Prospective evaluation of parental anxiety related to newborn foot disorder.

PURPOSE: The presence of a clubfoot is often found prenatally and some families seek counselling with a specialist. The purpose of this study was to compare the parental anxiety levels in families that: a) knew prenatally and had prenatal counselling; b) knew prenatally but did not seek prenatal counselling; and c) did not know until after delivery. METHODS: This prospective cohort study evaluated the anxiety of parents as they presented to the paediatric orthopaedic clinic with their newborn with a foot disorder (prior to the diagnostic confirmation of clubfoot). Each family filled out the 'Pre-visit orthopaedic surgeon questionnaire' and then after the initial visit with the orthopaedic surgeon (confirming the clubfoot diagnosis) the family filled out the 'Immediately post-visit orthopaedic surgeon questionnaire'. Through these questionnaires, anxiety level was assessed prior to meeting postnatally with the paediatric orthopaedic specialist, as well as after the meeting and compared across groups. RESULTS: A total of 121 parents completed questionnaires: 71% (86/121) confirmed clubfoot; 69% of families (59/86) received prenatal counselling (Group A); 16% (14/86) knew prenatally but had no counselling (Group B); and 15% (13/86) found out at birth (Group C). There was no difference in anxiety levels across groups before (p = 0.78) or after (p = 0.57) meeting with the paediatric orthopaedic surgeon; however, overall anxiety reduced significantly (p < 0.001). CONCLUSION: We found no difference in the anxiety levels of across the three groups. Prenatal counselling for parents of children with likely clubfoot may not decrease parental anxiety, but nonetheless is very appreciated by the families who receive it. LEVEL OF EVIDENCE: Prognostic Level II.

Clubfoot relapse: does presentation differ based on age at initial relapse?

PURPOSE: Treatment of idiopathic clubfoot with the Ponseti method is now standard, but predicting relapse can be difficult. Most experts recommend bracing to the age of four years, but this can be challenging for families, and may not be necessary in all patients. The purpose of this study is to compare patterns of bracing and age of relapse to help determine if predictable patterns exist. METHODS: The 70 patients with idiopathic clubfoot treated initially with the Ponseti technique who had relapse of their clubfoot were identified. Relapse was defined as a return to casting or surgery due to recurrent deformity. Data collected included demographics, treatment and brace adherence. Patients who sustained initial relapse before the age of two years were compared with those who sustained initial relapse after the age of two years. RESULTS: In total 56% (39/70) had their initial relapse prior to age two years while 44% (31/70) were after age two years. Of the patients who relapsed prior to the age of two years, 28% (11/39) were adherent with bracing while 72% were non--adherent. For patients who initially relapsed after age two, 74% (23/31) were adherent with bracing while 26% were non-adherent (p < 0.001). Of those who had initial -relapse -prior to age two, a subsequent relapse was seen in 69% (27/39). CONCLUSION: Patients with idiopathic clubfoot who experienced recurrence prior to age two years are significantly more likely to be non-adherent with bracing than those who sustain recurrence after age two. After initial relapse prior to age two, bracing adherence does not affect likelihood of subsequent recurrence.

Pediatric floating elbow.

SUMMARY: A retrospective review of 16 patients with floating elbow injuries over a 9-year period at a tertiary care children's hospital confirms that these injuries are associated with substantial swelling and the potential to develop compartment syndrome, particularly when circumferential cast immobilization is used. Among 10 patients in whom the forearm was treated with closed reduction and plaster immobilization, a compartment syndrome developed in 2, and 4 patients had incipient compartment syndrome that responded to splitting of the cast; 3 of these subsequently required remanipulation of the distal radius. One patient with compartment syndrome had Volkmann ischemic contracture. Six patients underwent stabilization of both the distal humeral and forearm fractures with percutaneously inserted Kirschner wires, thereby allowing postreduction immobilization in a split cast. None of these patients had problems with excessive swelling or compartment syndrome. Percutaneous Kirschner wire fixation of both the humeral and forearm fractures in pediatric floating elbow injuries allows noncircumferential immobilization, thereby reducing the risk of compartment syndrome.

Early failure of Pavlik harness treatment for developmental hip dysplasia: clinical and ultrasound predictors.

A cohort of 93 patients with developmental dysplasia of the hip (DDH) treated with a Pavlik harness were evaluated to determine predictors of treatment failure. Failure was defined as failure to achieve or maintain hip reduction in the Pavlik harness. Of 93 patients (137 hips), 17 (26 hips) failed Pavlik harness treatment. Univariate risk factors for failure included bilaterality, initial clinical exam, and initial ultrasound (US) percent coverage. Clinical exam and initial percent coverage were multivariate risk factors for failure. Among initially clinically dislocatable hips, a low initial US alpha angle correlated with an increased likelihood of failure. All (6/6) patients with an initially irreducible hip and an initial coverage of <20% by US eventually failed treatment. Gender, side of pathology, and age at diagnosis and initiation of treatment did not correlate with failure. Irreducibility by physical exam combined with US coverage of <20% identified a patient group that uniformly failed Pavlik harness treatment. These patients may be candidates for alternative bracing, traction, or closed or open reduction.

