Traumatic Posterior Hip Dislocation and Epiphysiolysis in a High School Football Player with Successful Outcome at 4 Years Follow-up: A Case Report.

CASE: We describe a case of posterior hip dislocation in a 13-year-old boy after a contact football injury with attempted closed reduction resulting in complete separation of the epiphysis from the femoral neck metaphysis with associated femoral head fracture and posterior dislocation of the femoral head. Treatment was emergently performed with a greater trochanteric osteotomy, open reduction internal fixation using cannulated screws, and additional small diameter drill holes in the femoral head to promote blood flow. The patient did well postoperatively and at over 4 years follow-up had no evidence of avascular necrosis and returned to full athletics participation. CONCLUSION: Particular attention should be taken when reducing hip dislocations in the adolescent population who may be predisposed to epiphysiolysis. Preservation of periosteal soft-tissue attachments and the use of small diameter drill holes to promote femoral head blood flow may have contributed to the excellent outcome.

Little League Shoulder in a 15-Year-Old Male Baseball Pitcher.

A 15-year-old baseball pitcher presented to physical therapy with a 1-week history of acute right shoulder pain experienced during the acceleration phase of throwing. The week after physical therapy evaluation, the patient returned with radiographs and magnetic resonance imaging results that revealed lateral physeal widening with adjacent edema. Additionally, a nondisplaced labral tear was noted. In this case, imaging was necessary for an accurate diagnosis of lateral physeal widening, commonly referred to as "Little League shoulder." J Orthop Sports Phys Ther 2018;48(1):51. doi:10.2519/jospt.2018.7369.

Slipped Capital Femoral Epiphysis: Diagnosis and Management.

Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents, occurring in 10.8 per 100,000 children. SCFE usually occurs in those eight to 15 years of age and is one of the most commonly missed diagnoses in children. SCFE is classified as stable or unstable based on the stability of the physis. It is associated with obesity, growth spurts, and (occasionally) endocrine abnormalities such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients with SCFE usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which should include anteroposterior and frog-leg views in patients with stable SCFE, and anteroposterior and cross-table lateral views in unstable SCFE. The goals of treatment are to prevent slip progression and avoid complications such as avascular necrosis, chondrolysis, and femoroacetabular impingement. Stable SCFE is usually treated using in situ screw fixation. Treatment of unstable SCFE also usually involves in situ fixation, but there is controversy about timing of surgery and the value of reduction. Postoperative rehabilitation of patients with SCFE may follow a five-phase protocol.

[Fractures of the upper limbs in childhood and adolescence]. / Frakturen der oberen Extremität im Kindes-/Wachstumsalter.

Fractures of the upper limbs are frequent and often need operative treatment in addition to a well-indicated conservative management. This depends on the maturity of the nearest growth plate and the local remodeling potential, which is dependent on age. Following conventional x­ray imaging an individual prognostic growth analysis leads to the therapeutic decision. Around the elbow and the shaft of the forearm, criteria are stricter than near the shoulder or wrist. Gilchrist or Desault bandages as well as braces are adequate for most subcapital and humeral shaft fractures. The short forearm cast is the method of choice at the wrist. In the case of osteosynthesis the elastic stable intramedullary nailing (ESIN) method is the first choice for subcapital humerus, radial neck and shaft fractures. Screw fixation is usually carried out for epicondylar and condylar fractures and for supracondylar and wrist fractures K­wires represent the standard procedure.

Is Assessment of Femoral Head Perfusion During Modified Dunn for Unstable Slipped Capital Femoral Epiphysis an Accurate Indicator of Osteonecrosis?

