The role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and epiphyseal growth arrest in the surgical treatment of distal tibial epiphysiolysis.

BACKGROUND: Distal tibial epiphyseal fractures damage to epiphyseal growth plate. Epiphyseal growth arrest (EGA), reflex sympathetic dystrophy and ankle joint stiffness may also occur after distal tibial epiphyseal injury. This study aims to evaluate the role of trauma mechanism, fracture pattern and fixation technique on clinical outcomes and EGA in the surgically treated distal tibial epiphyseal fractures. METHODS: Twenty seven patients who underwent surgery for distal tibial epiphyseal fracture between the 2011 and 2017 were evaluated retrospectively. The effects of trauma mechanism, fixation technique, preoperative duration, fracture patterns on the clinical results and EGA were examined. AOFAS (The American Orthopedic Foot and Ankle Score) and MOXFQ (The Manchester-Oxford Foot Questionaire) were used for clinical evaluation. RESULTS: Twenty seven patients (17 male and 10 female) were included in this study. The most important complication of epiphyseal injury was the growth pause in eight patients. No statistically significant difference was observed concerning clinical scores and complications according to trauma mechanism, fixation techniques and fracture patterns (p>0.05). CONCLUSION: Regardless of the trauma mechanism, fracture pattern and the fixation material, an anatomical reduction should be obtained in distal tibial epiphyseal fractures to reduce complications and prevent the EGA.

Is Assessment of Femoral Head Perfusion During Modified Dunn for Unstable Slipped Capital Femoral Epiphysis an Accurate Indicator of Osteonecrosis?

BACKGROUND: The modified Dunn procedure, which is an open subcapital realignment through a surgical dislocation approach, has gained popularity for the treatment of unstable slipped capital femoral epiphysis (SCFE). Intraoperative monitoring of the femoral head perfusion has been recommended as a method of predicting osteonecrosis; however, the accuracy of this assessment has not been well documented. QUESTIONS/PURPOSES: We asked (1) whether intraoperative assessment of femoral head perfusion would help identify hips at risk of developing osteonecrosis; (2) whether one of the four methods of assessment of femoral head perfusion is more accurate (highest area under the curve) at identifying hips at risk of osteonecrosis; and (3) whether specific clinical features would be associated with osteonecrosis occurrence after a modified Dunn procedure for unstable SCFE. METHODS: Between 2007 and 2014, we performed 29 modified Dunn procedures for unstable SCFE (16 boys, 11 girls; median age, 13 years; range, 8-17 years); two were lost to followup before 1 year. During this period, six patients with unstable SCFE were treated by other procedures. All patients undergoing modified Dunn underwent assessment of epiphyseal perfusion by the presence of active bleeding and/or by intracranial pressure (ICP) monitoring. In the initial five patients perfusion was recorded once, either before dissection of the retinacular flap or after fixation by one of the two methods. In the remaining 22 patients (81%), perfusion was systematically assessed before dissection of the retinacular flap and after fixation by both methods. Minimum followup was 1 year (median, 2.5 years; range, 1-8 years) because osteonecrosis typically develops within the first year after surgery. Patients were assessed for osteonecrosis by the presence of femoral head collapse at radiographs obtained every 3 months during the first year after surgery. Seven (26%) of the 27 patients developed osteonecrosis. Measures of diagnostic accuracy including sensitivity, specificity, and the area under the receiver operating curve (AUC) were estimated. Multiple variable logistic regression analyses were used to test whether the test options were better than random chance (AUC > 0.50) at differentiating between patients who did versus did not develop osteonecrosis. Nonparametric methods were used to test for a difference in AUC across the four methods. A secondary analysis was performed to identify risk factors associated with osteonecrosis. RESULTS: After adjusting for body mass index, which was found to be a confounding variable, assessment of femoral head perfusion with ICP monitoring before retinaculum dissection (adjusted AUC: 0.79; 95% confidence interval [CI], 0.58-0.99; p = 0.006), femoral head perfusion with ICP monitoring after definitive fixation (adjusted AUC: 0.82; 95% CI, 0.65-1.0; p < 0.001), bleeding before retinaculum dissection (adjusted AUC: 0.77; 95% CI, 0.58-0.96; p = 0.006), and bleeding after definitive fixation (adjusted AUC: 0.81; 95% CI, 0.63-0.99; p = 0.001) were found to be helpful at identifying osteonecrosis. We were not able to identify a specific test that had performed best because there was no difference (p = 0.8226) in AUC across the four methods. With the numbers available, we were unable to identify clinical factors predictive of osteonecrosis in our cohort. CONCLUSIONS: Assessments of femoral head blood perfusion by ICP monitoring or by the presence of active bleeding in combination with the patient's body mass index are effective at differentiating between patients who do versus do not develop osteonecrosis after a modified Dunn procedure for unstable SCFE. Additional research is needed to determine whether information gained from assessment of femoral head perfusion during surgery should be used to guide targeted treatment recommendations that may reduce the development of femoral head deformity secondary to osteonecrosis. LEVEL OF EVIDENCE: Level III, diagnostic study.

