[From surgery for esophageal atresia in the infancy to late complications of ib fusion and scoliosis]. / L'image du mois. D'une chirurgie pour atrésie de l'oesophage dans l'enfance à des complications tardives de type fusion costale et scoliose.

Following surgey for esophageal atresia, orthopedic complications can sometimes appear late in childhood, hence the importance of regular monitoring. These complications include rib fusion secondary to thoracic surgery and possible infectious complications. Undiagnosed, this condition can lead to severe scoliosis in adolescence.

Après une chirurgie thoracique pour une atrésie de l'œsophage, les complications orthopédiques peuvent apparaître parfois tardivement durant l'enfance, d'où l'importance d'un suivi régulier. Parmi ces complications figure la fusion costale secondaire à l'intervention chirurgicale et aux éventuelles complications infectieuses. Non diagnostiquée et traitée, cette complication peut être responsable d'une scoliose sévère à l'adolescence.

[Growth arrest after a physeal femur fracture in a child]. / Cas clinique. Arrêt de croissance après une fracture fémorale atteignant le cartilage de croissance chez l'enfant.

Physeal fractures are very frequent in pediatric trauma. This is explained by the fact that the epiphyseal growth plate is the weak point in long bones. These fractures may cause a growth arrest which can lead to very serious complications. The aim of this article, based on a case report, is to point out that pediatric traumatology requires a rigorous management and a systematic follow-up. Furthermore, it will remind the clinicians to be particularly cautious according to the location and the characteristics of the fracture.

Les fractures physéales sont très fréquentes en traumatologie pédiatrique. De fait, le cartilage de croissance représente la zone de faiblesse des os longs. Ces fractures peuvent causer un arrêt de croissance (ou épiphysiodèse) avec des conséquences parfois gravissimes. Ce travail, basé sur un cas clinique, a pour but de rappeler que la traumatologie pédiatrique nécessite une prise en charge rigoureuse ainsi qu'un suivi post-traumatique systématique. De plus, il permettra aux cliniciens d'être particulièrement attentifs selon la localisation et les caractéristiques de la fracture.

[Knee pain in a child : watch out for the hip !] / Gonalgie chez l'enfant : vérifier la hanche !

This is a case report of a 13-year old patient presenting with knee pain after a bike accident. Multiple investigations and medical examinations focused on the knee. They did not show any abnormality. About one year later, the patient comes back with increased hip pain, limited internal rotation and shortening of the left limb. Hip X-Ray exams reveal a bilateral slipped capital femoral epiphysis requiring already an osteotomy. Slipped capital femoral epiphysis is a disorder of the proximal femoral epiphysis. The femoral neck is displaced anteriorly and rotates externally while the epiphysis remains in the acetabulum. This pathology is more common in preadolescent boys and can be associated with hormonal disorders. Patients present with an externally rotated gait, a limited internal rotation, associated hip and knee pain. Diagnosis might be missed when patients present with knee pain and can lead to delayed treatment. When facing knee pain, it is essential to perform a clinical examination of the hip. Radiography is the first medical imaging. Surgical treatment by in situ fixation is recommended and prevents further slip with a high rate of success. When delayed, a much more invasive approach is required. A delay in diagnosis adversely affects long-term outcomes.

Il s'agit d'un patient de 13 ans présentant des gonalgies comme principale plainte. Vu l'apparition des douleurs suite à une chute, les investigations se sont focalisées sur le genou. De multiples examens complémentaires ont été réalisés sans mise en évidence de lésion. Après un an d'évolution, le patient se présente en consultation d'orthopédie en chaise roulante avec une impotence fonctionnelle majeure et des douleurs importantes au niveau des membres inférieurs. On note une boiterie, une inégalité des membres inférieurs et une raideur des hanches. Une radiographie du bassin démontre une épiphysiolyse fémorale supérieure bilatérale. Il s'agit d'un glissement de l'épiphyse par rapport au col fémoral, retrouvé plus fréquemment chez le garçon entre 10 et 15 ans. Le tableau clinique peut être caractérisé par des gonalgies, entrainant des retards diagnostiques. En cas de diagnostic précoce, un vissage in situ, peu invasif, empêche la progression de la déformation. Si le diagnostic est retardé, un traitement plus lourd et plus invasif comportant plus de risques et de moins bons résultats à long terme doit être pratiqué. En cas de mauvaise évolution, une arthroplastie précoce doit être réalisée. Une prise en charge rapide permet d'éviter cette escalade thérapeutique.