Wagner multiple K-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile 'tailor-made' high angle blade plate equivalent.

In 1978, Wagner described a technique using multiple Kirschner wires (K-wires) to stabilize an intertrochanteric osteotomy performed for the correction of coxa vara in small children. Multiple K-wires are used to create a custom high-angle blade plate for valgus osteotomy. The authors have evaluated a retrospective series of 17 Wagner intertrochanteric osteotomies that were performed in 10 children with coxa vara between the ages of 1 year and 8 years. The neck-shaft angle was corrected from 93.5 degrees to 129.5 degrees at long-term follow-up, and the Hilgenreiner epiphyseal angle was corrected from 71 degrees to 37.6 degrees at long-term follow-up. Revision surgery was performed on five hips with inadequate initial surgical correction. Complications included a single broken K-wire, a femur fracture after hardware removal, and one hip developed avascular necrosis postoperatively.

Osteonecrosis of the femoral head associated with slipped capital femoral epiphysis.

We performed a retrospective analysis of 212 patients (299 hips) with slipped capital femoral epiphysis (SCFE) over a 9-year period to assess the incidence of osteonecrosis of the femoral head. Risk factors for the occurrence of osteonecrosis and the influence of treatment on the development of osteonecrosis were determined. Osteonecrosis occurred in 4 hips with unstable SCFE (4/27) and did not occur in hips with stable SCFE (0/272). The proportion of hips in which osteonecrosis developed was significantly higher among the unstable hips (4/27 vs. 0/272, p < 0.0001). Among those with an unstable hip, younger age at presentation was a predictor of a poorer outcome. Magnitude of the slip, magnitude of reduction, and chronicity of the slip were not predictive of a poorer outcome in the unstable group. In situ fixation of the minimally or moderately displaced "unstable" SCFE demonstrated a favorable outcome. We have identified the hip at risk as an unstable SCFE. The classification of hips as unstable if the epiphysis is displaced from the metaphysis or if the patient is unable to walk is most useful in predicting a hip at risk for osteonecrosis.

Development of a virtual reality arthroscopic knee simulator.

The virtual reality arthroscopic knee simulator (VR-AKS) consists of a computer platform, a video display, and two force-feedback (haptic) interfaces which also monitor the position of the instruments in the user's hands. The forces that the user would normally apply to the lower limb during arthroscopy are directed through an instrumented surrogate leg. Proprietary software furnishes the mathematical representation of the physical world and replicates the visual, mechanical, and behavioral aspects of the knee while task-oriented programs monitor and record specific areas of user performance. A prototype has demonstrated the feasibility of the system and work on the first, fully functional simulator will begin soon.

Flexon-type Salter-Harris I injury of the proximal tibial epiphysis.

The authors report a case of a flexion-type epiphyseal separation of the proximal tibia. The injury described herein is a displaced Salter-Harris type I injury. Literature pertaining to this rare injury is reviewed, and management options are discussed.

Massive subperiosteal hemorrhage and femoral shaft osteonecrosis: a complication of tissue plasminogen activator therapy for purpura fulminans.

We present the case of a child who developed a massive subperiosteal hemorrhage and subsequent osteonecrosis of her right femur after treatment with tissue plasminogen activator for post-varicella streptococcal purpura fulminans. Radiographs showed posteromedial translation of the capital femoral epiphysis on the necrotic shaft, and the hip was immobilized. The femur slowly remodeled and has continued to grow. The child is independently ambulatory with a 2.1-cm leg length discrepancy, a varus deformity of the hip, and a valgus distal femur.

Orthopaedic aspects of child abuse.

Increased awareness of child abuse has led to better understanding of this complex problem. However, the annual incidence of abuse is estimated at 15 to 42 cases per 1,000 children and appears to be increasing. More than 1 million children each year are the victims of substantiated abuse or neglect, and more than 1,200 children die each year as a result of abuse. The diagnosis of child abuse is seldom easy to make and requires a careful consideration of sociobehavioral factors and clinical findings. Because manifestations of physical abuse involve the entire child, a thorough history and a complete examination are essential. Fractures are the second most common presentation of physical abuse after skin lesions, and approximately one third of abused children will eventually be seen by an orthopaedic surgeon. Thus, it is essential that the orthopaedist have an understanding of the manifestations of physical abuse, to increase the likelihood of recognition and appropriate management. There is no pathognomonic fracture pattern in abuse. Rather, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered in each case. Musculoskeletal injury patterns suggestive of nonaccidental injury include certain metaphyseal lesions in young children, multiple fractures in various stages of healing, posterior rib fractures, and long-bone fractures in children less than 2 years old. Skeletal surveys and bone scintigraphy with follow-up radiography may be of benefit in cases of suspected abuse of younger children. The differential diagnosis of abuse includes other conditions that may cause fractures, such as true accidental injury, osteogenesis imperfecta, and metabolic bone disease. Management should be multidisciplinary, with the key being recognition, because abused children have a substantial risk of repeated abuse and death.

Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.

BACKGROUND: A child who has an acutely irritable hip can pose a diagnostic challenge. The purposes of this study were to determine the diagnostic value of presenting variables for differentiating between septic arthritis and transient synovitis of the hip in children and to develop an evidence-based clinical prediction algorithm for this differentiation. METHODS: We retrospectively reviewed the cases of children who were evaluated at a major tertiary-care children's hospital between 1979 and 1996 because of an acutely irritable hip. Diagnoses of true septic arthritis, presumed septic arthritis, and transient synovitis were explicitly defined on the basis of the white blood-cell count in the joint fluid, the results of cultures of joint fluid and blood, and the clinical course. Univariate analysis and multiple logistic regression analysis were used to compare groups. A probability algorithm for differentiation between septic arthritis and transient synovitis on the basis of independent multivariate predictors was constructed and tested. RESULTS: Patients who had septic arthritis differed significantly (p < 0.05) from those who had transient synovitis with regard to the erythrocyte sedimentation rate, serum white blood-cell count and differential, weight-bearing status, history of fever, temperature, evidence of effusion on radiographs, history of chills, history of recent antibiotic use, hematocrit, and gender. Patients who had true septic arthritis differed significantly (p < 0.05) from those who had presumed septic arthritis with regard to history of recent antibiotic use, history of chills, temperature, erythrocyte sedimentation rate, history of fever, gender, and serum white blood-cell differential. Four independent multivariate clinical predictors were identified to differentiate between septic arthritis and transient synovitis: history of fever, non-weight-bearing, erythrocyte sedimentation rate of at least forty millimeters per hour, and serum white blood-cell count of more than 12,000 cells per cubic millimeter (12.0 x 10(9) cells per liter). The predicted probability of septic arthritis was determined for all sixteen combinations of these four predictors and is summarized as less than 0.2 percent for zero predictors, 3.0 percent for one predictor, 40.0 percent for two predictors, 93.1 percent for three predictors, and 99.6 percent for four predictors. The chi-square test for trend and the area under the receiver operating characteristic curve indicated excellent diagnostic performance of this group of multivariate predictors in identifying septic arthritis. CONCLUSIONS: Although several variables differed significantly between the group that had septic arthritis and the group that had transient synovitis, substantial overlap in the intermediate ranges made differentiation difficult on the basis of individual variables alone. However, by combining variables, we were able to construct a set of independent multivariate predictors that, together, had excellent diagnostic performance in differentiating between septic arthritis and transient synovitis of the hip in children.

Legg-Calvé-Perthes disease: MR imaging evaluation during manual positioning of the hip--comparison with conventional arthrography.

PURPOSE: To evaluate the use of magnetic resonance (MR) imaging during manual positioning of the hip, or multipositional MR imaging, in an open-magnet configuration to study femoral head containment, articular congruency, and femoral head deformity in Legg-Calvé-Perthes disease. MATERIALS AND METHODS: In 12 children with advanced Legg-Calvé-Perthes disease, multipositional MR imaging and conventional arthrography were compared in the assessment of containment, femoroacetabular congruency, and femoral head deformity. Images of the hips in several positions were compared subjectively and objectively. RESULTS: MR imging correlated well with arthrography for overall subjective assessment of severity of disease (r = 0.71, P = .01), with good interobserver agreement (kappa = 0.65, P < .001). MR images demonstrated all cases of hinge abduction shown arthrographically. However, MR imaging failed to depict one case of femoral head flattening. MR imaging correlated well with arthrography in the objective evaluation of joint fluid and lateral subluxation (r = 0.80, P < .01). MR imaging correlated poorly with arthrography in the measurement of sphericity of the femoral head. CONCLUSION: Multipositional MR imaging with an open-magnet configuration was comparable to arthrography for demonstration of femoral head containment and congruency of the articular surfaces of the hip. In the evaluation of deformity, it performed less well.

Radiographic appearance of the normal distal tibiofibular syndesmosis in children.

