[Skeletal trauma during the growing period. Radiological diagnostics]. / Skeletttraumatologie im Wachstumsalter: Radiologische Diagnostik.

Bone fractures in childhood are a common occurrence. A differentiated assessment of fractures is of great importance for the diagnostics, therapy planning and estimation of the prognosis. This review article explains the most important characteristics of skeletal trauma in childhood. Skeletal development, the mechanisms of fracture healing and growth disorders after injury to the epiphyseal plates and classification of fractures will be discussed and typical bone fractures in children and the pitfalls in X-ray diagnostics are demonstrated.

In-situ pinning for Slipped Capital Femoral Epiphysis in blacks: experience in a regional orthopaedic centre.

BACKGROUND: Slipped Capital Femoral Epiphysis (SCFE) is the commonest pathology affecting the adolescent hip with an incidence of approximately 2 per 100,000 population. Blacks are more commonly affected than Caucasians. Of many treatment options available, in-situ-pinning appears to be the most widely employed. AIMS AND OBJECTIVES: To determine the epidemiological pattern and the outcome of in-situ pinning for slipped capital femoral epiphysis in Nigerian adolescents. PATIENTS AND METHODS: This is a six-year retrospective review of all the cases of slipped capital femoral epiphysis treated by in-situ pinning between 1st January 1998 and 31st December 2003 at the National Orthopaedic Hospital, Igbobi, Lagos, Nigeria. RESULTS: Thirty-one patients with 35 affected hips were managed with in-situ pinning during the period of review. Twenty-one females (67.7%) and 10 males (32.3%) with a F:M ratio of 2.1:1 were affected. The mean age for all the patients was 12.45 years (range 6 - 16; SD ± 1.79). The most common presenting complaint was hip pain seen in 48.4% of cases. Satisfactory results were obtained in 13 hips (37%) while the results in the remaining 22 hips were unsatisfactory. The most common complication was limb length discrepancy. CONCLUSION: This study shows that SCFE is not an uncommon condition in orthopaedic practice in Nigeria. The high rate of unsatisfactory results is associated with the severity of the slips and the unavailability of image intensifier at the time of surgery.

Slipped capital femoral epiphysis: current concepts.

Slipped capital femoral epiphysis is a common hip disorder in adolescents, with an incidence of 0.2 (Japan) to 10 (United States) per 100,000. The etiology is unknown, but biomechanical and biochemical factors play an important role. Symptoms at presentation include pain in the groin, thigh, or knee. Ambulatory patients also may present with a limp. Nonambulatory patients present with excruciating pain. The slipped capital femoral epiphysis is classified as stable when the patient can walk and unstable when the patient cannot walk, even with the aid of crutches. Because the epiphysis slips posteriorly, it is best seen on lateral radiographs. The treatment of choice for stable slipped capital femoral epiphysis is single-screw fixation in situ. This method has a high probability of long-term success, with minimal risk of complications. In the patient with unstable slipped capital femoral epiphysis, urgent hip joint aspiration followed by closed reduction and single- or double-screw fixation provides the best environment for a satisfactory result, while minimizing the risk of complications.

Demographic predictors of severity of stable slipped capital femoral epiphyses.

BACKGROUND: The outcome of stable slipped capital femoral epiphysis is directly related to the severity of the slip. If it is assumed that the slip will be less severe if it is diagnosed early, then early diagnosis should improve the prognosis. It was our purpose to determine demographic predictors of the severity of a slipped capital femoral epiphysis. METHODS: A retrospective study of 243 children with a total of 328 stable slipped capital femoral epiphyses was performed. Gender, race, age, and symptom duration were noted. Slip severity was classified as mild (<30 degrees ), moderate (30 degrees to 50 degrees ), or severe (>50 degrees ). Statistical analyses included bivariate, multivariate, linear correlation, and logistic regression techniques. RESULTS: There were 159 boys and eighty-four girls; 149 children had unilateral and ninety-four had bilateral slipped capital femoral epiphysis. Of the bilateral slips, forty-two were simultaneous and fifty-two were sequential. The mean age (and standard deviation) was 12.6 +/- 1.8 years, the mean duration of the symptoms was 5.2 +/- 7.4 months, and the mean slip angle was 29 degrees +/- 20 degrees . There were 199 mild, sixty-eight moderate, and forty-five severe slips. The mean duration of symptoms was 3.5 +/- 5.0 months for the mild slips, 7.7 +/- 9.0 months for the moderate slips, and 8.8 +/- 10.6 months for the severe slips (p < 0.0001). Older children had more severe slips: the average age was 12.3 +/- 1.8 years for the children with a mild slip, 13.0 +/- 1.6 years for those with a moderate slip, and 13.8 +/- 1.8 years for those with a severe slip (p < 0.0001). Multivariate analyses demonstrated that, among the factors studied, only the age of the patient and the duration of the symptoms were associated with the slip severity. Symptom duration and patient age were used as predictors of slip severity in a logistic regression analysis, with > or =30 degrees and <30 degrees used as the categories for slip severity, older than 12.5 years old compared with 12.5 years old or younger used as the categories for age, and more than 2.0 months compared with 2.0 months or less used as the categories for symptom duration. This model predicted the probability of a slip with confidence (p < 0.0001). The odds ratios (with 95% confidence intervals) for age and symptom duration were 2.0 (1.15 to 3.53) and 4.1 (2.34 to 7.12), respectively. Thus, a child with a stable slipped capital femoral epiphysis is 2.0 times more likely to have a moderate or severe slip if he or she is older than 12.5 years of age at the time of the diagnosis and 4.1 times more likely to have a moderate or severe slip if the duration of symptoms was longer than two months. CONCLUSIONS: The only two known significant predictors of the severity of a slipped capital femoral epiphysis are age at diagnosis and symptom duration. For any individual child, slip severity and symptom duration are unique; in a large population, there is a general correlation between slip severity and increases in patient age and increases in the duration of symptoms.