BACKGROUND: The modified Dunn procedure, which is an open subcapital realignment through a surgical dislocation approach, has gained popularity for the treatment of unstable slipped capital femoral epiphysis (SCFE). Intraoperative monitoring of the femoral head perfusion has been recommended as a method of predicting osteonecrosis; however, the accuracy of this assessment has not been well documented. QUESTIONS/PURPOSES: We asked (1) whether intraoperative assessment of femoral head perfusion would help identify hips at risk of developing osteonecrosis; (2) whether one of the four methods of assessment of femoral head perfusion is more accurate (highest area under the curve) at identifying hips at risk of osteonecrosis; and (3) whether specific clinical features would be associated with osteonecrosis occurrence after a modified Dunn procedure for unstable SCFE. METHODS: Between 2007 and 2014, we performed 29 modified Dunn procedures for unstable SCFE (16 boys, 11 girls; median age, 13 years; range, 8-17 years); two were lost to followup before 1 year. During this period, six patients with unstable SCFE were treated by other procedures. All patients undergoing modified Dunn underwent assessment of epiphyseal perfusion by the presence of active bleeding and/or by intracranial pressure (ICP) monitoring. In the initial five patients perfusion was recorded once, either before dissection of the retinacular flap or after fixation by one of the two methods. In the remaining 22 patients (81%), perfusion was systematically assessed before dissection of the retinacular flap and after fixation by both methods. Minimum followup was 1 year (median, 2.5 years; range, 1-8 years) because osteonecrosis typically develops within the first year after surgery. Patients were assessed for osteonecrosis by the presence of femoral head collapse at radiographs obtained every 3 months during the first year after surgery. Seven (26%) of the 27 patients developed osteonecrosis. Measures of diagnostic accuracy including sensitivity, specificity, and the area under the receiver operating curve (AUC) were estimated. Multiple variable logistic regression analyses were used to test whether the test options were better than random chance (AUC > 0.50) at differentiating between patients who did versus did not develop osteonecrosis. Nonparametric methods were used to test for a difference in AUC across the four methods. A secondary analysis was performed to identify risk factors associated with osteonecrosis. RESULTS: After adjusting for body mass index, which was found to be a confounding variable, assessment of femoral head perfusion with ICP monitoring before retinaculum dissection (adjusted AUC: 0.79; 95% confidence interval [CI], 0.58-0.99; p = 0.006), femoral head perfusion with ICP monitoring after definitive fixation (adjusted AUC: 0.82; 95% CI, 0.65-1.0; p < 0.001), bleeding before retinaculum dissection (adjusted AUC: 0.77; 95% CI, 0.58-0.96; p = 0.006), and bleeding after definitive fixation (adjusted AUC: 0.81; 95% CI, 0.63-0.99; p = 0.001) were found to be helpful at identifying osteonecrosis. We were not able to identify a specific test that had performed best because there was no difference (p = 0.8226) in AUC across the four methods. With the numbers available, we were unable to identify clinical factors predictive of osteonecrosis in our cohort. CONCLUSIONS: Assessments of femoral head blood perfusion by ICP monitoring or by the presence of active bleeding in combination with the patient's body mass index are effective at differentiating between patients who do versus do not develop osteonecrosis after a modified Dunn procedure for unstable SCFE. Additional research is needed to determine whether information gained from assessment of femoral head perfusion during surgery should be used to guide targeted treatment recommendations that may reduce the development of femoral head deformity secondary to osteonecrosis. LEVEL OF EVIDENCE: Level III, diagnostic study.

Traumatic atlantoaxial rotatory dislocation and displaced ossiculum terminale epiphysiolysis treated with a halo device: a case report.

INTRODUCTION: The horizontal synchondroses of the infant axis are biomechanical weak regions in trauma. CASE: We report the case of a 6-year-old girl who presented with delayed atlantoaxial dislocation and displaced ossiculum terminale epiphysiolysis after a fall from a tree. TREATMENT: The patient was treated with halo traction for 3 days after which a CT scan showed normal position of the C1/C2 joint, and an acceptable position of the ossiculum terminale whereafter a halo brace was applied. Because of delayed union on CT scans, the treatment was prolonged to a total of 21 weeks. RESULT: At final follow-up 26 months after halo brace removal, the patient demonstrated normal range of movement of the neck on clinical examination and radiographs of the cervical spine including lateral flexion/extension radiographs showed no sign of instability of the atlantoaxial joint. DISCUSSION: Conservative treatment with a halo device versus surgical treatment is discussed.

