A unique fracture pattern of the proximal phalanx in children: fractures through the phalangeal neck with an attached dorsal bony flange.

This paper describes a unique fracture pattern of the proximal phalanx in children that has not been specifically studied in the literature. Volarly, the fracture line passes through the phalangeal neck and then the fracture line passes dorsally to include a dorsal flange of the metaphysis. Fractures were classified into three types: type I fractures were undisplaced with no finger deformity; type II fractures were mildly displaced in the antero-posterior plane without lateral angulation or scissoring; while type III fractures were severely displaced or had associated lateral angulation or scissoring deformity. Over a 6-year-period, nine cases were seen by the authors. The mechanism of injury was by entrapping the digit in a closing door in all cases. The mean age of patients was 5 years. Types I and II fractures were seen in five children and all were treated by splinting with an excellent outcome. Two children with type III fractures were treated with closed reduction and either splinting (one case) or k-wire (one case), and both had a poor initial outcome. The remaining two children with type III fractures were treated with open reduction and internal fixation with an excellent outcome. Differences between these fractures and the classic phalangeal neck fractures are discussed.

An intramuscular myxoma of the hand.

Myxomas of the upper limb are rare and are classified according to their tissue of origin into tumours arising from periosteum, bone or soft tissues such as skin, fascia and muscle. In the literature, one case of intramuscular myxoma of the forearm has been reported. The current report describes the first intramuscular myxoma within the hand muscles.

Dislocations of the elbow in children.

A total of 33 children were treated for acute traumatic dislocation of the elbow between 1994 and 2002; 30 dislocations were posterior and three anterior. Eight children had a pure dislocation and 25 had an associated fracture of the elbow. Two had compound injuries. Two children had injury to the ulnar nerve, one to the radial nerve and one to the median nerve together with injury to the brachial artery. Twenty required open reduction. Complications included pseudarthrosis of the medial epicondyle in one child and loss of flexion and rotation of between 10 degrees and 30 degrees in ten others. Meticulous clinical and radiological assessment is mandatory in children with dislocation of the elbow to exclude associated injuries. The results were excellent to good in 22 patients, fair in ten and poor in one.

Osseous manifestations of tuberculosis in children.

Forty-two children with tuberculous osteomyelitis were seen and treated between 1984 and 1999. The age ranged from 1 to 12 years (average 6); there were 31 boys and 11 girls. There were 50 osseous lesions (excluding spinal and synovial). Five children had multifocal bone involvement. There were four basic types of lesions: cystic (n = 26), infiltrative (n = 10), focal erosions (n = 8), and spina ventosa (n = 6). The majority of the lesions were in the metaphyses (n = 25); the remainder were in the diaphysis, epiphysis, short tubular bones, flat bones, and small round bones. The erythrocyte sedimentation rate was normal in seven, and the Mantoux test was negative in four. Bone lesions resembled pyogenic and fungal infections and benign and malignant bone tumors. Histologic confirmation was obtained in all patients. Curettage and antituberculous treatment yielded good results in the majority of patients, with follow-up of 6 months to 9 years. Biopsy is mandatory to confirm the diagnosis.

Hematogenous osteomyelitis of the calcaneus in children.

Fourteen children (average 9 years) with primary hematogenous osteomyelitis of the calcaneus are reported. Four were seen early and 10 late. Clinical presentation was dramatic, with fever, pain, swelling, and fluctuance around the foot and ankle. The diagnosis was missed initially in 8 cases because the patients were treated for septic arthritis of the ankle, cellulitis, and subcutaneous abscess. The 4 patients seen early healed well, with no complications. The 10 patients seen late had chronic osteomyelitis with growth arrest; shortening of the foot; limb length deficiency; fusion of subtalar, calcaneocuboid, and ankle joints; calcaneus and equinus deformity; avascular necrosis of the talus; and phalangeal loss. Hospital stay was prolonged in 4 patients. Total calcanectomy (3 patients) and talectomy (2 patients) with heel pad preservation were useful salvage procedures avoiding ablation of the limb in chronic cases.