Delay in diagnosis of slipped capital femoral epiphysis.

OBJECTIVE: Delay in diagnosis of slipped capital femoral epiphysis (SCFE) has important implications in terms of slip severity and long-term hip outcome. The purpose of this study was to identify predictors of delay in the diagnosis of SCFE. METHODS: A review of 196 patients with SCFE was performed. The primary outcome measure was delay from onset of symptoms to diagnosis. Covariates included age, gender, side, weight, pain location, insurance status, family income, slip severity, and slip stability. Delay in diagnosis was not normal in distribution; therefore, nonparametric univariate and multivariate analyses were performed. RESULTS: The median delay in diagnosis was 8.0 weeks. There was a significant relationship between delay in diagnosis and slip severity (<30 degrees : 10.0 weeks; 30 degrees to 50 degrees : 14.4 weeks; >50 degrees : 20.6 weeks). There were no significant associations between delay in diagnosis and covariates of age, gender, side, and weight. There were significant associations between longer delay in diagnosis and covariates of knee/distal-thigh pain versus hip/proximal-thigh pain (6.0 vs 15.0 weeks), Medicaid coverage versus private insurance (12.0 vs 7.5 weeks), lower family income, and stable slips versus unstable slips (8.0 vs 6.5 weeks). Controlling for the other covariates, knee/distal-thigh pain, Medicaid insurance, and stable slips remained significant independent multivariate predictors of delay in diagnosis. CONCLUSIONS: Patients who present with primarily knee or distal-thigh pain, patients with Medicaid coverage, and patients with stable slips have longer delays in diagnosis of SCFE. Focused intervention programs to reduce the delay in diagnosis of SCFE should emphasize patients with knee/thigh pain and patients with Medicaid coverage.

Epifisiolisis de cadera / Slipped capital femoral epiphysis

El presente trabajo es un estudio retrospectivo descriptivo de 51 caderas con epifisiolisis, en 40 pacientes, tratados en nuestro servicio. Cuarenta y cuatro fueron estables (progresivas) a las de grado 1 y 2 se les realizo fijacion in situ, a las de grado 3 se les realizo fijacion in situ a 5 caderas y a las otras 4 osteotomia de Southwick, 2 fueron grado 4, a una se le realizo osteotomia de Southwick y a la otra fijacion in situ. En las de grado 1 y 2 hemos obtenido excelentes resultados, con fijacion in situ percutanea utilizando en los ultimos 10 años 1 solo tornillo canulado percutaneo, guiados con radioscopia intraoperatoria. En las de grado 3 y 4 (con marcada deformidad) hemos obtenido mejores resultados con osteotomia tipo Southwick en el mismo momento de realizar la fijacion in situ, para mejorar la movilidad y asi evitar otra futura cirugia. En las inestables (agudas) hemos obtenido mejores resultados con la reduccion con maniobras muy suaves y fijacion con 2 tornillos

