Radiologic evaluation of juvenile tillaux fractures of the distal tibia.

This study evaluated the accuracy of plain radiographs and computerized tomography (CT) in assessing juvenile Tillaux fractures of the distal tibia. A simulated Tillaux fracture was made in four cadaver specimens and displaced 0, 1, 2, 3, and 5 mm. Plain radiographs and CT were performed on each specimen at each amount of displacement, and the results were compared with the actual amount of displacement present. Plain radiographs and CT were accurate within 1 mm in depicting the actual fracture displacement about 50% of the time. CT was more sensitive than plain radiographs in detecting fractures with >2 mm of displacement. Fracture displacement of >2 mm is generally considered an indication for fracture reduction. Because of its sensitivity in detecting fractures displaced >2 mm, CT is the preferred imaging modality in the assessment of juvenile Tillaux fractures.

Management of leg length inequality.

Leg length inequality is common. Treatment objectives include obtaining leg length equality, producing a level pelvis, and improving function. Clinical assessment should include determination of a level pelvis with the patient standing using a set of blocks of various heights to estimate the amount of leg length inequality. Radiographic measures include the teleroentgenogram, orthoradiograph, and computed tomography (CT). A prediction of the ultimate leg length inequality at skeletal maturity will be needed to determine treatment. Our guidelines for treatment of leg length inequality are as follows: <2 cm--no treatment or a lift in the shoe; 2 to 6 cm--an epiphysiodesis or shortening procedure is considered; 6 to 15 cm--a lengthening procedure is considered. A leg length inequality of 15 to 20 cm--may require a staged lengthening, lengthening combined with epiphysiodesis, or amputation. Numerous complications of limb lengthening procedures occur frequently, even in experienced hands.

Development dysplasia of the hip from birth to six months.

The term "developmental dysplasia or dislocation of the hip" (DDH) refers to the complete spectrum of abnormalities involving the growing hip, with varied expression from dysplasia to subluxation to dislocation of the hip joint. Unlike the term "congenital dysplasia or dislocation of the hip," DDH is not restricted to congenital problems but also includes developmental problems of the hip. It is important to diagnose these conditions early to improve the results of treat- ment, decrease the risk of complications, and favorably alter the natural history. Careful history taking and physical examination in conjunction with advances in imaging techniques, such as ultrasonography, have increased the ability to diagnose and manage DDH. Use of the Pavlik harness has become the mainstay of initial treatment for the infant who has not yet begun to stand. If stable reduction cannot be obtained after 2 weeks of treatment with the Pavlik harness, alternative treatment, such as examination of the hip under general anesthesia with possible closed reduction, is indicated. If concentric reduction of the hip cannot be obtained, surgical reduction of the dislocated hip is the next step. Toward the end of the first year of life, the toddlerTs ability to stand and bear weight on the lower extremities, as well as the progressive adaptations and soft- tissue contractures associated with the dislocated hip, preclude use of the Pavlik harness.

Fibrous dysplasia of the proximal part of the femur. Long-term results of curettage and bone-grafting and mechanical realignment.

We reviewed the long-term outcomes of treatment of fibrous dysplasia of the proximal part of the femur in twenty-two patients (twenty-seven femora). There were fifteen male patients and seven female patients. Patients who had monostotic disease had no involvement of the calcar femorale, fewer microfractures, less deformity, and stronger bone that could support internal fixation. Patients who had polyostotic disease had frequent involvement of the calcar femorale; more microfractures; severe deformity, including shepherd's crook deformity; and, in many instances, bone that could not support internal fixation. Twenty-two of the twenty-seven femora had a microfracture at the time of the initial presentation. At least one osteotomy was performed in four femora that had monostotic disease and in nine femora that had polyostotic disease. Curettage and cancellous or cortical bone-grafting did not appear to have any advantage compared with osteotomy alone in the treatment of symptomatic lesions, as all grafts resorbed with persistence of the lesion. At the time of the latest follow-up evaluation, no lesion had been eradicated or had decreased in size. A satisfactory clinical result was achieved in twenty patients (twenty-four femora): nine who had monostotic disease and eleven who had polyostotic disease. Two patients who had polyostotic disease and an endocrinopathy (one of whom had bilateral involvement) had an unsatisfactory result. All three femora in these two patients had a neck-shaft angle of less than 90 degrees at the time of the most recent follow-up evaluation. Varus deformity of the proximal part of the femur is best treated with valgus osteotomy and internal fixation early in the course of the disease. If the calcar of the femoral neck is involved or if the quality of the bone is such that internal fixation is not possible, a medial displacement valgus osteotomy can provide a more mechanically favorable position for healing of the microfracture.

Charcot-Marie-Tooth disease associated with hip dysplasia: a case report.

A 31-year-old woman with a known history of hip dysplasia was found to have Charcot-Marie-Tooth disease following abnormal conduction studies done at the time of surgery. Physical examination in this patient was otherwise normal, and the diagnosis of Charcot-Marie-Tooth disease had not been previously considered. This report demonstrates the importance of keeping in mind the association between hip dysplasia and Charcot-Marie-Tooth disease.

The effects of the interosseous membrane and partial fibulectomy on loading of the tibia: a biomechanical study.