Primary subacute haematogenous osteomyelitis in children.

Between 1990 and 1998 we saw 21 children with primary subacute haematogenous osteomyelitis. Pain, swelling and a limp had been present for two to 12 weeks with little functional impairment. Laboratory tests were non-contributory. The lesions were classified radiologically into metaphyseal, diaphyseal, epiphyseal and vertebral. There were 24 sites involved, with most (20) being in the tibia; 17 lesions were in the diaphysis, five in the metaphysis and two in the epiphysis. The diagnosis was confirmed histologically in all cases. Staphylococcus aureus was cultured in six patients. Healing occurred in all patients after treatment with antibiotics for six weeks and radiological improvement was seen after three to six months. Subacute osteomyelitis develops as a result of increased host resistance and decreased bacterial virulence. The radiological features can mimic various benign or malignant bone tumours and non-pyogenic infections. Histological confirmation is necessary to avoid a delay in diagnosis.

Salmonella typhi spondylitis.

We report on five patients with Salmonella typhi spondylitis who were immunologically normal and had no prodromal gastrointestinal illness. The diagnosis was confirmed on blood cultures, Widal test, and needle biopsy of the spine. Appropriate antibiotic treatment resulted in a favorable outcome.

Supracondylar fractures: posterolateral type with brachialis muscle penetration and neurovascular injury.

Twenty-seven children with vascular deficit associated with the displaced posterolateral type of supracondylar fracture were explored surgically. Twenty-two children had median nerve signs. Associated clinical findings were bruising, tethering or puckering of the skin in the antecubital region, and a palpable subcutaneous medial spike of the proximal humeral fragment, indicating that the brachialis muscle was penetrated. Manipulation was avoided in such cases. At exploration, the neurovascular bundle was found trapped anterior to the fracture edge in 18 cases, dislocated behind the fracture edge in five cases, and separated by the spike in four cases. Fasciotomy of the antecubital region was performed, and the neurovascular bundle was released from entrapment. The vessel pulsated after release in 21 cases, vascular procedures were done in four, and the vessel ends were ligated in two completely lacerated vessels. Manipulation should be avoided in displaced posterolateral supracondylar fractures with neurovascular deficit when there is clinical evidence that the brachialis muscle belly has been buttonholed.

Ulnar nerve injury after K-wire fixation of supracondylar humerus fractures in children.

Six cases of ulnar nerve injury resulted from crossed K-wire fixation of displaced supracondylar humeral fractures in children. The age ranged between 4 and 10 years. Pain on extension of the little and ring fingers and early clawing were important post operative signs of ulnar nerve involvement. Early exploration of all six cases revealed medial pin placement in the cubital tunnel in five cases. In two of these, the nerve was directly penetrated, and in three, it was constricted by the cubital tunnel retinaculum. In the case 6, the nerve was hypermobile and found to be fixed anterior to its groove over the medial epicondyle. The nerve was decompressed in all cases, and the wire was repositioned. Follow-up ranged from 4 to 14 months. Full nerve recovery occurred in three cases, partial in two, and no recovery in one. Early exploration rather than simple pin removal is safer and diagnostic of the mechanism of injury.

Rubber band constriction of the wrist.

We report the effects of rubber bands placed as decorative bands around the wrists of two infants by older children. These bands went unnoticed by their parents for several hours until swelling of the hand occurred. Early decompression of the carpal tunnel and fasciotomy of the dorsum of the hand are recommended. Education of the community is important in avoiding complications from placement of these rubber bands around an extremity.

Osseous localization of Rosai-Dorfman disease.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a disease of bone marrow stem cell origin which primarily affects lymph nodes. Solitary bone lesions are rare and can cause diagnostic difficulties. A primary lesion in the right index finger of a 10-month-old child is reported.

Atypical spinal tuberculosis in children.