Digital Chondrolysis and Epiphysiolysis Associated With Snakebite: A Report of 2 Cases.

BACKGROUND: Here, we present 2 cases of the unusual sequelae of a venomous bite to the finger in children resulting in chondrolysis and physeal loss. There have been few isolated case reports documenting this phenomenon. Currently, there is no preventative treatment, and patients should be warned of this possible complication of envenomation. METHODS: Two patients with chondrolysis and physeal loss have been seen in our practice. RESULTS: Chondrolysis and epiphysiolysis occurred in 2 patients. One patient was treated with proximal interphalangeal joint fusion and one is being managed conservatively. CONCLUSION: The toxic action of snake venom may cause loss of the growth plate and chondrolysis in the pediatric hand. LEVEL OF EVIDENCE: Level IV.

Shoulder injuries in the skeletally immature baseball pitcher and recommendations for the prevention of injury.

Since 1996, when the first article on pitch restriction recommendations was published, the number of research articles involving skeletally immature pitchers has increased. Potential shoulder injuries in this age group are proximal humeral epiphysiolysis, glenohumeral instability, rotator cuff dysfunction, and superior labrum anteroposterior lesions. Fatigue, improper biomechanics, and overuse are the most common reasons for these injuries. In the hopes of preventing injury to young pitchers, numerous organizations, including the USA Baseball Medical & Safety Advisory Committee, The American Sports Medicine Institute, Little League Baseball & Softball, and the Long Term Athlete Development Program for Baseball Canada, have developed recommendations on pitching restrictions that include limits on pitch count, pitches per week, pitches per season, and rest between pitching. Awareness by sports medicine providers, coaches, and parents/guardians of the most up-to-date recommendations on injury prevention and return to play guidelines should reduce the incidence of acute and chronic injuries in adolescent baseball pitchers.

[Skeletal trauma during the growing period. Radiological diagnostics]. / Skeletttraumatologie im Wachstumsalter: Radiologische Diagnostik.

Bone fractures in childhood are a common occurrence. A differentiated assessment of fractures is of great importance for the diagnostics, therapy planning and estimation of the prognosis. This review article explains the most important characteristics of skeletal trauma in childhood. Skeletal development, the mechanisms of fracture healing and growth disorders after injury to the epiphyseal plates and classification of fractures will be discussed and typical bone fractures in children and the pitfalls in X-ray diagnostics are demonstrated.

Bone apposition of the acetabular rim in deep hips: a distinct finding of global pincer impingement.

BACKGROUND: Hips with coxa profunda can develop a pincer-type impingement with linear impact between the proximal part of the femur and the acetabulum, leading to bone apposition on the acetabular rim. METHODS: Twenty hips with radiographic features of rim ossification were isolated from a pilot cohort of 220 patients for histologic assessment of the acetabular rim and the labrum. In the second part of the study, the prevalence of radiographic signs of bone apposition in a cohort of 148 hips treated for femoroacetabular impingement was assessed. RESULTS: Histologic analysis confirmed that the labrum may become displaced and replaced by the appositional bone formation. The double-line sign and the recess sign are suggestive of an ongoing process of this bone formation, and the described phenotypes of bone apposition indicate the site of the impingement problem. Morphological anomalies of the proximal part of the femur, such as a low neck-shaft angle or a short femoral neck, may further contribute to the mechanism of pincer impingement. CONCLUSIONS: In later stages, this bone formation cannot be distinguished from the native bone and the labrum may appear to be nearly absent on imaging studies. While the bone apposition on the rim is first reactive to chronic impingement, the impingement then increases and may lead to further bone apposition.

