Metaphyseal fractures mimicking abuse during treatment for clubfoot.

BACKGROUND: Metaphyseal injuries resembling the classic metaphyseal lesion (CML) of abuse may occur as the result of serial casting during treatment of clubfoot deformity. Mentioned in the orthopedic literature in 1972, this iatrogenic fracture has not been described in the radiologic literature nor has the similarity to injuries occurring with abuse been previously recognized. OBJECTIVE: To describe the mechanism and radiographic appearance of metaphyseal injury observed during serial casting of clubfoot. Note similarities to the CML of abuse. MATERIALS AND METHODS: Eight children ranging in age from 1 to 4 months underwent casting for clubfoot. Five orthopedic surgeons from three different institutions performed the casting. Two patients had spina bifida and one, arthrogryposis. A complete skeletal survey was performed on one child who was abused; there was no suspicion of abuse in the remaining seven. RESULTS: All children manifest injury with periosteal new bone. One child had clear evidence of abuse with 24 rib fractures. X-rays of lower extremities in short leg casts revealed bilateral tibial metaphyseal fractures. Four other children had metaphyseal fractures resembling the CML of abuse, and three developed an area of sclerosis within the metaphysis. CONCLUSION: In the setting of serial casting for equinovarus deformity, metaphyseal injury even the CML of abuse may be noted. Since inflicted injuries are almost always unobserved and explanations rarely offered, the fact that the CML occurs as a result of orthopedic maniuplation may offer some further insight concerning the pathogenesis of this well-described abuse injury.

Chondronecrosis of the hip. The protective role of the ossific nucleus in an animal model.

The presence of the ossific nucleus and its role in reducing the risk of ischemic necrosis in developmental dysplasia of the hip remains a matter of controversy. Ischemic necrosis of the pre-osseous capital femoral epiphysis, defined as chondronecrosis, was evaluated in a rabbit model. Histologic evidence of chondronecrosis after casting in maximum abduction was greater in 1-day-old New Zealand White rabbits before the radiographic appearance of the ossific nucleus, compared with 16-day-old New Zealand White rabbits with an ossific nucleus already present. This preliminary study supports the hypothesis that the ossific nucleus may decrease the risk of intracapsular compressive ischemic injury to the developing capital femoral epiphysis in a rabbit model.

Custom 95 degree condylar blade plate for pediatric subtrochanteric femur fractures.

Subtrochanteric fractures in the older child and adolescent often are not amenable to conservative methods of treatment. The anatomic constraints of the proximal femur including the small diameter of the femoral neck and the presence of the capital femoral physis may limit the type of internal fixation used in these patients. This article presents our preliminary experience with a custom 95 degree condylar blade plate for subtrochanteric fractures in older children and adolescents.

Replantation of the midfoot in a child--six-year follow-up with pedobarographic analysis.

A 22-month old child underwent successful replantation of her midfoot at the level of Chopart's joint after a traumatic lawn mower amputation. The child demonstrated good sensation and function. Heel-to-toe length was 2 cm shorter, along with anterior migration of the heel pad on the injured foot. Pedobarographic analysis at 6-year follow-up demonstrated a normal range in the dynamic distribution of foot pressure measurements, except in the region of the medial heel. With replantation more commonly considered as an option in traumatic injuries, long-term functional evaluation is important in demonstrating the success of a replantation. The patient demonstrated a good result at 6-year follow-up, but will need further evaluation until skeletal maturity is reached.

The contribution of the ossific nucleus to the structural stiffness of the capital femoral epiphysis: a porcine model for DDH.

The preosseous femoral head is thought to be vulnerable to compressive ischemic injury during the treatment of developmental dysplasia of the hip. The ossific nucleus has been proposed to increase the mechanical strength of the capital femoral epiphysis (CFE) and to decrease the risk of avascular necrosis. Sixty mixed-breed fetal and postgestational femoral head specimens were evaluated for structural stiffness in relation to the size of the ossific nucleus within the CFE. The structural stiffness of the CFE in the porcine model was found to increase exponentially with the size of the ossific nucleus. A finite-element model revealed that the presence of an ossific nucleus occupying 40% of the epiphyseal volume reduced the compressive strain in the region of the posterior-superior branch of the medial circumflex artery by an average of 54%. The results of this study support the hypothesis that the presence of the ossific nucleus may protect the CFE from compressive ischemic injury in the treatment of DDH.

Avascular necrosis after treatment of DDH: the protective influence of the ossific nucleus.

We retrospectively reviewed the results of open or closed reduction for developmental dysplasia of the hip (DDH) in 49 children younger than 12 months old, who had 57 hip dislocations. Group A (18 hips) developed partial or complete avascular necrosis (AVN), and group B (39 hips) did not develop AVN. Thirty-eight hips were treated by closed reduction, and 17 had open reduction. One patient with bilateral hip dislocation initially had closed reductions followed by bilateral open reduction 3 months later. With the numbers available for study, there was no significant difference in the occurrence of AVN with respect to variables such as preliminary traction, closed versus open reduction, Pavlik harness use, and age at the time of operative intervention. However, the presence of the ossific nucleus before reduction, detected either by radiographs (p < 0.001) or ultrasonography (p = 0.033) was statistically significant in predicting AVN. Only one (4%) of 25 hips with an ossific nucleus developed AVN, whereas 17 (53%) of 32 hips without an ossific nucleus before reduction developed AVN. Our results suggest that the presence of the ossific nucleus before closed or open reduction for DDH may decrease the risk of AVN.

Dysplasia epiphysealis hemimelica of the sacroiliac joint: a case report.

Dysplasia epiphysealis hemimelica is a rare developmental abnormality involving aberrant epiphyseal cartilage growth. This is the first known case report describing dysplasia epiphysealis hemimelica arising from the sacroiliac joint. The operative technique described through an indirect computed tomography guided approach limited the exposure and potential morbidity involving the sacroiliac joint.

