Outcome of distal clavicular fracture separations and dislocations in immature skeleton.

BACKGROUND: There are only a few studies with long-term follow-up of distal clavicular injuries in children and their treatment is not clearly defined. The purpose of our study is to suggest a new classification system according to the fracture pattern and the degree of the displacement, to evaluate the long-term follow-up and also to propose an algorithm for treatment. METHODS: We conducted a retrospective study from 1983 to 2008. Seventy-five children and adolescents, age ranging from 3 to 16 years (46 >8 years), were treated in our department. We classified all these injuries into five groups according to the fracture pattern and into subgroups according to the displacement of the bony particles: greenstick fractures as group I, transverse fractures as group II, oblique fractures as group III (IIa and IIIa: undisplaced, IIb and IIIb: displaced), comminuted fractures as group IV and true dislocation of the acromioclavicular joint as group V. Sixty-three patients were treated conservatively, while 12 sustained surgical treatment. RESULTS: Fifty-nine patients were re-examined after 2-18 years. All the patients included in groups I, IIa and IIIa had no loss in the motion of their shoulder. Seven of the 29 patients in groups IIb, IIIb, IV and V appeared to have minor loss of motion. A constant score was noted in 52 patients and the results were excellent. None of the patients complained of limitations in daily activities, while five patients, who were treated conservatively, complained of visible prominence at the fracture site. One of them had a clavicular duplication, while another patient treated surgically complicated with coracoclavicular synostosis. CONCLUSION: The aforementioned proposed classification of these injuries is based on the fracture pattern and is simple, leading to decision making concerning therapy of these injuries. The functional results after a distal clavicle fracture will be excellent, either after conservative or surgical treatment. Older patients (>8 years) from groups IIb, IIIb, IV and V, with greater displacement, could be treated surgically to have better cosmetic results.

Long-term follow-up of combined fractures of the proximal radius and ulna during childhood.

Forty-five children with combined fractures of the proximal end of the radius and ulna were treated in our orthopedic department over a period of 16 years (1984-1999). The age of the patients ranged from 5 to 12 years (mean 8 years) with a peak of 7-8 years. The mechanism of injury was a fall on the outstretched hand with the elbow extended and with a valgus force being applied to the elbow. In 35 patients, closed reduction or immobilization in plaster, or both, were performed. In the other 10 patients, a surgical treatment was followed either for fractures of the radius (4) or for both the radius and ulna (6). The follow-up period ranged from 4 to 20 years (mean 12 years 3 months). The functional results were satisfactory in most cases despite the poor radiological appearance of some of them. In three patients we found a notable restriction, mainly in forearm pronation-supination and less in elbow flexion-extension, because of upper radioulnar joint synostosis. Poor results related with initial damages at the time of injury and the age of the patient (> 10 years) rather than with the way of treatment. Valgus deformity, restriction in flexion-extension, and pronation-supination were related with the extent of the initial injury but not related with the way of treatment. Overgrowth of the radial head, which had minor impact mainly on the pronation-supination, was found in the majority of cases that underwent surgical treatment. Minor residual abnormalities of the radius, ulna, or both were present without having marked functional influence.

Elongation of the femoral neck in Perthes disease.

We present the long-term clinical and radiological results of a series of 168 young patients with unilateral Perthes disease who were treated in our department between 1989 and 1997, using a combined osteotomy in the longitudinal and horizontal axis of the proximal femur and elongation of the femoral neck. Surgical treatment was undertaken for any group II (Catterall's classification) patient, with the presence of two or more radiographic signs of the "head at risk" and the clinical sign of flexion with abduction, as well as for all cases classified by Catterall as groups III and IV. The surgical procedure we describe provided 147 radiologically and clinically normal hips in the short and long-term. However, in the long-term, 21 out of 168 patients presented with residual deformities such as shallow acetabulum, thickening of the acetabular floor, coxa magna, thicker and slightly shorter femoral neck. Thus for the vast majority of patients, the operation we describe here provided leg length equalisation and restored the working length of the abductors by maintaining the tip of the greater trochanter at the same level as on the unaffected side.

Chronic osteomyelitis of the pelvis in children and adolescents.

Osteomyelitis of the pelvis is rare in children as well as in adults. This explains why the diagnosis is often missed, so that the infection becomes chronic. The authors report five chronic paediatric cases, seen between 1993 and 2003. The diagnosis was initially missed in two patients. In two others, the osteomyelitis was recognised but insufficiently treated, so that it also became chronic. The fifth patient developed exogenous osteomyelitis 6 months after an open pelvic fracture. The bone scan was useful for the differential diagnosis, but laboratory and radiographic findings were not. Treatment was the same for all patients, including wide surgical debridement, antibiotic therapy and prolonged immobilisation. Four patients were free of symptoms at the last clinical evaluation, after an average follow-up period of 7 years. Only one patient had a recurrence 3 months postoperatively and was re-operated. This study demonstrates that surgical treatment of chronic pelvic osteomyelitis in children and adolescents yields encouraging results.

Outcome of physeal and epiphyseal injuries of the distal tibia with intra-articular involvement.

The authors reviewed 83 physeal and epiphyseal injuries of the distal tibia with intra-articular involvement. The children, aged 11 to 14 years, were treated in the authors' department during 1987 to 1999. Treatment was nonoperative for 72.25% (60/83) and surgical for 27.75% (23/83) according to specific indications. This gives the basis for a classification of these injuries. The main purpose of the study was to investigate the long-term results of these injuries according to a radiologic classification. The parameters considered were the patient's age, the mechanism of injury, and the possibility of growth deformities or functional disorders. They were studied relative to the long-term results, with a follow-up of 2 to 13 years. Regardless of treatment, varus deformity, ranging from 10 to 15 degrees in relation to the normal opposite leg, occurred in four cases. In only one case was there painful limitation of ankle joint movement; in two other children an overgrowth of the medial malleolus was detected, with no functional impairment.

Talus fracture associated with a fracture dislocation of the distal tibia in an immature skeleton.

A 12-year-old boy with a severe injury of his right ankle was treated in the accident unit. The local condition was an extensive open wound with parts of the fractured bones prominent. Radiographs showed a severely displaced fracture of the body of the talus associated with a Salter-Harris IV injury of the distal tibia and subluxation of the ankle. After proper debridement the fractured bones were reduced and fixed. Eleven years later both fractures are completely healed without any sign of avascular necrosis, the patient has full painless ankle movement and he can perform his demanding occupation without any problem.