[Rotationplasty as an alternative to amputation]. / La plastie de rotation, une alternative intéressante à l'amputation.

Rotationplasty can be used as an alternative to amputation when conservative treatment is not possible, for example in malignant tumours of the knee. The principle of the operation is to rotate the lower leg through 180 ° after resection of the distal femur and in this way the ankle joint replaces the knee joint. This surgical technique, although complex, allows satisfactory carcinological resection with a functional outcome superior to amputation above the knee as well as a better quality-of-life. Patients do not develop phantom pain, neuroma or stump discomfort because it is not an amputation. In addition, they can actively control their knee and having proprioception and normal contact with the ground. This results in a coordinated, harmonious and elegant gait pattern similar to the normal population. Patients are more efficient in their activities of everyday life and sports. The major disadvantage is the particular aesthetic aspect and the psychological acceptance.

La plastie de rotation peut être utilisée comme alternative à l'amputation quand le traitement conservateur n'est pas possible, par exemple dans le cadre des tumeurs malignes au niveau du genou. Le principe de l'opération consiste à faire pivoter la jambe de 180° après résection du fémur distal et, ainsi, l'articulation de la cheville remplace l'articulation du genou. Cette technique chirurgicale, bien que complexe, permet une exérèse carcinologique satisfaisante, avec un résultat fonctionnel supérieur à celui de l'amputation au-dessus du genou, ainsi qu'une meilleure qualité de vie. En effet, les patients ne développent pas de douleurs fantômes, névromes ou gêne du moignon puisqu'il ne s'agit pas d'une amputation. De plus, ils peuvent contrôler activement leur genou et gardent une proprioception et une sensation d'un contact normal avec le sol. Il en résulte un schéma de démarche coordonné, harmonieux et élégant, similaire à la population normale. Les patients sont plus performants dans leurs activités quotidiennes et sportives. L'inconvénient majeur est l'acceptation psychologique de cet aspect esthétique particulier.

[How I explore... protrusio acetabuli in children]. / Comment j'explore le protrusio acetabuli chez l'enfant.

Protrusio acetabuli is a clinical entity with variable clinical presentation consisting of a medial deviation of the acetabulum in the pelvic direction. Qualified as a silent deformity in view of its asymptomatic nature until the onset of early degenerative changes, the patient will present with progressive joint pain and stiffness until the development of secondary osteoarthritis. In view of the potentially destructive primary causes associated with the development of secondary protrusion acetabuli, the radiological demonstration of this pathology in young patients cannot be neglected and should lead to the investigation of the underlying pathologies associated with this anomaly. This entity must generate regular clinical and radiological monitoring, and potentially multidisciplinary approach in the event of the appearance of diagnostic criteria for Marfan syndrome, which may vary over time and across individuals.

Le protrusio acetabuli (PA) est une entité clinique à présentation clinique variable consistant en une déviation médiale de l'acétabulum en direction pelvienne. Qualifiée de déformation silencieuse au vu de son caractère asymptomatique jusqu'à la survenue de modifications dégénératives précoces, le patient présentera une douleur et raideur articulaire progressivement évolutive jusqu'au développement d'une coxarthrose secondaire. Au vu des causes primaires potentiellement destructrices associées au développement d'un PA secondaire, la mise en évidence radiologique de cette pathologie chez le patient jeune ne peut être négligée et doit faire rechercher les pathologies sous-jacentes associées à cette anomalie. Cette entité doit également engendrer un suivi clinique et radiologique régulier, et potentiellement multidisciplinaire en cas d'apparition de critères de diagnostic du syndrome de Marfan, variables en fonction du temps et des individus.

Translocation (16;17)(q22;p13) is a recurrent anomaly of aneurysmal bone cysts.

Recently, Panoutsakopoulos et al. (1999) reported 2 cases of aneurysmal bone cysts with a recurrent (16;17)(q22;p13) translocation. We present here two additional cases harboring the same translocation as well as additional chromosomal changes.

[Botulinum A in the treatment of equinus dynamic spasticity in children with cerebral palsy. Preliminary study]. / La toxine botulinique A dans le traitement de la spasticité dynamique en équin chez les enfants porteurs d'infirmité motrice d'origine cérébrale. Etude préliminaire.