In situ fixation for slipped capital femoral epiphysis: perspectives in 2011.

Slipped capital femoral epiphysis is usually treated with in situ fixation to prevent progression of deformity. However, slipped capital femoral epiphysis always is associated with structural risk factors for hip dysfunction in addition to the risk of slip progression. Femoro-acetabular impingement causes some mechanical abnormality in every hip affected by slipped capital femoral epiphysis, even when the slip is mild. The severity of femoro-acetabular impingement caused by slipped capital femoral epiphysis depends on several factors. Cumulative injury to the articular cartilage can result from impingement, and it is better to prevent this type of injury than to treat it later. In situ fixation alone rarely relieves femoro-acetabular impingement in slipped capital femoral epiphysis. Skillful and precise in situ fixation allows careful analysis of hip function in the stabilized slip by eliminating the major risk of acute instability. The more subtle risk of long-term articular damage caused by femoro-acetabular impingement must be considered. The treatment of femoro-acetabular impingement in patients who have slipped capital femoral epiphysis is a separate issue from instability of the proximal femoral physis. Femoro-acetabular impingement must be assessed in every hip that is affected by slipped capital femoral epiphysis, even when the deformity is mild. Several treatment options exist for treating femoro-acetabular impingement associated with slipped capital femoral epiphysis.

Slipped capital femoral epiphysis in a cerebral palsy patient: a case report.

This report is a case of slipped capital femoral epiphysis in a nonambulatory patient with spastic quadriplegic type of cerebral palsy. Such a case is unusual as no weight-bearing forces were acting on the hip; however, spasticity may have played a role. To the best of our knowledge no earlier cases have been reported in the literature.

Cams and pincer impingement are distinct, not mixed: the acetabular pathomorphology of femoroacetabular impingement.

BACKGROUND: Many impinging hips are said to have a mix of features of femoral cam and an overcovered acetabulum causing pincer impingement. Correction of such a mixed picture by reduction of the cam lesion and the acetabular rim is the suggested treatment. QUESTIONS/PURPOSES: We therefore asked two questions: (1) Is the acetabulum in cam impingement easily distinguishable from the pincer acetabulum, or is there a group with features of both types of impingement? (2) Is version or depth of socket better able to distinguish cam from pincer impingement? METHODS: We analyzed the morphologic features of the acetabulum and rim profile of 20 normal, healthy hips, 20 with cams and 20 with pincers on CT. Pelvises were digitized, orientated to the best-fit acetabular plane, and a rim profile was plotted. RESULTS: Cam hips were shallower than normal hips, which in turn were shallower than pincer hips (84 degrees +/- 5 degrees versus 87 degrees +/- 4 degrees versus 96 degrees +/- 5 degrees, respectively). The rim planes of cam, normal, and pincer hips had similar version (23 degrees, 24 degrees, 25 degrees), but females were 4 degrees more anteverted than males. CONCLUSIONS: We concluded cam and pincer hips are distinct pathoanatomic entities. Cam hips are slightly shallower than normal, whereas pincers are deeper. CLINICAL RELEVANCE: Before performing surgery for cam-type femoroacetabular impingement, surgeons should consider measuring the acetabular depth. The cam acetabulum is shallower than normal and may be rendered pathologically shallow by acetabular rim resection leading to early joint failure.

Femoroacetabular impingement after slipped capital femoral epiphysis: does slip severity predict clinical symptoms?

BACKGROUND: Femoroacetabular impingement (FAI) may be common after slipped capital femoral epiphysis though the actual frequency is unknown. The purpose of this study was to determine the frequency of symptomatic FAI in young adults after slipped capital femoral epiphysis and define its relationship with slip severity. METHODS: We retrospectively reviewed a consecutive series of 49 patients (65 hips) to determine patient and slip characteristics and treatments. Patients were then recalled for clinical and radiographic review to assess symptoms, particularly impingement, and outcomes after skeletal maturity. RESULTS: Thirty-six patients (49 hips) were reviewed clinically and radiographically with a mean follow-up of 6.1 years (range: 2.2 to 13.1 y). All patients had reached skeletal maturity. Thirty-one percent (15/49) of patients complained of hip pain or stiffness, whereas 32% (16/49) had clinical signs of impingement. The Southwick slip angle and grade of slip or Loder's classification of physeal stability were not predictive of impingement at follow-up. The anterior head-neck offset angle (alpha angle) correlated most strongly with FAI (r=0.26). No pre-slips or prophylactically pinned hips developed clinical impingement in this review. CONCLUSIONS: In the absence of radiographic indicators to predict FAI, we advocate all but those hips pinned prophylactically or for pre-slip should be followed into adulthood and clinically monitored for impingement. Grade of slip in adolescence cannot be used as a predictive tool for FAI later in life. LEVEL OF EVIDENCE: Level II, retrospective study.

