Correlation of femoral head coverage and Graf alpha angle in infants being screened for developmental dysplasia of the hip.

Ultrasonography has become accepted as a useful imaging modality in the early detection of developmental dysplasia of the hip (DDH). The purpose of this study was to investigate the extent to which ultrasonographic measurements of femoral head coverage correspond to the categories of hip maturity defined by Graf's angle alpha. The infants in this study (1,037 infants, 2,034 hips) were examined as part of an ultrasound screening program for detecting DDH. We found that femoral head coverage is positively correlated with alpha angle, and we also found upper and lower threshold values of femoral head coverage (51% and 39%), such that all hips having these values or beyond had mature or pathological development, respectively. For the detection of hips having mature development, this provided a specificity of 100% (by definition) and a sensitivity of 82.6%. For hips having pathological development, specificity was 100% and sensitivity was 79.2%.

Clinical examination versus ultrasonography in detecting developmental dysplasia of the hip.

Although hip ultrasonography is gaining acceptance as the most effective method for the early diagnosis of developmental dysplasia of the hip, there is still some controversy regarding the use of ultrasonography as a screening method. The purpose of this study was to investigate prospectively the capacity of clinical examination findings and associated risk factors to detect developmental dysplasia of the hip defined ultrasonographically in infants. A total of 3,541 infants underwent clinical examination and hip ultrasonography. Measured against ultrasonography as a standard, the sensitivity and specificity of clinical examination were 97% and 13.68%, respectively. Graf type IIb or more severe developmental dysplasia was found in 167 infants (208 hips), at an overall frequency of 4.71%. Graf type IIa physiological immaturity was encountered in 838 hips, and of these, 15 hips (1.78%) developed Graf type IIb dysplasia and underwent treatment. Patient characteristics that were found to be significant risk factors were swaddling use, female gender, breech delivery and positive family history. Given its low specificity, our findings suggest that clinical examination does not reliably detect ultrasonographically defined developmental dysplasia of the hip in infants being screened for this disease.

Indicators of successful use of the Pavlik harness in infants with developmental dysplasia of the hip.

This study examined the outcomes of ultrasound-monitored Pavlik harness treatment in 25 infants (2 boys and 23 girls) representing a total of 31 cases of developmental dysplasia of the hip of Graf type IIc or more severe. For all infants, Pavlik harness treatment started after ultrasonographic diagnosis in our clinic. If there was no improvement by the third week of follow-up, the harness treatment was discontinued. Of the 25 patients (31 hips), 16 patients (18 hips) were successfully treated with the Pavlik harness. The effects of age at start of treatment, gender, side of pathology, first clinical evaluation findings, bilaterality, and Graf type on Pavlik harness treatment success were analysed. We found that the outcome of treatment with the Pavlik harness was related to Graf type, age at start of treatment, and bilaterality.

Cutis marmorata telangiectatica congenita: an unusual cause of lower extremity hypoplasia.

Cutis marmorata telangiectatica congenita is a relatively benign, rare cutaneous disorder with various manifestations. A seven-year-old girl, who presented with extremity hypoplasia, had the characteristic reticular, patchy, blue-pink cutaneous lesions, which became more prominent with exposure to cold temperatures. She had 4.8 cm shortening of her right lower extremity, which was also thinner than on the left side. The patient did not have skin atrophy, ulcers, glaucoma or macrocephaly. She is being followed for a future extremity lengthening procedure.

Lateral premalleolar bursitis as a result of sitting on the foot.

Lateral premalleolar bursitis develops on the dorsolateral aspect of the foot in people who sit on their feet for prolonged periods. Twenty-nine premalleolar bursae in 21 patients were diagnosed. The patients presented with one or more of the complaints of swelling, pain and difficulty in wearing shoes. One bursa was infected. Initial treatment was non-surgical. With avoidance of the sitting position, the problem resolved in eight of the sixteen patients who were followed. Four bursae were injected with cortisone, three without success. Six bursae were surgically excised, and four of them, with a minimum of one year follow-up were doing well.

Carpal tunnel release using a short palmar incision and a new knife.

A new knife with its own battery powered light source (Knifelight, Stryker Instruments, Kalamazoo, Michigan, USA) was used for carpal tunnel release in 31 wrists of 25 patients. Under local anaesthesia, a short palmar incision was used and the carpal tunnel contents were visualized during division of the flexor retinaculum. The mean operation time was 11 minutes and no major complications were seen. The patients could use their hands for self-care after 3 days and returned to work at a mean of 23 days. At a minimum follow-up of 6 months, all but one of the patients were satisfied with the final result. Mild scar tenderness was seen in two patients and pillar pain in one patient.

Relation of the radial nerve with the sulcus nervi radialis: a morphometric study.

The radial nerve's course from the axillary region, branch patterns and the relation of the nerve to fixed anatomical landmarks in the arm region were studied in 27 embalmed intact cadavers. The radial nerve and its relation with the sulcus nervus radialis (SNR) was analyzed. The direct contact of the nerve with humerus in SNR was observed during the dissections. The following measurements were made: the total length of the humerus (the palpable uppermost point of the tuberculum majus and the lateral epicondyle); proximal safe zone (the tuberculum majus and the proximal beginning of the SNR); distal safe zone (the intercondylar axis and the middle of SNR); lateral safe zone (the lateral epicondyle and the distal end of SNR). In conclusion, it was aimed to correlate the osseus palpable landmarks of humerus with the course of the radial nerve for a safe surgery as the sulcus nervi radialis region is one of the main risky areas for the radial nerve palsies.