PURPOSE OF THE STUDY: The purpose of this clinical prospective study is to better assess the efficacy of intramuscular injections of botulinum-A toxin in the treatment of spastic dynamic equinus deformities in children with cerebral palsy. MATERIAL: Ten walking children (14 feet) with cerebral palsy were treated with botulinum-A toxin (the American type, Botox) for spastic dynamic equinus, equinovalgus or equinovarus deformity of the foot. The mean age was 6 years (range 4 to 12 years of age). METHOD: Two units of botulinum-A toxin per kilogram were injected in each involved extremity: the lateral and medial gastrocnemius were injected in equinus or equinovalgus foot and one more injection was done in the tibialis posterior in equinovarus foot. A clinical assessment (based on opinion of caretakers, functional evaluation of gait, detailed orthopaedic clinical evaluation and video of the gait) and a gait analysis were performed prior to the first injections and then at 1, 3 and 6 months afterwards. RESULTS: All patients showed a clinical improvement. The functional possibilities increased in 6 out of the 10 children. Five children showed a better endurance in their walking capacities. The clinical orthopaedic exam showed improvement for 10 out of the 14 injected feet in passive dorsiflexion from 3 to 15 degrees at one month. Twelve feet improved their score on the Physician Rating Scale from 1 to 4 points. For gait analysis, 6 children (8 feet) had an improvement often minor of their curves in terms of improvement of the dorsal flexion of the ankle and the EMG of the gastrocnemius was improved in terms of decrease of spastic activity in 7 children (10 feet). The response to the injections was seen within 10 days (3 to 10 days) and lasted 3 to 6 months except in one child where it stopped already after 1 month. No side effect was noted. DISCUSSION: All ten patients of our study showed some type of improvement even if only minor or limited in time in some of them. These data corroborate previous studies performed by other authors. Since this study, the recommended dosage has greatly increased (from 2 U/kg up to 10 U/kg or even more). The most interesting new element is that we noted that it seems to increase the endurance of the patient regarding walking distance. CONCLUSION: The intramuscular injection of botulinum-A toxin in spastic dynamic equinus deformities in children with cerebral palsy is an useful treatment modality, but the indications have to be respected scrupulously. The subject needs more study with the higher dosage and clinical evaluation to confirm the possible increased endurance.

Role of exercise testing in the functional assessment of cerebral palsy children after botulinum A toxin injection.

The purpose of this clinical prospective study was to assess the effect of intramuscular injections of botulinum toxin A on energy cost of movement and walking endurance in 15 children with cerebral palsy, aged 4 to 13 years, by using incremental walking treadmill protocol to voluntary exhaustion. Oxygen-uptake response to exercise stress and endurance time were analyzed before and 2 and 6 months after botulinum toxin A injection. Endurance time was significantly improved 2 months after botulinum toxin A injection in 13 patients, and a residual improvement was still present 6 months after injection in some of them. The effect of botulinum toxin A on energy cost of movement was very variable. This study provides clinical evidence of the efficacy of botulinum toxin A in reducing the energy cost of movement and in improving the endurance of spastic muscles in children with cerebral palsy.

Reflex sympathetic dystrophy in children: review of a clinical series and description of the particularities in children.

Few series on reflex sympathetic dystrophy syndrome (RSDS) have included children. The present series reviewed 10 affected children. The group consisted of 9 girls and one boy with an average age at onset of 11 years (5 years to 16 years). The diagnosis was based on the clinical findings of pain, dysesthesia and autonomic system dysfunction. All patients underwent x rays and bone scans. Their results showed great variation. Minor trauma was the most common trigger factor. The lower extremities were more often involved. The treatment consisted of pain relief and progressive mobilization. Less conventional treatments in children, such as calcitonin and bisphosphonate were also used. The severity and duration of the disease varied greatly among these children. Moderate pain and sympathetic dysfunction persisted often up to two years after onset. Reflex sympathetic dystrophy is more common in children than previously thought. There are differences with the adult form in presentation and clinical course: the diagnosis is often delayed, the lower extremities are more often involved, girls are affected more often and idiopathic forms are frequent. Significant emotional dysfunction is found in a majority of patients and they are best treated as inpatients by a multidisciplinary team.

[Why and how to examine the newborns' hips?]. / Comment et pourquoi examiner précocement les hanches du nouveau-né?

The authors insist on the importance of a careful clinical examination of newborn's hips, and on the necessity of an early diagnosis of congenital hip dislocation, in order to optimize the probability of therapeutic success. They don't consider hip dislocations resulting from neuromuscular diseases or from complex malformations (e.g. arthrogryposis) included in a wider context with very different prognosis and treatment.

Adolescent idiopathic scoliosis: treatment with the Wilmington brace. A comparison of full-time and part-time use.