The epiphyseal tubercle in adolescent hips.

BACKGROUND: It has already been shown in animals and using anatomical human specimens that chronic slippage of the adolescent upper (capital) femoral epiphysis is unlikely to take place by shearing due to the presence of an epiphyseal tubercle projecting down into the metaphysis. MATERIAL, RESULTS, AND INTERPRETATION: Plain radiographs of 20 adolescents and CT scans of 9 of them were analyzed for evidence of the size and presence of this tubercle in vivo. These cases showed that CT scanography is the investigation of choice to illustrate this largely undescribed anatomical feature. They also illustrate the epiphyseal tubercle well, both in the anatomical position and at various stages of "epiphyseal slippage", and confirm that it has a significant restraining effect on any tendency of the epiphysis to alter its position relative to the metaphysis.

Capital realignment for moderate and severe SCFE using a modified Dunn procedure.

Moderate to severe slipped capital femoral epiphysis leads to premature osteoarthritis resulting from femoroacetabular impingement. We believe surgical correction at the site of deformity through capital reorientation is the best procedure to fully correct the deformity but has traditionally been associated with high rates of osteonecrosis. We describe a modified capital reorientation procedure performed through a surgical dislocation approach. We followed 40 patients for a minimum of 1 year and 3 years from two institutions. No patient developed osteonecrosis or chondrolysis. Slip angle was corrected to 4 degrees to 8 degrees and the mean alpha angle after correction was 40.6 degrees. Articular cartilage damage, full-thickness loss, and delamination were observed at the time of surgery, especially in the stable slips. This technique appears to have an acceptable complication rate and appears reproducible for full correction of moderate to severe slipped capital femoral epiphyses with open physes.

Femoral morphology due to impingement influences the range of motion in slipped capital femoral epiphysis.

Femoroacetabular impingement due to metaphyseal prominence is associated with the slippage in patients with slipped capital femoral epiphysis (SCFE), but it is unclear whether the changes in femoral metaphysis morphology are associated with range of motion (ROM) changes or type of impingement. We asked whether the femoral head-neck junction morphology influences ROM analysis and type of impingement in addition to the slip angle and the acetabular version. We analyzed in 31 patients with SCFE the relationship between the proximal femoral morphology and limitation in ROM due to impingement based on simulated ROM of preoperative CT data. The ROM was analyzed in relation to degree of slippage, femoral metaphysis morphology, acetabular version, and pathomechanical terms of "impaction" and "inclusion." The ROM in the affected hips was comparable to that in the unaffected hips for mild slippage and decreased for slippage of more than 30 degrees. The limitation correlated with changes in the metaphysic morphology and changed acetabular version. Decreased head-neck offset in hips with slip angles between 30 degrees and 50 degrees had restricted ROM to nearly the same degree as in severe SCFE. Therefore, in addition to the slip angle, the femoral metaphysis morphology should be used as criteria for reconstructive surgery.

Demographics and clinical presentation of slipped capital femoral epiphysis in Singapore: comparing the East with the West.

This study examines the demographics and clinical presentation of slipped capital femoral epiphysis in Singapore. Sixty-six patients (53 boys, 13 girls) with 77 involved hips were reviewed retrospectively. Local prevalence was 1.2/100,000 children. Twenty-four patients were Chinese, 12 were Malay, 27 were Indians, and three patients were Eurasians. A total of 76.6% of patients above the 90th percentile for body weight were present; 16.7% of patients had bilateral involvement. Seventeen patients had endocrine-related problems. We had a high male preponderance, and a disproportionately high number of Indian patients. A high proportion of patients were obese. Our incidence of bilateral involvement seems to be higher than our Indonesian neighbors. The differences seen may be due to genetic and sociocultural variations.

Increased intracapsular pressures after unstable slipped capital femoral epiphysis.

