A modified Jones procedure for managing clawing of lesser toes in pes cavus: long-term follow-up in 8 patients.

UNLABELLED: Pes cavus is a complex foot deformity in which surgical correction remains challenging. We treated lesser-toe clawing in 11 feet of 8 patients (5 women, 1 bilateral; 3 men, 2 bilateral) with a modified Jones procedure and assessed long-term functional outcomes. We reviewed case notes and completed the Bristol Foot Score, the modified American Orthopaedic Foot & Ankle Society Midfoot Score, and a patient satisfaction questionnaire by means of telephone interviews. Mean age of the patients at the time of surgery was 30 years (range, 10-58 years). Mean time from surgery to the last clinical follow-up was 7 years (range, 0.5-17 years), and mean time from surgery to the telephone interview was 9 years (range, 1-18 years). At the final clinical review, all 11 feet were improved, although 6 had minor complications. The mean Bristol Foot Score was 27 (range, 16-55), and the mean modified American Orthopaedic Foot & Ankle Society Midfoot Score was 76 (range, 47-90), indicative of excellent results. Half of the patients had mild persistent foot pain, but all were satisfied with the outcome. Based on our experience with this group of patients, the modified Jones procedure yields satisfactory correction of lesser toe clawing in patients with flexible pes cavus. LEVEL OF CLINICAL EVIDENCE: 4.

Forearm rotational profile in obstetric brachial plexus injury.

Children with obstetric brachial plexus palsy (OBPP) most commonly have weakness of supination. There is little previous information on later progress of forearm rotation movements, although severe supination contracture has been reported in a small proportion of children. The aims of this study were to evaluate forearm rotation after initial recovery from OBPP, to define the relationship with the severity of disease, and to assess which factors might limit rotation. Measurements of active and passive pronation and supination were recorded in 56 children (37 boys and 19 girls) who had had OBPP and did not have full recovery. The mean age was 8 years (minimum, 2.5 years). Care was taken to measure forearm rotation in isolation from shoulder movements. According to the Narakas classification for severity of the original brachial plexus lesion, there were 23 group I cases, 16 group II cases, 11 group III cases, and 6 group IV cases. Twenty-one children underwent reconstructive procedures for shoulder deformity. Mallet scores for shoulder function were available for all patients. Overall pronation was more limited than supination. Active movements were more limited than passive movements. Active pronation was less than normal in 48 children, active supination was less than normal in 36, passive pronation was less than normal in 22, and passive supination was less than normal in 9. Active pronation and active and passive supination were significantly limited in children with worse Mallet scores and in Narakas group IV children. Both active supination and passive supination were decreased in children with more severe elbow flexion contractures. No significant relationship was found between forearm rotation movements and the time of biceps recovery. Many children have persisting limitation of forearm rotation after OBPP. Despite the initial weakness of supination, pronation is more often reduced in the longer term. Patients with more severe OBPP and poorer recovery of shoulder function have greater limitation of forearm rotation.

Lateral versus crossed wire fixation for displaced extension supracondylar humeral fractures in children.

Reduction and percutaneous pin fixation is widely accepted treatment for displaced humeral supracondylar fractures in children, but the best pin configuration is still debatable. This study examined the outcome for crossed and lateral pins placement in type IIB and III supracondylar humeral fractures. Clinical notes and radiographs of 131 children with an average age of 6 years were retrospectively reviewed. Lateral pins fixation was used in 66 children and crossed wires in 65. The groups were similar with regard to gender, age, follow-up, severity of displacement and number of closed/open reductions. There was no statistical difference between the two groups either clinically or radiologically in the quality of outcome. However, postoperative ulnar nerve injuries occurred in 6% of patients treated with crossed wire fixation, whilst none of the group with pins inserted laterally suffered this complication. We recommend fixation of displaced humeral supracondylar fractures with two or three lateral pins inserted parallel or in a divergent fashion. This method of fixation gives similar results to crossed wires but prevents iatrogenic ulnar nerve injuries.

Missed Monteggia injuries.

The classical Monteggia injury comprises a dislocation of the radial head with an associated fracture of the ulna. In the variant type, there is no ulnar fracture merely plastic deformation. We performed a retrospective study of all Monteggia injuries from 1992 to 2001. A total of 39 were reviewed, of which 8 were missed (1 classical and 7 variant). Of those, five were male and three female with a mean age of 6.3 years. The mean follow-up was 2.5 years, with a mean interval between injury and diagnosis of 33.5 weeks. Two Monteggia injuries diagnosed within 4 weeks were successfully treated by closed manipulation. The other six required ulnar osteotomy, repair of the annular ligament and stabilisation of the radial head with a transcapitellar pin. A protocol for the diagnosis of Monteggia injuries is described. Doubtful cases require an immediate review since early treatment improves the outcome. Acceptable clinical and radiological results in late diagnosed Monteggia injuries can result from ulnar osteotomy, open reduction of the radial head with repair of the annular ligament and transcapitellar pin stabilisation of the reduced radial head.

The efficacy of the Pavlik harness, the Craig splint and the von Rosen splint in the management of neonatal dysplasia of the hip. A comparative study.

We have reviewed the outcome of 134 hips in 96 children with Graf type-III or type-IV dysplasia of the hip on ultrasound examination. We treated 28 affected hips in 22 children with the Craig splint, 43 hips in 30 children with the Pavlik harness, and 26 hips in 16 children with the von Rosen splint. A total of 37 affected hips in 28 children was not splinted. All children were less than three months of age at referral. Those treated with the von Rosen splint had a significantly better ultrasound appearance at 12 to 20 weeks of age and fewer radiological abnormalities than those not splinted or treated with the Pavlik harness. In the von Rosen group no hip required further treatment with an abduction plaster or operation compared with ten in the Pavlik harness group, three in the Craig splint group and eight in the group without splintage. Our results suggest that the von Rosen splint is more likely to improve the outcome of neonatal dysplasia of the hip and a definitive, large-scale randomised trial is therefore indicated.