Epiphyseal separation of the proximal humerus after birth trauma.

The purpose of this study was to report a new entity of epiphyseal slipping, which is a slipping of the upper humeral epiphysis in neonates due to birth trauma, and reporting the results of their management. Eight neonates presented with pseudo-paralysis with associated shoulder swelling and pain on passive movements of the upper limb; the radiographs revealed slipping of the proximal humeral epiphyses in six cases and associated shoulder dislocations in the other 2 cases. Failed attempts of closed reduction were done for all cases; they were managed through open reduction of the slipping and relocation of the glenohumeral joint when dislocated. The deltopectoral approach was used for management, and the slipping was fixed with k-wires through the skin. A full painless range of motion of the shoulder was achieved in all patients; no limb-length discrepancy or deformity was detected and no recurrent shoulder dislocation. In the last follow-up, all radiographs showed an anatomic reduction of the epiphyses, and all the epiphyseal plates were open. All cases showed normally growing well-formed epiphyses with no evidence of a vascular necrosis or collapse. A new entity of epiphyseal slipping was reported in this study; slipping of the upper humeral epiphysis in neonates due to birth trauma whether it is associated with shoulder dislocation or not is a benign injury with excellent results with open reduction.

Persisting growth after prophylactic single-screw epiphysiodesis in upper femoral epiphysis.

BACKGROUND: Prophylactic fixation of the contralateral hip in cases of slipped upper femoral epiphysis is controversial. Therefore, using a single-cannulated screw has been widely accepted. However, differing reports exist on the occurrence of persisting growth after prophylactic epiphysiodesis. The aim of this retrospective study was to evaluate the presence of persisting growth of the upper femoral epiphysis after prophylactic fixation. METHODS: From 2006 until 2009, 11 children underwent prophylactic pinning using a single-cannulated 6.5-mm cancellous screw. Time to fusion, persisting growth, and overgrowing of the screw were measured on plain radiographs taken postoperatively and at least after the growth plate was fused. RESULTS: All patients except 1 (91%) showed a persisting growth of the epiphysis, and in 2 cases a hardware replacement was necessary. The mean increase of the femoral neck length was 8.2% (SEM 1.46%). Mean follow-up was 37 months (range, 12 to 49 mo). All patients had a Risser sign grade 0 at the time of surgery, and equal or less than grade 3, when the growth plate was fused. CONCLUSIONS: Despite previous reports that a prophylactic fixation using a single-cannulated cancellous screw is unproblematic and safe, we showed that in our series growth persistence was the rule and in some cases the physeal overgrowth necessitates a hardware replacement. Careful follow-up until fusion of the growth plate should be recommended.

Frequency of radiographic signs of slipped capital femoral epiphysiolysis sequelae in hip arthroplasty candidates for coxarthrosis.

INTRODUCTION: The rate of osteoarthritis of the hip secondary to slipped capital femoral epiphysis (SCFE) is a subject of debate, and its frequency is underestimated in particular because of subclinical forms that may not be diagnosed during childhood. HYPOTHESIS: The frequency of radiographic anomalies subsequent to SCFE in adults requiring hip arthroplasty is higher than that reported in recent studies (6% to 15%). MATERIALS AND METHODS: A prospective single-center epidemiological radiography study was performed by one observer. Hip X-rays of patients who were being treated by arthroplasty for advanced hip osteoarthritis between January 2010 and May 2012 were analyzed. The etiology of osteoarthritis was classified in each patient according to the data obtained (primary, SCFE, dysplasia, protrusio acetabuli, other). The lateral view head-neck index (LVHNI) was used to quantify posterior translation of the femoral head, and identify SCFE sequelae. RESULTS: One hundred and eighty-six hips were included. Osteoarthritis was considered primary in 51 patients (27.4%), secondary to dysplasia in 42 (22.5%), protrusio acetabuli in 38 (20.5%) or another disease in nine (4.9%) while 46 hips (24.7%) presented a radiographic image suggesting SCFE past history. SCFE type deformities were the primary etiology of osteoarthritis in patients less than 60years old (30/84 or 35.7%). The mean age of patients in the SCFE group was 56.2years old (26-80) compared to 66 (54-91) for the primary osteoarthritis group (P<0.0001). The mean LVHNI was 13% (9-24%) in the SFCE group, the mean body mass index was 27.1kg/m(2) (±3.5; 18.2-35.4) in the SFCE group and the male to female ratio was 7.3/1. CONCLUSION: Our study identified a population with a morphological SCFE type anomaly of the coxofemoral joint (LVHNI>9%), which results in the development of earlier osteoarthritis than that found in the rest of the population. SCFE is more common than reported in the literature because it is the first etiology of osteoarthritis of the hip in subjects less than 60years old. LEVEL OF EVIDENCE: Level III. Diagnostic prospective study with a control group.

