this complication is likely to rise. All four subtrochanteric fractures occurred through unused drill holes, and avoiding extraneous screw holes seems to be the best way to prevent postoperative subtrochanteric fracture. Once subtrochanteric fracture occurs, immediate open reduction and internal fixation with a compression hip screw device is the recommended treatment.

Prediction of angular deformity and leg-length discrepancy after anterior cruciate ligament reconstruction in skeletally immature patients.

Injuries to the anterior cruciate ligament (ACL) in young children and adolescents are becoming more common as more youngsters participate in organized sports. The dilemma for the orthopaedic surgeon is that untreated ACL ruptures may result in meniscal damage and joint degeneration, whereas surgical treatment may result in physeal arrest, with shortening and angular deformity. To help determine the appropriate timing for ACL repair in skeletally immature patients, graphs have been developed to predict the amount of shortening and angular deformity to expect after repair.

Interlocking intramedullary nailing of femoral-shaft fractures in adolescents: preliminary results and complications.

Thirty-one femoral-shaft fractures in 30 patients were treated with interlocking intramedullary nails. The 19 boys and 11 girls ranged in age from 10 to 15 years (average age 12 + 3 years) at the time of injury. All fractures united, and the average leg-length discrepancy (comparing the injured to the uninjured extremity) was 0.51 cm. Two patients had overgrowth of > 2.5 cm; none had angular or rotational malunions. One patient developed asymptomatic segmental avascular necrosis of the femoral head, which was not seen on radiographs until 15 months after injury. All nails were removed at an average of 14 months after injury; no refracture or femoral neck fracture has since occurred. Intramedullary nailing is a reasonable alternative for the treatment of isolated femoral-shaft fractures in older adolescents and in younger adolescents with multiple trauma.

Fractures of the patella in children and adolescents.

Patellar fractures are rare in children and usually result from high-energy trauma. Treatment guidelines generally are the same as for patellar fractures in adults. Between 1942 and 1987, 66 children with patellar fractures were treated. Exclusion of those with < 2-year follow-up, osteochondral fractures, or incomplete records left 24 patients for long-term follow-up. Overall results were good in 13, fair in eight, and poor in three. Children with fractures of the ipsilateral femur and/or tibia and those with comminuted, displaced fractures had the poorest results.

Long-term follow-up of patients with avascular necrosis after treatment of slipped capital femoral epiphysis.

A retrospective review of 264 patients treated for slipped capital femoral epiphysis (SCFE) identified 36 who developed avascular necrosis (AVN). Twenty-two patients (24 hips) were evaluated at an average follow-up of 31 years. Nine have undergone reconstructive surgery: four during adolescence and five during adulthood. The remaining 13 patients (15 hips) have had no further operations, but all show degenerative changes on current roentgenograms. The natural history appears to be that of gradual degenerative changes for which reconstructive surgery most often can be delayed until adulthood.

Fractures of the olecranon in children: long-term follow-up.

Olecranon fractures are relatively uncommon in children, and most are nondisplaced or minimally displaced fractures that can be treated by closed methods. During a 30-year period, 44 olecranon fractures were treated. Of 41 fractures with adequate follow-up, 37 (90%) had satisfactory results. Of 30 undisplaced or minimally displaced (< 5 mm) fractures, 28 (93%) had satisfactory results. Seven of 9 (78%) displaced fractures had satisfactory results. The most common cause of unsatisfactory results was loss of motion, although this usually did not prevent good function.

Ruptures of the proximal biceps tendon in middle-aged patients.

Treatment of ruptures of the proximal biceps tendon has been based on clinical observations, with little objective data to substantiate treatment guidelines. Evaluation of 25 patients (all > 40 years of age) at an average of 7.9 years after injury found few objective or subjective differences between those treated nonoperatively and those treated operatively. Only 1 patient (treated nonoperatively) was dissatisfied with the result, and her dissatisfaction was with a cosmetic defect. Objective manual muscle testing and Cybex II (Cybex Corporation, Ronkonkoma, New York) evaluation of 19 patients found no significant differences in supination or elbow flexion strength in the two groups.

Iselin's disease.

Iselin's disease (traction apophysitis of the tuberosity of the fifth metatarsal) has been reported rarely, but is probably more common than appreciated. It appears to be more common in athletically active older children and adolescents. Four patients with this condition were treated conservatively and all had resolution or improvement of symptoms. In one, however, nonunion developed and continues to cause intermittent pain at age 20 years. Early recognition and treatment may prevent long-term complications.

A fluoroscopic technique for determining the incision site for percutaneous fixation of slipped capital femoral epiphysis.

A fluoroscopic technique, and its geometric basis, used to determine the incision site for percutaneous fixation of slipped capital femoral epiphysis (SCFE), is described.

Fractures of the neck of the talus.

Talar neck fractures should be managed with meticulous attention to detail, and anatomical reduction is mandatory. Most type I fractures can be treated closed, unless there is loss of reduction, but type II, III, and IV, especially if displaced, usually require open reduction and internal fixation. Closed reduction may be attempted, but if the reduction is lost, or satisfactory reduction cannot be obtained, open reduction should be performed. Two incisions may be necessary to confirm accurate anatomical reduction. Poor results occur because of avascular necrosis, malunion, subtalar arthritis, and infection. Attention to detail can decrease the incidence of the latter three of these complications; the development of avascular necrosis does not seem to be related to the type of treatment. Though the most serious complication, avascular necrosis, may not require surgical intervention, many of the authors' patients have done well with conservative treatment.

Techniques for epiphysiodesis about the knee.

Percutaneous epiphysiodesis is an attractive alternative to traditional open procedures. With the aid of image intensification, the procedure is simple and reliable, has little morbidity, and produces a more pleasing cosmetic result.

Fractures of the hip in children and adolescents.

Hip fractures account for fewer than 1% of all fractures in children, and many can be successfully treated nonoperatively. Transepiphyseal, transcervical, and displaced cervicotrochanteric fractures, however, generally require closed reduction or open reduction and internal fixation to avoid complications of coxa vara deformity and nonunion. Avascular necrosis appears to be related to the severity of the initial injury and unaffected by treatment.

Problems and complications of slipped capital femoral epiphysis.

In summary, epiphysiodesis, by either "pinning" or "pegging," seems to be necessary to further prevent displacement of the SCFE. To minimize complications, aggressive closed reduction, open reduction, pin penetration, and unnecessary drill holes should be avoided. Avascular necrosis and chondrolysis, the most frequent and devastating complications, appear to be related to the severity of the slip and the type of treatment.

Synovectomy of the knee in young patients with hemophilia.

We performed 16 synovectomies of the knee in 14 children, adolescents, and young adults with hemophilia A for boggy synovium due to hemophilia. Pain was eliminated or decreased in all patients postoperatively. The number of bleeding episodes was dramatically decreased in all patients at three-year follow-up. Some knee motion was lost in five patients. A continuous passive motion machine used in patients operated upon later in the series appears to be beneficial in regaining motion. Synovectomy did not appear to alter the course of joint destruction, especially if done late.