Spinal tuberculosis characteristically involves two contiguous vertebral bodies with narrowing of the disk space. We report on 11 children with atypical spinal tuberculosis. Three had disease confined to a single body, four had extradural extraosseous involvement presenting as an abscess, and isolated infection of the neural arch was seen in four children. Seven children had neurological involvement. Treatment included posterior decompression for the extradural extraosseous involvement, biopsy and drainage for the neural arch infection, and anterior decompression and fusion for the single-body disease. The patients had antituberculosis treatment for 18 months, and all seven children with neurological involvement recovered.

Cystic tuberculosis of bone in children.

We treated 13 children with histologically confirmed cystic tuberculosis of bone. Ten had solitary cystic lesions and three had the multicystic form. Signs and symptoms were related mainly to the joint adjacent to the cyst. Most lesions were in the metaphyses of long bones. They were radiolucent, round or oval, and resembled pyogenic infections, aneurysmal and simple bone cysts, cartilaginous tumours or osteoid osteoma. Only two of the children had pulmonary tuberculosis. The Mantoux skin test was negative in four children and the ESR was normal in five. Curettage followed by anti-tuberculosis therapy for one year resulted in good healing, but two children had residual joint contractures. Biopsy should be taken from the cystic area rather than from the synovium when a joint is involved.

Foot deformities and occult spinal abnormalities in children: a review of 16 cases.

A retrospective clinical and radiologic study was made of 16 children with foot deformities and associated occult spinal abnormalities in a 3-year period. Eleven children had bilateral foot deformities; the deformities were unilateral in five. Midline cutaneous lesions of the back were noted in 13 children; the most common dermal sign was a hairy patch. All children had radiologic features of spinal dysraphism on combined computed tomography (CT) scan and myelogram. Spinal dysraphism was not considered in the initial assessment of four children. Children with foot deformity should therefore have a careful assessment of the spine, including a neurologic evaluation.

Infections of the clavicle in children.

Of 23 children with infections of the clavicle, 11 had pyogenic osteomyelitis, four had tuberculosis, and eight (infants) had congenital syphilis. Acute pyogenic infections were treated by drainage. Resection of the clavicle was performed in chronic cases. Curettage and antituberculosis drugs were effective for children with tuberculous infection of the clavicle. Procaine penicillin was used for the treatment of congenital syphilis. Biopsy is generally necessary to differentiate chronic infection from neoplasm.

Spinal injuries in children.

We reviewed 47 children with spinal injuries. Three distinct patterns of injury were observed: subluxations and dislocations without a fracture (type 1), spinal cord injury without radiographic abnormality (type 2), and spinal fractures which may be associated with subluxation or dislocation (type 3). The neurological recovery was poor in complete lesions associated with type 2 injuries.

Osseous sporotrichosis.

We report on four patients with osteomyelitis due to Sporothrix schenckii who were successfully treated with potassium iodide.

The skeletal manifestations of congenital syphilis. A review of 197 cases.

In a retrospective review of 302 clinically suspected cases of congenital syphilis, bone changes were found in 197. The skeletal manifestations were periostitis (102 cases), osteitis (20), and metaphyseal changes (71). Combinations of more than one lesion were found in 61. Pseudoparalysis was a presenting sign in 34 infants; 12 of these were found to have had pathological fractures and four had dactylitis. Complete radiological healing without residual changes was seen in all 59 cases that were recalled for review. The orthopaedic surgeon should consider the diagnosis of congenital syphilis when destructive lesions of bone are seen in an infant.

Treatment of femoral shaft fractures in children by early spica casting.

Eighty-five children with femoral shaft fractures were studied prospectively to determine the benefits of early application of a single-hip spica cast. They were compared with 85 children with similar fractures treated by skin traction for 4 weeks followed by a spica cast for 2 weeks. The study revealed that femoral shaft fractures in children can be treated in a single-hip spica cast with results comparable to those achieved by traction. The additional advantages were substantial savings in cost, early reunion of child with parents and increased availability of beds.