The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective.

BACKGROUND: The modified Dunn procedure has rapidly gained popularity as a treatment for unstable slipped capital femoral epiphysis (SCFE), but limited data exist regarding its safety and efficacy. The purpose of this study was to present results and complications following this procedure in a large multicenter series. METHODS: We reviewed the outcomes of all patients who had been treated with the modified Dunn procedure by five surgeons from separate tertiary-care institutions. All slipped capital femoral epiphyses were defined as unstable according to the Loder criteria. Patients with less than one year of follow-up and those with an underlying endocrinopathy or syndrome were excluded. All surgical procedures were performed by pediatric orthopaedic surgeons who had specific training in the modified Dunn procedure. Operative reports, outpatient records, and follow-up radiographs were used to determine the demographic information, type of fixation, final slip angle, presence of osteonecrosis, and any additional complications. Standardized surveys were administered to determine the pain level (0 to 10 scale), satisfaction (0 to 100 scale), function (modified Harris hip score, 0 to 91 scale), and activity level (UCLA [University of California Los Angeles] activity score, 0 to 10 scale) at time of the most recent follow-up. RESULTS: Twenty-seven patients (twenty-seven hips) with a mean of 22.3 months (range, twelve to forty-eight months) of follow-up met the inclusion criteria. Four patients (15%) had broken implants at three to eighteen weeks after surgery and required revision fixation. Seven patients (26%) developed osteonecrosis at a mean of 21.4 weeks (range, ten to thirty-nine weeks), with each surgeon having at least one case of osteonecrosis. The mean slip angle at the time of the most recent follow-up was 6° (95% confidence interval, 2° to 11°). Patients who did not develop osteonecrosis had significantly better clinical results compared with those who developed osteonecrosis, as demonstrated by a lower mean pain score (0.3 compared with 3.1, p = 0.002), higher level of satisfaction (97.1 compared with 65.8, p = 0.001), higher modified Harris hip score (88.0 compared with 60.0, p = 0.001), and higher UCLA activity score (9.3 compared with 5.9, p = 0.031). CONCLUSIONS: This largest reported series of unstable slipped capital femoral epiphyses treated with the modified Dunn procedure demonstrated that the procedure is capable of restoring anatomy and preserving function after a slip but that implant complications and osteonecrosis can and do occur postoperatively.

Distal humeral epiphysiolysis in the newborn: utility of sonography and differential diagnosis.

Fracture-separation of the distal humeral epiphysis in newborn is a rare entity, usually the result of a traumatic delivery. It can mimic elbow dislocation and, due to the absence of ossification of the epiphysis at that time, cannot be diagnosed radiographically. However, ultrasound is an important diagnostic tool for this purpose because it is able to clearly visualize the cartilaginous epiphysis. In addition, it allows the differential diagnosis with posterior elbow dislocation whose therapeutic management and prognosis are different. We report the case of a preterm newborn in which a fracture-separation of the distal humeral epiphysis was diagnosed with the help of sonography. The purpose of this report is to emphasize the utility of echography as a cheap, available, and noninvasive tool for the evaluation of the nonossified epiphysis in the newborn elbow.