Epifisiolisis de cadera / Slipped capital femoral epiphysis

El presente trabajo es un estudio retrospectivo descriptivo de 51 caderas con epifisiolisis, en 40 pacientes, tratados en nuestro servicio. Cuarenta y cuatro fueron estables (progresivas) a las de grado 1 y 2 se les realizo fijacion in situ, a las de grado 3 se les realizo fijacion in situ a 5 caderas y a las otras 4 osteotomia de Southwick, 2 fueron grado 4, a una se le realizo osteotomia de Southwick y a la otra fijacion in situ. En las de grado 1 y 2 hemos obtenido excelentes resultados, con fijacion in situ percutanea utilizando en los ultimos 10 años 1 solo tornillo canulado percutaneo, guiados con radioscopia intraoperatoria. En las de grado 3 y 4 (con marcada deformidad) hemos obtenido mejores resultados con osteotomia tipo Southwick en el mismo momento de realizar la fijacion in situ, para mejorar la movilidad y asi evitar otra futura cirugia. En las inestables (agudas) hemos obtenido mejores resultados con la reduccion con maniobras muy suaves y fijacion con 2 tornillos

Sequential magnetic resonance imaging in slipped capital femoral epiphysis: assessment of preslip in the contralateral hip.

Thirty-three images using magnetic resonance imaging (MRI) in 10 patients with slipped capital femoral epiphysis were evaluated. The MRI of affected hips delineated typical widening of the physis. Sequential MRI demonstrated the process of premature closure of the physis developing from the posterior portion anteriorly. In 4 of the 10 asymptomatic contralateral hips, physeal widening was clearly observed in the center or posteromedial region of the physis on T1-weighted images. We performed prophylactic pinning for the four cases showing physeal widening on MRI, and none of the other cases developed a slip. MRI accurately documented detailed features of slips, as well as physeal changes, and may provide indicative information on prophylactic pinning for contralateral hips.

Risk-benefit analysis of prophylactic pinning in slipped capital femoral epiphysis.

There is a broad and controversial discussion about the surgical procedure and the type of hardware for internal transfixation of the epiphysis and metaphysis in slipped capital femoral epiphysis (SCFE). Prophylactic pinning is even more controversial. One hundred and nine patients showing SCFE underwent a one-stage bilateral fixation of the epiphysis with three or four Kirschner wires (pins). From these 109 patients (69 male and 40 female), 94 had an unilateral slip and were operated prophylactically on the contralateral side. There were no complications such as avascular necrosis of the femoral head, chondrolysis, bone fracture, failure of metal implant, osteomyelitis or deep wound infection either at the time of surgery or at the minimum follow-up of 1 year with prophylactic pinning in SCFE. Therefore, we consider pinning allows for efficient stabilization, reliably preventing any progression of SCFE on the affected side and, furthermore, prevents the incidence of a secondary slip on the primarily nondisplaced contralateral side. The transfixation of epiphysis and metaphysis with Kirschner wires (pins) shows good subjective and objective long-term results compared with other surgical methods and implants. There is only a low morbidity rate with this method, because reoperations may only become necessary in the younger age group owing to normal growth of the femoral neck, compared with a high benefit from prophylactic surgical treatment of the nonaffected opposite side at the time of unilateral onset of the disease. The pins may no longer catch the epiphysis but further growth will allow for remodeling of the femoral head and for an optimal neck/shaft ratio. In case of further growth and relative shortening of the pins, refixation may become necessary. Therefore, we like to recommend the Kirschner-wire transfixation (pinning) of the epiphysis and metaphysis in patients with SCFE for primary treatment of SCFE as well as for prophylactic pinning of the contralateral side in one sitting.

Effect of femur position on the angular measurement of slipped capital femoral epiphysis.

SUMMARY: A femur model was used to simulate a slipped capital femoral epiphysis (SCFE). Wedges were inserted into a cut in the femoral neck to create SCFEs of 25, 50, and 75 degrees. The effects of femur position on the angular measurement of SCFE were studied by taking radiographs of the SCFE at preselected positions of rotation and abduction, which were ensured by a holding device. The views selected were the cross table lateral (CTL), Billing lateral, and frog lateral (FL) projections. FL views were obtained at 22.5, 45, and 67.5 degrees of abduction. The rotational positions were 20 degrees internal, neutral, and 15, 30, 45, and 60 degrees external. Slip angles were measured from these radiographs. The CTL and FL projections accurately portrayed any severity of an SCFE at all positions except for 45 and 60 degrees of external rotation. The Billing view falsely portrayed a severe SCFE at all positions of rotation. The most accurate representation of an SCFE is seen on either the CTL or FL view when the external rotation of the femur does not exceed 30 degrees.

Clinical characteristics of children with atypical and idiopathic slipped capital femoral epiphysis: description of the age-weight test and implications for further diagnostic investigation.

