Tibial fractures in children. A retrospective 27-year follow-up study.

BACKGROUND: Tibial fracture is the third most common long-bone fracture in children. Traditionally, most tibial fractures in children have been treated non-operatively, but there are no long-term results. METHODS: 94 children (64 boys) were treated for a tibial fracture in Aurora City Hospital during the period 1980-89 but 20 could not be included in the study. 58 of the remaining 74 patients returned a written questionnaire and 45 attended a follow-up examination at mean 27 (23-32) years after the fracture. RESULTS: 89 children had been treated by manipulation under anesthesia and cast-immobilization, 4 by skeletal traction, and 1 with pin fixation. 41 fractures had been re-manipulated. The mean length of hospital stay was 5 (1-26) days. Primary complications were recorded in 5 children. The childrens' memories of treatment were positive in two-thirds of cases. The mean subjective VAS score (range 0-10) for function appearance was 9. Leg-length discrepancy (5-10 mm) was found clinically in 10 of 45 subjects and rotational deformities exceeding 20° in 4. None of the subjects walked with a limp. None had axial malalignment exceeding 10°. Osteoarthritis of the hip and/or knee was seen in radiographs from 2 subjects. INTERPRETATION: The long-term outcome of tibial fractures in children treated non-operatively is generally good.

Childhood femoral fracture can lead to premature knee-joint arthritis. 21-year follow-up results: a retrospective study.

BACKGROUND AND PURPOSE: During the past decades, treatment of pediatric femoral fractures in Finland has changed from mostly non-operative to more operative. In this retrospective study, we analyzed the long-term results of treatment. PATIENTS AND METHODS: 74 patients (mean age 7 (0-14) years) with a femoral fracture were treated in Aurora City Hospital in Helsinki during the period 1980-89. 52 of 74 patients participated in this clinical study with a mean follow-up of 21 (16-28) years. Fracture location, treatment mode, time of hospitalization, and fracture alignment at union were assessed. Subjective assessment and range of motion of the hip and knee were evaluated. Leg-length discrepancy and alignment of the lower extremities were measured both clinically and radiographically. RESULTS: Of the 52 children, 28 had sustained a shaft fracture, 13 a proximal fracture, and 11 a distal fracture. 44 children were treated with traction, 5 by internal fixation, and 3 with cast-immobilization. Length of the hospital treatment averaged 58 (3-156) days and the median traction time was 39 (3-77) days. 21 of the 52 patients had angular malalignment of more than 10 degrees at union. 20 patients experienced back pain. Limping was seen in 10 patients and leg-length discrepancy of more than 15 mm was in 8 of the 52 patients. There was a positive correlation between angular deformity and knee-joint arthritis in radiographs at follow-up in 6 of 15 patients who were over 10 years of age at the time of injury. INTERPRETATION: Angular malalignment after treatment of femoral fracture may lead to premature knee-joint arthritis. Tibial traction is not an acceptable treatment method for femoral fractures in children over 10 years of age.

Range of motion and strength after surgery for brachial plexus birth palsy.

BACKGROUND: There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy. PATIENTS AND METHODS: 107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated. RESULTS: 61 patients (57%) had no active shoulder external rotation (median 0° (-75-90)). Median active abduction was 90° (1-170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0-83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5-80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0-79)). Median active extension of the wrist was 55° (-70-90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0-121). Patients with total injury had poorer ROM and strength than those with C5-6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values. INTERPRETATION: ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.

Brachial plexus birth injury: US screening for glenohumeral joint instability.