BACKGROUND: Osteonecrosis of the femoral head is the most dreaded complication associated with an unstable slipped capital femoral epiphysis (SCFE). We hypothesize that the hip joint pressure will be increased in unstable slips, confirming that emergent treatment and decompression are warranted. METHODS: Thirteen unstable SCFE hips were evaluated. Hip pressure monitoring was performed. Postcapsulotomy measurements were also performed in all of the patients. Five of these under gentle manipulation. Six patients underwent measurement of the hip pressure on the unaffected side. RESULTS: The mean pressure on the affected hip was 48 mm Hg. The mean pressure on the unaffected side was 23 mm Hg. There was a significant increase in intraarticular hip pressure after attempted manipulation (mean, 75 mm Hg). DISCUSSION: Hip pressures are increased in unstable SCFE to levels higher for those of a compartment syndrome probably causing a tamponade effect. There is a need to perform a capsulotomy if manipulation is performed.

Shear stress in epiphyseal growth plate is a risk factor for slipped capital femoral epiphysis.

BACKGROUND: Slipping of the capital femoral epiphysis is an important orthopaedic problem of early adolescence. Many hypotheses about its etiology have been examined, yet the underlying mechanisms have not yet been fully elucidated. We examined elevated shear stress in the epiphyseal growth plate and elevated contact hip stress exerted on the femoral head as risk factors for slipping of the capital femoral epiphysis. METHODS: Two groups of hips were compared: a group of 100 hips contralateral to the slipped ones and a group of 70 age- and gender-matched healthy hips. The characteristics of individual hips were incorporated by means of geometrical parameters determined from standard anteroposterior radiographs. Shear stress was calculated by using a mathematical model where the femoral neck was considered to function as an elastic rod. Contact hip stress was calculated by the HIPSTRESS method. RESULTS: Hips contralateral to the slipped ones had higher average shear stress (0.81 vs 0.51 MPa; P < 0.001) and more vertically inclined physeal angle (55.4 vs 63.2 degrees.; P < 0.001) in comparison to healthy hips. Shear stress in the contralateral hips to the slipped ones remained significantly higher even when normalized to the body weight (1400 vs 1060 Pa/N; P < 0.001). There was no significant difference in the average contact hip stress (1.86 vs 1.74 MPa; P = 0.145). CONCLUSIONS: Elevated shear stress, but not elevated contact stress, is a risk factor for slipping of the capital femoral epiphysis. LEVEL OF EVIDENCE: III (prognostic study, case-control study).

A biomechanical analysis of youth pitching mechanics.

BACKGROUND: It is estimated that nearly 6% of youth baseball participants seek medical attention for injuries sustained during play. Most injuries are overuse injuries, and 26% are to the shoulder or upper arm. By quantifying youth pitching biomechanics, knowledge can be gained concerning the manner in which these injuries are sustained during play. METHODS: Sixteen healthy right hand-dominant baseball pitchers participated in this study. After digitization of 21 bony landmarks, kinematic calculations were conducted using the 3-dimensional coordinates from each video frame. Data were time normalized, forcing major temporal components of the movement to occur at specific intervals. Segment-based reference frames were established, and resultant joint kinetics were projected onto each reference frame. Kinetic data were normalized and calculated along or about the anterior/posterior, medial/lateral, and proximal/distal axes. RESULTS: Maximum trunk rotation and external shoulder rotation were observed during arm cocking. Each of the remaining kinematic parameters peaked after ball release. All maximum values for joint kinetics were measured during arm cocking with the exception of compressive forces experienced at the shoulder and elbow, which peaked after the instant of ball release. CONCLUSIONS: Data produced in this study indicate that youth pitchers initiate trunk rotation early in the movement, which can lead to shoulder hyperangulation. Opposing torques at each end of the humerus also produce a large net torque about the longitudinal axis of the humerus during late arm cocking and may increase humeral retrotorsion in youth pitchers. Underdeveloped musculature in the rotator cuff may lead to difficulty controlling throwing-arm deceleration, causing an increase in horizontal adduction across the torso. CLINICAL RELEVANCE: An improved understanding of youth pitching mechanics is gained from the data collected, analyzed, and discussed in this study. Through increases in the knowledge pertaining specifically to the mechanics of youth pitchers, the opportunity to develop pitching mechanics specifically designed for preventing injuries in little league pitchers arises. LEVEL OF EVIDENCE: This study is a Level 4 study describing youth pitching biomechanics and how they relate to possible injuries.