Slipped upper tibial epiphysis in infantile tibia vara: three cases.

We describe three cases of infantile tibia vara resulting from an atraumatic slip of the proximal tibial epiphysis upon the metaphysis. There appears to be an association between this condition and severe obesity. Radiologically, the condition is characterised by a dome-shaped metaphysis, an open growth plate and disruption of the continuity between the lateral borders of the epiphysis and metaphysis, with inferomedial translation of the proximal tibial epiphysis. All patients were treated by realignment of the proximal tibia by distraction osteogenesis with an external circulator fixator, and it is suggested that this is the optimal method for correction of this complex deformity. There are differences in the radiological features and management between conventional infantile Blount's disease and this 'slipped upper tibial epiphysis' variant.

Primary hyperparathyroidism presenting with bilateral slipped capital femur epiphysiolysis. A pictorial essay.

It has become rare to find the typical radiological manifestations of primary hyperparathyroidism like generalized osteoporosis, brown tumors and advanced bone resorption because of the generalized usage of biochemical screening techniques. We present a 17-year-old patient with a parathyroid adenoma resulting in these typical skeletal manifestation throughout the skeleton combined with secondary bilateral slipped capital femur epiphysiolysis.

Prediction of contralateral slipped capital femoral epiphysis using the modified Oxford bone age score.

BACKGROUND: The purpose of the present study was to determine whether the modified Oxford bone score can be used as a predictor for the risk of developing contralateral slipped capital femoral epiphysis (SCFE) in children who present with a unilateral slip. METHODS: We identified 260 patients treated for unilateral SCFE between 1980 and 2002 and followed them up to skeletal maturity or until development of contralateral slip. Exclusion criteria included patients with endocrine or metabolic disorder, Down syndrome, and those with radiographs inadequate to determine the modified Oxford bone score. The initial radiographs were given a score ranging from 16 to 26. Statistical analysis was used to determine whether the modified Oxford bone score was predictive of future development of contralateral slip. A linear regression model was used to estimate the probability of future development of a contralateral slip as related to the modified Oxford bone score. RESULTS: Of the 260 patients, 64 (24%) developed a contralateral slip, at an average of 10 months after initial presentation. Race, sex, age, and weight at initial presentation were not predictive of the development of contralateral slip. The modified Oxford score and a triradiate score of 1 were found to be significant (P<0.0001) predictors, with the modified Oxford score a better overall predictor. CONCLUSIONS: The modified Oxford bone age score is the best predictor of the risk of development of a contralateral SCFE in patients presenting with a unilateral slip. Controversy exists regarding prophylactic pinning of a normal hip in patients presenting with unilateral SCFE. The benefits of prophylactic pinning must outweigh risk. This study provides probability data for predicting a contralateral slip based on the modified Oxford bone maturity score that can be shared with families and allows physicians to decide their threshold for prophylactically pinning the contralateral hip in patients presenting with a unilateral slip. LEVEL OF EVIDENCE: Therapeutic level IV, Case series.

Acetabulotrochanteric distance in slipped capital femoral epiphysis.

BACKGROUND: A pathognomonic finding of slipped capital femoral epiphysis (SCFE) is a combination of the decrease in the height of the slipped epiphysis and the position of external rotation and flexion of hip. We believe that decrease in the acetabulotrochanteric distance (ATD) on an anteroposterior (AP) radiograph represents this finding. MATERIAL AND METHODS: In a retrospective study of 25 consecutive cases of unilateral SCFE, we defined ATD as the distance between a line connecting the superolateral margins of the acetabulae with a second line, parallel to the first line, which goes through the tip of the greater trochanter on each hip and acetabulotrochanteric angle (ATA) as the angle between a line connecting the superolateral margins of the acetabulae with a second line connecting the tip of greater trochanter on each side. The difference in ATD and ATA between both hips in each case was evaluated and their correlation was determined using the Pearson correlation coefficient. RESULTS: Nineteen cases (76%) showed difference in ATD of > 2 mm and positive ATA divergence of >1 degree. The average difference in ATD was 6.6 mm (range, 0 to 25 mm); the average ATA divergence was 2.4 degree (range, 0 to 5.3 degree). CONCLUSIONS: Our findings show that the difference in acetabulotrochanteric distance (ATD) between hips is an easy, reliable, and sensitive finding present on an AP radiograph of patients with unilateral SCFE. ATD should be taken into consideration while evaluating AP radiographs of a patient suspected to have SCFE, and further evaluation with lateral hip radiographs should be carried out to confirm the diagnosis. LEVEL OF EVIDENCE: Level IV.