Comparison of the results of short-term rigid and semi-rigid cast immobilization for the treatment of grade 3 inversion injuries of the ankle.

In this prospective, randomized study, short-term immobilization with semi-rigid (Soft Cast) and rigid (Scotchcast Plus) synthetic cast materials were compared for the functional treatment of acute grade 3 lateral ligament injuries of the ankle. Degree of ligament injury was assessed by clinical criteria. Duration of immobilization was 2 weeks for both groups and home physiotherapy was started thereafter. Fifty-seven patients completed the study and both materials were found to be equally effective in providing a stable ankle at the end of 6 weeks follow-up. Soft Cast group had better range of motion and could walk better at 2 weeks, but these differences diminished at 6 weeks. With the Soft Cast, patient satisfaction was higher, need for a support for walking was less and return to work was earlier. When combined with the reduced cost of application, Soft Cast is the material of choice for the initial short-term immobilization for the functional treatment of acute ankle ligament injuries.

A large Turkish kindred with syndactyly type II (synpolydactyly). 1. Field investigation, clinical and pedigree data.

A very large Turkish family with syndactyly type II (synpolydactyly (SPD)) is described, which originated from and is mainly concentrated in the village of Derbent, Afyon. The kindred consists of 425 subjects over seven generations, of whom 182 are affected. It appears that a founder effect in this village has led to this extensive kindred. This condition is inherited as an autosomal dominant trait with variable expressivity and an estimated penetrance of 96%. Penetrance is different between the upper (96%) and lower (69.5%) extremities. No excess of affected males or females or other associated features were documented in this condition. Variations in the involvement of one or both hands, upper or lower extremities, bone and soft tissue, as well as variation in the affected subjects of two successive generations were documented. We also noted that metacarpal and metatarsal involvement and middle phalangeal hypoplasia of the feet are the consistent features of SPD and, therefore, should be considered as characteristic of this phenotype. We observed four different phenotypes in various branches of the Derbent kindred: (1) subjects presenting typical features of SPD; (2) subjects exhibiting both pre- and post-axial polydactyly simultaneously; (3) persons manifesting postaxial polydactyly type A; and (4) subjects born to two affected parents with severe hand and foot deformities that have not been previously described in any other SPD families (that is, homozygotes). A total of 27 affected offspring were born to two such affected parents, of whom seven are expected to be homozygous for the SPD gene. This group is presented in an accompanying paper in this issue of the Journal. A molecular study is currently under way to identify the chromosomal location of the defective gene.

A large Turkish kindred with syndactyly type II (synpolydactyly). 2. Homozygous phenotype?

Syndactyly type II (synpolydactyly (SPD)) is an autosomal dominant condition with typical abnormalities of the distal parts of both upper and lower limbs. We report here a previously undescribed phenotypic feature of people with severe hand and foot deformities who were born to two affected parents. This is the first example of SPD subjects manifesting a very distinctive phenotype, suggesting that they must be homozygous for this condition. The typical characteristic clinical features in these subjects are as follows: (1) short hands with wrinkled fatty skin and short feet; (2) complete soft tissue syndactyly involving all four limbs; (3) polydactyly of the preaxial, mesoaxial, and postaxial digits of the hands; (4) loss of the normal tubular shape of the carpal, metacarpal, and phalangeal bones, so as to give polygonal structures; (5) loss of the typical structure of the cuboid and all three cuneiform bones while the talus calcaneus and navicular bones remain intact; (6) large bony islands instead of metatarsals, most probably because of cuboid-metatarsal and cuneiform-metatarsal fusions; and (7) severe middle phalangeal hypoplasia/aplasia as well as fusion of some phalangeal structures that are associated with the loss of normal phalangeal pattern. We report seven subjects with this phenotype from three different branches of a very large SPD pedigree exhibiting the same phenotype with minimal variation. In mice, the Polysyndactyly (Ps) mutation shows a pattern of synpolydactyly very similar to that of human SPD, suggesting that they may well be homologous mutations. A molecular genetic study is currently under way to determine the chromosomal location of the SPD locus in humans and to identify the corresponding homologous region in mice.

Determination of tibial torsion by computed tomography.

Torsional malalignment of the lower extremity, especially during childhood, is a common concern and even an anxiety to the parents. Torsional deformity may be seen at one or more sites, and tibial torsion is a frequent cause of this problem. Medial femoral torsion and metatarsus adductus also affects the alignment of the extremity. Although a corrective osteotomy for tibial torsion is performed very rarely, the precise determination is mandatory. Tibial torsion and the torsion of the leg was measured in 25 adults by computed tomography. The inclination between the dorsal tangent to the tibial condyles and the distal reference line was considered as tibial torsion. The distal reference line was formed with intersection of centers of medial and lateral malleoli. While measuring the torsion of the leg, tangent dorsal to the femoral condyles was used for proximal reference line. In the females, the average of tibial torsion was 31.07 degrees for the right side and 30.02 degrees for the left. For the males, the averages were 32.7 and 35.26 degrees for the right and left sides, respectively.

Pachydermoperiostosis: a case report.

Pachydermoperiostosis in three males of seven siblings from a village of mid-Anatolia is presented. Although X-linkage could not have been ruled out, the autosomal recessive inheritance was considered most likely. It differs from the autosomal dominant form by growth retardation, early ulcers, and acrolysis of the distal parts of the extremities with secondary contractures.