We reviewed the clinical records and the radiographs of 188 patients who had adolescent idiopathic scoliosis. Our purpose was to determine whether part-time and full-time bracing had been equally effective in preventing progression of the curve. Full-time bracing had been used for ninety-eight patients; part-time bracing, for forty-nine; and electrical stimulation, for forty-one. Eighty-eight patients had had a curve of less than 30 degrees and 100 patients, a curve of 30 to 40 degrees. The treatment was considered a failure if the curve had increased 5 degrees or more. The curve progressed 5 degrees or more in thirteen (36 per cent) of the thirty-six patients who had had full-time bracing for a curve of less than 30 degrees, in thirteen (41 per cent) of the thirty-two who had had part-time bracing for such a curve, and in fourteen (70 per cent) of the twenty who had had electrical stimulation for such a curve. Compared with electrical stimulation, both full-time and part-time bracing prevented progression significantly more effectively (p < 0.02 and p < 0.04, respectively). With the numbers available, the difference in progression between the groups that had had full-time and parttime bracing was not significant (p < 0.18). The curve progressed 5 degrees or more in thirty-six (58 per cent) of the sixty-two patients who had had full-time bracing for a curve of 30 to 40 degrees, in ten of the seventeen who had had part-time bracing for such a curve, and in eighteen (86 per cent) of the twenty-one who had had electrical stimulation for such a curve. The difference in progression between each bracing program and electrical stimulation was significant (p < 0.03 for the full-time program and p < 0.05 for the part-time program). With the numbers available, the difference in progression between full-time and part-time bracing was not significant (p < 1.14).

Occult fracture of the calcaneus in toddlers.

Five children 14-33 months of age were treated for calcaneal fractures. All had a history of trauma with limping or refusal to walk. Physical examination could not localize the fracture. Initial radiographs were negative. There were no signs of systemic illness. They were treated with long-leg casts. Radiographs after 2 weeks revealed an arc of sclerosis across the tuberosity of the calcaneus. In no case was a bone scan instrumental in making the diagnosis. Awareness of calcaneal fractures in the child younger than 36 months can prevent the routine use of bone scans to make the diagnosis.

Clubfeet associated with congenital constriction bands of the ipsilateral lower extremity.

The purpose of this study was to examine the outcome of treatment of clubfeet distal to a lower extremity constriction band. Eighteen patients with 21 clubfeet distal to a lower extremity constriction band were treated during the years 1946 to 1992. Three types of bands (I to III) were defined. Three grades of feet (A to C), based on the severity of the deformity, were recognized. After treatment, the feet were classified as good, fair, or poor. At follow-up, six of 18 feet were classified as good, six as fair, and nine as poor. These results were correlated with the type of band and the grade of the foot. A grade A foot associated with type III band had the best result.

C1-C2 posterior soft-tissue injuries with neurologic impairment in children.

A retrospective study of the initial lateral cervical spine radiographs (read as normal) of five multiply traumatized quadriplegic children showed a subtle widening between the spinous processes of C1 and C2. To verify the accuracy of this widening, five distances, two calculations, and four angles were defined and measured in the pathologic group and in a control group of 12 normal children. There was a significant difference (p less than 0.05) between the two groups. A widening of greater than 10 mm between the spinous processes of C1-C2 on a neutral lateral radiograph should alert the physician to an underlying spinal cord injury. The other measurements could then confine the pathology at that level.

Massive bone allografts in large skeletal defects after tumor surgery: a clinical and microradiographic evaluation.

Massive deep-frozen bone allografts were implanted in 13 patients after en bloc tumor resection. Patients were followed up for 14 months to 17 years. Most of the reconstructive procedures included a segmental bone allograft with knee or ankle fusion. Graft infections were the most critical complications in regard to the end results, finally requiring amputation in two cases. There were three stress fractures; two of which were successfully treated without further complication. Graft incorporation was assessed by bone scintimetry in four cases. Isotope uptake by the center of the graft was found to be superior to control bone segments at only 15 years after surgery. Two recovered allograft specimens were available for a microradiographic study. Creeping substitution was a very slow process, initiated at the outer surface of the graft and characterized at 2-3 years after implantation by large, incompletely filled osteons. The present investigation demonstrates that massive bone allografts are very slowly revascularized and are intimately anchored by the host bone. Provided that tumor control is effective and graft infection is avoided, reconstructive surgery with massive bone allografts represents a successful alternative to prosthetic implants in young adult with a long life expectancy.