[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.

[Total hip replacement after slipped capital femoral epiphysis]. / Totalna endoprotezoplastyka stawu biodrowego po zluszczeniu glowy kosci udowej.

BACKGROUND: Total hip replacement (THR) is at present an accepted treatment in patients with severe osteoarthritis of the hip after slipped capital femoral epiphysis. The aim of this paper is to evaluate the results of THR in patients suffering from secondary osteoarthritis, operated from 1987 to 2004 in the Orthopaedic and Traumatologic Department of Poznan University of Medical Sciences. MATERIAL: Material included 16 patients, 9 females and 7 males, on whom 18 THR were performed, lateral approach was used in all cases. At the time of operation, the age of patients ranged from 32 to 70 years (mean 50). THR was carried out after 33 years afterwards slippage of capital femoral epiphysis. Follow-up ranged from 6 to 23 years (mean 11 years). The operative treatment was a multistage process (during one operation only one joint was replaced). Cemented total hip arthroplasty was used during 5 of the THR, 13 of them were cementless. METHOD: The patients were clinically and radiologically evaluated preoperatively, postoperatively, and at final examination. The clinical state was evaluated with Harris hip score and WOMAC scale. We based our radiological examination on Hip Society system. RESULTS: The average preoperative Harris score for the group of patients was 32, WOMAC score 74. After an average of 11-years follow-up all hips were considered excellent, with average Harris score of 91, WOMAC Score of 6. All patients had increased function and decreased pain. The radiograms of all patients revealed that the acetabular and femoral components were correctly positioned with no radiographic evidence of loosening in the last examination. The inclination angle of the acetabular component was 22-49 degrees (mean: 36 degrees) and the acetabular opening angle was 0-10 degrees (mean: 4 degrees). The stem was valgus-oriented in 1 hip, and neutral-oriented in 17 hips. No ectopic ossification concentrations were found. CONCLUSION: . Clinical and radiological evaluation of our material showed that total hip replacement in the treatment of osteoarthritis secondary to slipped capital femoral epiphysis allows regaining good lower limb function, which helps the patients staying less dependant on the surrounding environment. The results of THR are good regardless of the type of prosthesis and the type of fixation. Importantly, THR was carried out after a quite long time after slippage of capital femoral epiphysis.

Bone apposition of the acetabular rim in deep hips: a distinct finding of global pincer impingement.

BACKGROUND: Hips with coxa profunda can develop a pincer-type impingement with linear impact between the proximal part of the femur and the acetabulum, leading to bone apposition on the acetabular rim. METHODS: Twenty hips with radiographic features of rim ossification were isolated from a pilot cohort of 220 patients for histologic assessment of the acetabular rim and the labrum. In the second part of the study, the prevalence of radiographic signs of bone apposition in a cohort of 148 hips treated for femoroacetabular impingement was assessed. RESULTS: Histologic analysis confirmed that the labrum may become displaced and replaced by the appositional bone formation. The double-line sign and the recess sign are suggestive of an ongoing process of this bone formation, and the described phenotypes of bone apposition indicate the site of the impingement problem. Morphological anomalies of the proximal part of the femur, such as a low neck-shaft angle or a short femoral neck, may further contribute to the mechanism of pincer impingement. CONCLUSIONS: In later stages, this bone formation cannot be distinguished from the native bone and the labrum may appear to be nearly absent on imaging studies. While the bone apposition on the rim is first reactive to chronic impingement, the impingement then increases and may lead to further bone apposition.