The biomechanical basis for the treatment of delayed union of tibial fractures by partial fibulectomy has yet to be fully evaluated. To gain further insight into this problem, nine intact cadaveric lower extremities were instrumented with strain gauges on the surfaces of the tibia and fibula. The limbs were then subjected to axial loading with the ankle and subtalar joints placed in multiple positions. The specimens were loaded either through the distal femur or by direct loading of the tibial plateau. All specimens were first tested intact then after sectioning of the interosseous membrane and finally after partial fibulectomy. It was shown that during loading of the leg, the primary effects of the interosseous membrane were to stabilize the fibula and constrain its posterolateral bending. The fibular strains were not reduced to zero following sectioning of the interosseous membrane. Tibial strains measured on the anteromedial and anterolateral surfaces were consistently in relative tension, indicating a posterior bending force (anterior bowing) of the tibia. After partial fibulectomy, strains on these surfaces became relatively more compressive. With the ankle and subtalar joints in neutral position (0 degree flexion, 0 degree inversion/eversion) the strains on the anterior surface averaged approximately 10% more compressive relative to the intact condition. Tibial strains were observed to vary with the position of the ankle and subtalar joints. The fact that the anteromedial and anterolateral tibia surfaces were always in tension may explain why partial fibulectomy has not proved to be a uniformly successful treatment method for delayed union of the tibia. Furthermore, it points to the important role of "fracture personality" in the selection of treatment.

Risk factors in Klippel-Feil syndrome.

STUDY DESIGN: This study kinematically evaluated radiographs of the cervical spine of patients with the Klippel-Feil syndrome in flexion and in extension to determine alterations from normal motion and potential risk. OBJECTIVES: The results in the study group were compared with those of a control group and with published standards for expected motion of the cervical spine. SUMMARY OF BACKGROUND DATA: The body of orthopedic and neurologic literature suggests a significant problem with neurologic deficit in patients with Klippel-Feil syndrome. No previous study has evaluated the kinematics of the cervical spine with a control group of normal individuals and published standards. METHOD: Lateral flexion-extension radiographs of the cervical spine of 111 patients with Klippel-Feil syndrome were kinematically evaluated to determine the motion of each open interspace and to compare motion with that of a control group and published standards. RESULTS: A statistically significant difference of increased motion per open interspaces in the upper cervical segment was noted in individuals with Klippel-Feil syndrome when compared with the control population. Conversely, total motion of the lower cervical segment was significantly decreased in the Klippel-Feil population when compared with normal controls. Lower segment motion per open interspace was not significantly different when the two groups were compared. CONCLUSION: The results of this study suggest that individuals with Klippel-Feil syndrome with hypermobility of the upper cervical segment are at risk for neurologic sequelae, whereas those with alteration in motion of the lower cervical segment are predisposed to degenerative disease.

Syringomyelia and developmental scoliosis.

We attempted to characterize the signs and symptoms of patients presenting with scoliosis as a manifestation of occult syringomyelia, and to determine the effect of syrinx decompression on the deformity and neurologic deficits. This study represented 21 patients treated from 1981 through 1991 at the authors' institution. All patients with occult syringomyelia and no other central nervous system lesions underwent decompression of the syrinx, with improvement in neurologic signs and symptoms. Three of the four with scoliosis that were not treated by arthrodesis showed improvement of their deformity at an average follow-up of 35 months. Three of five patients with myelodysplasia, occult syringomyelia, and scoliosis not previously treated with spinal arthrodesis showed stabilization or improvement of their deformity at an average follow-up of 21 months. We conclude that syringomyelia is associated with a high incidence of developmental scoliosis, and that decompression of the syrinx leads to improvement in, or stabilization of, the majority of scoliotic curves, or postpones the need for fusion.

The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: a prospective analysis.

Seventy-eight diaphyseal femur fractures in 77 children were stabilized with flexible intramedullary nails. The patients ranged in age from 2 + 9 to 18 years. All patients had open femoral growth plates at the time of fixation. Eleven percent of the fractures had an average varus or valgus malalignment of 6 degrees. Eight percent of the fractures had an average anterior or posterior malalignment of 8 degrees. Eight percent of the patients had a rotational malalignment that averaged 8 degrees. Sixty-eight percent of the children had equal leg lengths at follow-up. There were four unscheduled reoperations, but no major complications; all fractures united. The results obtained using flexible intramedullary nails for the stabilization of select pediatric diaphyseal femur fractures are comparable to nonoperative methods of treatment, but with less disruption to family life and a shorter hospitalization.

The prognostic significance of the skeletal manifestations of acute lymphoblastic leukemia of childhood.

The variety and distribution of skeletal pathology in children with acute lymphoblastic leukemia is rarely seen in other disease states. Skeletal radiographic changes associated with and/or suggestive of acute leukemia include diffuse osteopenia, metaphyseal bands, periosteal new bone formation, geographic lytic lesions, sclerosis, mixed sclerosis/lysis, and permeative destruction. This retrospective analysis of 83 children with acute lymphoblastic leukemia suggests that children without radiographic skeletal abnormalities have an "aggressive" form of leukemia. Children with one to four lesions have an "indolent" form of leukemia that is of short duration. Children with five or more lesions have an indolent form of leukemia that is of longer duration. The longer duration of symptoms before diagnosis reduces the survival rate to that of the aggressive form of leukemia. It is therefore imperative that physicians who treat children recognize the orthopaedic/radiographic manifestations of acute leukemia (the most common pediatric malignancy) to facilitate diagnosis, and, thereby, improve survival.

Triple osteotomy of the innominate bone in treatment of developmental dysplasia of the hip.

Ten children (11 hips) who underwent triple innominate osteotomy between the ages of 11 and 16 years for treatment of symptomatic acetabular dysplasia and who had > 10 years of follow-up since operation were reviewed to determine if satisfactory results reported in an earlier review were maintained. The mean length of follow-up was 12 years (range 10-16 years). All hips were examined roentgenographically, and functional assessment was made with the Iowa hip scoring system. Ten of the 11 hips improved roentgenographically and eight improved functionally after operation. One hip required replacement arthroplasty 16 years after triple innominate osteotomy.