Valgus slipped capital femoral epiphysis. Fact or fiction?

The cases of 2 patients with valgus slipped capital femoral epiphysis are presented. Additional imaging studies provide support for true posterolateral epiphyseal displacement. Increased femoral anteversion and coxa valga contribute to the pathogenesis of valgus slipped capital femoral epiphysis. In situ pin fixation is recommended for stable valgus slipped capital femoral epiphysis. The importance of valgus slipped capital femoral epiphysis lies in its recognition and appropriate screw placement when internal fixation is used. The percutaneous technique should be used with caution. A limited open technique is recommended when the anterior skin portal is near the femoral neurovascular bundle.

The development of rickets as a complication of chemotherapy for the treatment of Wilms' tumor.

Musculoskeletal complaints were the presenting symptoms in four of 44 children (9%) treated for relapsed Wilms' tumors with ifosfamide, a derivative of cyclophosphamide. Subsequent radiologic examination revealed rachitic bone and joint changes. A fifth child manifested clinical and radiographic signs of rickets after presenting with hypophosphatemia, hypouricemia, and glycosuria. Recognition of a potential drug-induced Fanconi syndrome is important when managing pediatric oncology patients previously treated with ifosfamide. Early replacement therapy is recommended when proximal renal tubular abnormalities are detected to help prevent and control the severe metabolic bone disease associated with the Fanconi syndrome.

Wire-holding frame for sublaminar segmental spinal instrumentation.

METHODS: A wire-holding frame developed for sublaminar segmental instrumentation (SSI) has been used at the authors' institution for 14 years. RESULTS: In addition to careful technique of sublaminar wire passage, the frame reduces the risk of potential neurologic injury after wire passage by keeping the wires taut against the undersurface of the lamina. CONCLUSION: Operative efficiency is increased by organizing the sequence of the wires. The risk of glove perforation is also reduced by keeping the sharp ends of the wires away from the operative field.

Spine fracture in ochronosis. Report of a case.

Ochronosis, the musculoskeletal manifestation of alkaptonuria, primarily involves the larger joints of the body, including the spine. Ankylosis of the thoracolumbar spine leads to progressive loss of flexibility. The case described is that of a 72-year-old man with ochronosis who suffered a hyperextension injury to his spine in a fall, resulting in a fracture through an ankylosed L2-L3 disk space. To the authors' knowledge, this is the first reported fracture of an ankylosed ochronotic spine.

Anterior ankle dislocation with associated trigonal process fracture. A case report and literature review.

Anterior ankle dislocations without concomitant malleolar fractures are rare injuries. Review of the English-language literature disclosed only three previously reported cases. A 21-year-old man sustained an isolated anterior ankle dislocation with an associated fracture of the trigonal process, which was reduced without difficulty. At follow-up examination 33 months later, the patient's major complaint was chronic, posttraumatic peroneal tendon dislocation. The proposed mechanism of injury suggested in this case is forced plantar flexion.

Complications of posterior arthrodesis of the cervical spine in patients who have Down syndrome.

Ten patients who had Down syndrome and had had a posterior arthrodesis of the upper cervical spine were studied. The mean age at the time of the operation was 8.9 years, and the patients had been followed for three days to forty-nine months. Complications related to the operation occurred in all patients. They included infection and dehiscence at the site of the wound, incomplete reduction of the atlanto-axial joint, instability of the adjacent motion segment, neurological sequelae, resorption of the autogenous bone graft, and death in the postoperative period. Resorption of the bone graft, which occurred in six of the patients, has not previously been reported in patients who have Down syndrome, to our knowledge. Several theoretical mechanisms for this complication are proposed. We recommend non-operative management for patients who have Down syndrome and atlanto-axial instability without neurological signs or symptoms. If the severity of symptoms necessitates a posterior arthrodesis, a high rate of complications must be anticipated.

Growth disturbances of the proximal femur after pinning of juvenile slipped capital femoral epiphysis.

Premature closure of the capital femoral physis after pin fixation of slipped capital femoral epiphysis (SCFE) in the juvenile population (at least 1 year less than the established mean) can lead to growth disturbances of the proximal femur. A retrospective review of 21 patients (33 hips) who had a pinning of a juvenile SCFE was performed. Growth disturbances including greater trochanteric overgrowth, coxa vara, and coxa breva were noted in 64% of the hips. An 80% incidence of bilateral involvement was noted in the juvenile group. Consideration should be given to prophylactic pinning of the contralateral hip and use of a smooth pin construct to prevent premature closure of the growth plate in children with significant growth remaining.

Ipsilateral fracture-dislocation of the hip, knee, and ankle: case report.

A case of ipsilateral fracture-dislocation of the hip, knee, and ankle is presented. The patient had no neurovascular compromise or postoperative complications. A review of the literature produced no previous reports of this combination of injuries.

Calcaneal gait in spastic diplegia after heel cord lengthening: a study with gait analysis.

Calcaneal gait or deformity can be a significant complication after heel cord lengthening. After heel cord lengthening, 20 children with spastic diplegia were evaluated by gait analysis to define calcaneal gait objectively and describe associated morbidity. Mean age was 5 years 2 months (range 2 years 7 months to 8 years 2 months), and mean length of follow-up was 5 years 8 months (range 1 years 1 month 11 year 3 months). Calcaneal gait was defined as dorsiflexion 1 SD beyond the mean in the sagittal plane for all phases of stance. Increased ankle dorsiflexion during mid-stance most accurately predicts calcaneal gait. Through gait analysis, a 30% (6 of 20) prevalence of calcaneal gait suggests that an increased incidence of calcaneal gait may be present after heel cord lengthening.