SUMMARY: Slipped capital femoral epiphyses (SCFEs) can be idiopathic or atypical (associated with renal failure, radiation therapy, and endocrine disorders). The demographics of 433 children (285 idiopathic, 148 atypical) with 612 SCFEs were studied to define predictors of atypical SCFEs. Multiple logistic regression analysis showed that age and weight were predictors. For two patients of equal weight, those younger than 10 or older than 16 years of age were 4.2 times more likely to have an atypical SCFE; for two patients of equal age, those <50th percentile weight were 8.4 times more likely. The age-weight test was defined as negative when age younger than 16 years and weight > or = 50th percentile and positive when beyond these boundaries. The probability of a child with a negative test result having an idiopathic SCFE was 93%, and the probability of a child with a positive test result having an atypical SCFE was 52%. An evaluation of the child's age and weight is useful when considering the cause of an SCFE.

Nuestra experiencia en el tratamiento de la epifisiolisis femoral proximal. Algunos aspectos controvertidos / Our experience in the treatment of slipped capital femoral epiphysis. Controversial points

Se presenta una revisión de 17 casos de epifisiolisis de cadera en 14 pacientes (tres de ellos con afectación bilateral). Se analizan los resultados obtenidos: a) en la fijación con agujas de Kirschner y con tornillos y b) en tres casos que fueron tratados con osteotomías arciformes tridimensionales. Se emplearon las escalas de valoración clínica de Heyman y Herndon y la radiológica de Boyer. Se analiza también la fijación de la cadera contralateral de manera profiláctica. Por otro lado se revisa la bibliografía referente a la presentación con carácter familiar, a raíz de tres casos acontecidos en nuestra casuística (AU)

Primary healing of physeal separation under rigid fixation.

We observed the healing process under rigid external fixation after Salter-Harris type-1 or type-2 physeal separation at the proximal tibia in immature rabbits. Metaphyseal vessels grew across the gap with little delay; the site of separation then came to lie in the metaphysis and was bridged by endochondral ossification. Union was achieved within two days in all rabbits. Progression of endochondral ossification repaired the separated physis, thus showing 'primary healing of physeal separation'. This depends on accurate reduction and stable fixation to allow the survival of vessels across the gap.

Epifisiolistesis femoral proximal: fijación percutánea in situ con tornillo de Schanz / Proximal femoral epiphisiolisthesis: percutaneous in situ fixation by Schanz screw

Nosotros consideramos que la fijación in situ percutánea con tornillo de Schanz es suficiente para dar estabilidad de deslizamientos leves o moderados de la cadera femoral y este estudio tiene como objetivo analizar la eficacia de este método. Se estudiaron 38 niños (50 caderas) entre noviembre de 1993 y marzo de 1995 tratados con la técnica descrita. La edad de los pacientes varió de los 7 a los 15 encontrándose 35 caderas con deslizamiento grado I, 10 con deslizamiento grado II y 4 con deslizamiento grado III, 40 eran crónicos, 9 crónico-agudizados y uno agudo además de un predeslizamiento. Se observó un 94 por ciento de buenos resultados en los deslizamientos leves, 80 por ciento de buenos resultados en los moderados y 0 por ciento en los severos. Se demuestra un 86 por ciento de resultados satisfactorios en la serie, los malos resultados estuvieron directamente relacionados con la severidad del deslizamiento. En 7 caderas se presentó penetración articular, sin embargo ninguno desarrolló condrólisis. Consideramos que la fijación in situ con tornillo de Schanz da excelentes resultados en los deslizamientos leves y buenos en los moderados por lo que esta técnica es recomendable en estos pacientes y no así para los casos severos

Slipped capital femoral epiphysis.

Slipped capital femoral epiphysis occurs during the adolescent growth spurt and is most frequent in obese children. Up to 40 percent of cases are bilateral. Recent classification methods emphasize epiphyseal stability rather than symptom duration. Most cases of slipped capital femoral epiphyses are stable and have a good prognosis if diagnosed early. Unstable slipped capital femoral epiphysis has a much poorer prognosis because of the high risk of avascular necrosis. Early radiographic clues are the metaphyseal blanch sign and Klein's line. Once diagnosed, treatment should begin immediately. The most widely accepted treatment for a stable slipped capital femoral epiphysis is in situ fixation with a single central screw. The treatment for an unstable slipped capital femoral epiphysis is much more controversial. Corrective osteotomy is usually reserved for treatment of severe deformities after the patient has stopped growing.

Epifisiólise proximal do fêmur / Sliped capital femoral epiphysis

O autor realiza uma revisäo da literatura sobre o tema Epifisiólise Proximal do Fêmur, abordando principalmente os seguintes aspectos: epidemiologia, etiologia, patologia, diagnóstico e história natural