PURPOSE: To prospectively evaluate the use and optimal timing of ultrasonographic (US) screening for posterior shoulder subluxation in infantswith brachial plexus birth injury (BPBI). MATERIALS AND METHODS: Approval of the ethics committee and informed consent of guardians was obtained. This population-based prospective study included neonates with BPBI who were born in Helsinki from January 1, 2003 through December 31, 2006, and in whom BPBI was verified with sequential clinical examinations. US was performed at 1, 3, 6, and 12 months. Size (width and height) of the humeral head and its ossification center and congruency of the shoulder (alpha angle) were measured. Frequency of BPBI and permanent changes were evaluated. This study also included patients who were referred from the tertiary catchment area. For statistical analysis, 95% confidence intervals were calculated, and analysis of variance was performed. RESULTS: BPBI was seen in 132 of 41980 neonates (3.1 per 1000). In 27 cases (0.64 per 1000), BPBI did not heal during the 1st year of life and was considered permanent. The humeral head and its ossification center were smaller on the affected side in permanent BPBI. Nine patients with permanent palsy had posterior subluxation of the humeral head depicted with US (alpha angle, >30 degrees ). In five patients, posterior subluxation [corrected] was detected at 3 months. Nineteen of 21 patients with BPBI from the tertiary catchment area had permanent palsy. Ten of 19 patients developed posterior subluxation of the shoulder, which was verified with US. Altogether, three of these cases were not detected by surgeons. Posterior subluxation of the humeral head developed during the 1st year of life in one-third of patients with permanent BPBI. In more than one-half (55% [five of nine]) of the patients, posterior subluxation [corrected] was detected with US at 3 months, and in 89% (eight of nine), it was detected at 6 months. CONCLUSION: US is a fast and useful tool for diagnosis of posterior subluxation of the humeral head, and examination of the glenohumeral joint should be performed at 3 and 6 months of age in infants with BPBI if symptoms persist.

Muscle changes in brachial plexus birth injury with elbow flexion contracture: an MRI study.

BACKGROUND: Muscle pathology of the arm and forearm in brachial plexus birth injury (BPBI) with elbow flexion contracture has not been evaluated with MRI. OBJECTIVE: To determine whether limited range of motion of the elbow in BPBI is correlated with specific patterns of muscular pathology. MATERIALS AND METHODS: For 15 BPBI patients, total active motion (TAM) of the elbow (extension-flexion) and the forearm (pronation-supination) were measured. MRI of the elbow joints and musculature allowed assessment of elbow congruency. Fatty infiltration and size reduction of the muscles were graded semiquantitatively. RESULTS: Mean TAM of the elbow was 113 degrees (50 degrees-140 degrees) and that of the forearm 91 degrees (10 degrees-165 degrees). The greater the size reduction of the brachioradialis muscle, the more diminished was elbow TAM. The more extensive the BPBI and muscle pathology of the pronator teres muscle, the more limited was the TAM of the forearm. Pathology of the supinator and brachialis muscles was evident in every patient. CONCLUSION: Extensive BPBI may result in marked limitation of TAM. Elbow flexion contracture seems to be caused mainly by brachialis muscle pathology. Prosupination of the forearm is better preserved when the pronator teres is not severely affected. MRI can reliably show the extent of muscle pathology in BPBI.

MRI of rotator cuff muscle atrophy in relation to glenohumeral joint incongruence in brachial plexus birth injury.

PURPOSE: To evaluate rotator cuff muscles and the glenohumeral (GH) joint in brachial plexus birth injury (BPBI) using MRI and to determine whether any correlation exists between muscular abnormality and the development of glenoid dysplasia and GH joint incongruity. MATERIALS AND METHODS: Thirty-nine consecutive BPBI patients with internal rotation contracture or absent active external rotation of the shoulder joint were examined clinically and imaged with MRI. In the physical examination, passive external rotation was measured to evaluate internal rotation contracture. Both shoulders were imaged and the glenoscapular angle, percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the greatest thickness of the subscapular, infraspinous and supraspinous muscles were measured. The muscle ratio between the affected side and the normal side was calculated to exclude age variation in the assessment of muscle atrophy. RESULTS: All muscles of the rotator cuff were atrophic, with the subscapular and infraspinous muscles being most severely affected. A correlation was found between the percentage of humeral head anterior to the middle of the glenoid fossa (PHHA) and the extent of subscapular muscle atrophy (r(s)=0.45, P=0.01), as well as between its ratio (r(s)=0.5, P P=0.01). Severity of rotator cuff muscle atrophy correlated with increased glenoid retroversion and the degree of internal rotation contracture. CONCLUSIONS: Glenoid retroversion and subluxation of the humeral head are common in patients with BPBI. All rotator cuff muscles are atrophic, especially the subscapular muscle. Muscle atrophy due to neurogenic damage apparently results in an imbalance of the shoulder muscles and progressive retroversion and subluxation of the GH joint, which in turn lead to internal rotation contracture and deformation of the joint.