In adults, a tibiofibular clear space (i.e., distance from the incisura fibularis to the medial fibula) of > or = 6 mm or a loss of tibiofibular overlap has been reported to correlate with injury to the distal tibiofibular syndesmosis. We reviewed anteroposterior (AP), lateral, and mortise ankle radiographs from 106 children (50 boys, 56 girls) aged 1-15 years in an attempt to assess whether these criteria are applicable to children. The incisura was detectable at a mean age of 8.2 years for girls and 11.2 years for boys. The range of tibiofibular clear space among the 48 children with a detectable incisura was 2-8 mm; seven (23%) of these 48 children had a clear space of > or = 6 mm in one or more views. The mean age at which the tibiofibular overlap began to appear on the AP view was 5 years for both genders, whereas on the mortise view, it was 10 years for girls and 16 years for boys. The criteria used to evaluate the integrity of the distal tibiofibular syndesmosis in adults do not apply to children in this normal study population.

Femur fractures in children: treatment with early sitting spica casting.

The purpose of this article is to review our experience with early spica casting and determine risk factors for loss of reduction and skin complications. The radiographic and clinical charts of 114 children were retrospectively reviewed. At the time of fracture union, excessive shortening and angular malunion were not significant problems. Loss of reduction and skin complications occurred in 20 and 14% of patients, respectively. In addition to previously described risk factors, we identified spica knee flexion angle < 50 degrees as predictive of eventual loss of reduction and found that > 2 cm of initial shortening was not a contraindication to early spica casting. Factors associated with skin problems included younger age and abuse as a mechanism of injury. In our opinion, early spica casting is the treatment of choice for all isolated, closed femur fractures in otherwise healthy children aged 6 years or younger, regardless of the degree of initial deformity.

Protrusio acetabuli and bilateral basicervical femoral neck fractures in a patient with Marfan syndrome.

A 22-year-old man with Marfan syndrome and bilateral protrusio acetabuli presented with bilateral femoral neck stress fractures after vigorous stretching exercises for hip "stiffness." Fifteen years later, his fractures, which were treated with internal fixation, have healed, his acetabular protrusion has not worsened, and his perceived hip "stiffness" persists. This case demonstrates a rare manifestation of Marfan syndrome, protrusio acetabuli, and a possible side effect of vigorous stretching in the face of abnormal joint mechanics.

Accuracy of leg length prediction in children younger than 10 years of age.

In this study, the authors attempted to predict the ultimate leg length in normal children with normally growing legs, using Green-Anderson and Moseley techniques with chronologic and skeletal age. The predictions were based on serial growth studies of children between 5 and 10 years of age. Using skeletal age for prediction, the absolute mean error in predicting the ultimate leg length was 2.4 cm using the Green-Anderson method and 2.58 cm using the Moseley method. Using the Moseley method for length prediction in boys, the mean error was 3.8 cm using skeletal age and 1.5 cm using chronologic age. For girls, using the Moseley method of leg length prediction, the mean error was 1.55 cm with skeletal age and 2.46 cm with chronologic age. The significance of this study is that skeletal age, as determined by the Gruelich and Pyle Atlas, does not improve the accuracy of prediction of ultimate leg length in children younger than 10 years of age, except in girls with advanced bone age.

Chronic physeal fractures in myelodysplasia: magnetic resonance analysis, histologic description, treatment, and outcome.

Thirteen myelodysplastic children with 19 chronic physeal fractures were treated. All were treated with prolonged immobilization (average, 5.8 months; range, 3-18 months) in either braces or casts; four of the fractures required operative fixation to facilitate healing. All were healed at 4.8-years follow-up but, in four of the fractures, the growth plate closed prematurely. Three of the children underwent magnetic resonance imaging (MRI) of the injured physes, and one underwent physeal biopsy as part of her operative epiphysiodesis. Histologic analysis revealed three distinct zones of physeal pathoanatomy: a normal zone of proliferation; a thickened, disorganized zone of hypertrophy; and a vascularized zone of fibrous tissue adjacent to the metaphysis. On MRI, there was thickening of the physis and irregularity of the zone of provisional calcification. The physeal cartilage and the juxtametaphyseal fibrovascular tissue enhanced with gadolinium. These findings corroborate earlier mechanistic proposals for physeal injury in myelodysplasia: chronic stress or trauma to the poorly sensate limb produces micromotion at the zone of hypertrophy, yielding a widened, disorganized physis, and leading to fracture, displacement, and delayed union.

Postreduction computed tomography in developmental dislocation of the hip: part I: analysis of measurement reliability.

Twenty computed tomographic (CT) scans of infants in spica casts after closed or open reduction for developmental hip dislocation (DDH) were analyzed for intra- and interrater reliability. Ten measurements of infant hip anatomy were assessed by three raters by using standard statistical analysis. All six measurements of acetabular anteversion and lateral or posterior displacement of the femoral metaphysis from the acetabulum or from a modified Shenton's line drawn from the pubic rami demonstrated both intra- and interrater reliability. All four measurements of acetabular structure could not be reliably measured either within or between observers. We also introduced a new measurement based on the principle of Shenton's line to aid in the assessment of femoral-head location after reduction in patients with DDH; this was reliably determined both within and among observers.