Cervical spine in patients with diastrophic dysplasia--radiographic findings in 122 patients.

BACKGROUND: In previous studies, typical radiological findings in the cervical spine of patients with diastrophic dysplasia (DD) have been kyphosis, displacement of the vertebrae, spina bifida occulta (SBO), anterior hypoplasia of vertebrae C3-5, and hyperplasia and dysmorphism of the odontoid process. OBJECTIVES: To make a radiological analysis of the cervical spine in patients with DD. MATERIALS AND METHODS: The study comprised 122 patients (50 males, 72 females), with an average age of 19 years (range newborn-63 years). Follow-up was available on 62 patients (51%), for an average duration of 11 years. Cervical spine alignment was measured according to Cobb's method. The height (H) and depth (D) of the vertebral body and sagittal diameter (S) of the spinal canal were measured. H/D and S/D ratios were then calculated from the measurements. The shape of the vertebrae was assessed. Displacement and movement of cervical vertebrae in neutral and bending radiographs were measured. RESULTS. The average lordosis in the last radiograph was 17(degrees) (range 4 degrees -55(degrees)). Five (4%) patients had a cervical kyphosis with an average of 92(degrees) (range 10-165(degrees)) on their last radiograph. The H/D ratio increased slowly during growth and showed significant correlation with age. There was no growth spurt at puberty. The S/D ratio was fairly stable until 7-8 years of age, when it started to decline slowly. The percentage of vertebrae with a flat vertebral body and narrow spinal canal value tended to increase with age. Vertebral hypoplasia and displacement between vertebrae were most common in the mid-cervical region and resolved spontaneously with age. Degenerative changes seemed to increase with age and were already visible during the second decade of life. SBO was noted in 79% of patients. CONCLUSIONS: The most common alignment in the cervical spine is lordosis in adulthood. The vertebral bodies are flattened and the spinal canal is narrowed. Vertebral body hypoplasia and displacement usually resolve spontaneously during growth. Degenerative changes in the cervical spine are common, but vertebral anomalies are rare. Prevalence of SBO is high.

Does genotype predict development of the spinal deformity in patients with diastrophic dysplasia?

This study analyzed whether genotype can be used to predict development of spinal deformity in patients with diastrophic dysplasia (DD). Severity and natural history of scoliosis vary among patients, but the magnitude of the curves is similar among siblings. Plain radiographs were taken of 69 patients aged 16 years or older. The degree of scoliosis was measured according to Cobb's method. Blood samples were collected from patients clinically diagnosed as having DD and the genotype was determined. Fifty-six patients were found to be homozygous for the Finnish founder DTD mutation, DTDST(Fin). Of these 56, 51 (91%) had scoliosis, with an average curve of 43 degrees (range 12 degrees-188 degrees ). The DTDST(Fin)/R279 W genotype was found in nine patients, and of these, eight (89%) had scoliosis, with an average curve of 34 degrees (range 11 degrees-70 degrees ). The DTDST(Fin)/nondetermined genotype was found in four patients. Three (75%) of them had scoliosis, with an average curve of 126 degrees (range 77 degrees-188 degrees ). Statistical analysis found no difference in the prevalence or magnitude of curves between subgroups. The development and severity of the scoliosis cannot, therefore, be predicted from the genotype. It seems possible that scoliosis development is affected by several genes as well as by external factors.