Three weeks of Kirschner wire fixation for displaced lateral condylar fractures of the humerus in children.

The authors assessed whether a period of 3 weeks, rather than the commonly used 6 weeks, of smooth Kirschner wire fixation and cast immobilization of the elbow was sufficient to achieve union of displaced fractures of the lateral humeral condyle treated by open reduction. The authors found only one nonunion in a case series of 104 children treated with 3 weeks of fixation. Infections occurred in two children (2%). Late review of 63 children (61%) showed abnormalities of elbow shape in 28 (44%) and wide surgical scars in 43 (68%). The abnormalities of elbow shape were mainly due to overgrowth of the lateral humeral condyle, to the formation of excessive amounts of bone over the outer surface of the condyle, or both. The authors' findings indicate that a period of 3 weeks of smooth Kirschner wire fixation and elbow immobilization is sufficient to achieve healing in most displaced fractures of the lateral humeral condyle treated by open reduction. The findings also indicate that new strategies are needed to reduce the occurrence of overgrowth of the lateral condyle, excessive formation of bone over the condyle, and wide scars.

The use of bone scan to investigate back pain in children and adolescents.

Children with back pain frequently undergo detailed investigation because of the perception that a high percentage will have a treatable spinal condition. The purposes of this study was (i) to determine the percentage of children with disabling back pain presenting to our institution who had a diagnosis (i.e., to explain their back pain), (ii) to evaluate the clinical markers that should alert clinicians to underlying pathology, (iii) and to determine the prognosis of children with back pain and no specific diagnosis. This study was a retrospective analysis of consecutive children undergoing single-photon emission computed tomography for a primary complaint of back pain. Data collection included chart review, radiographic analysis, and clinical follow-up with the Roland and Morris scale for pain and disability. Two hundred and seventeen patients with an average age of 13 years (range, 2.7-17.7) were reviewed on average 4.4 years after presentation (range, 1.1-7.2 years). One hundred and seventy children (78.3%) had no specific diagnosis to explain their back pain, 15 children (6.9%) had spondylosis, 10 children (4.6%) had tumor, and the remaining 22 children (10.1%) had various diagnoses including infection, Scheuermann's kyphosis, herniated disc, kidney disease, facet arthritis, degenerative disc disease, congenital anomalies, and tethered cord. Factors associated with positive diagnoses were constant pain and male gender. Night pain, constant pain, and duration of symptoms <3 months were associated with the diagnosis of a tumor. Although the majority of children presenting with persistent back pain had no demonstrable cause, of 132 contactable patients 94 (71%) had persisting pain at the time of clinical follow-up. In conclusion, the majority of children with disabling back pain has no demonstrable cause and the majority will continue to have pain years after initial presentation.

Is there a difference between the epidemiologic characteristics of hip dislocation diagnosed early and late?

OBJECTIVE: To determine if there are epidemiologic differences between patients with early and late developmental dislocation of the hip (DDH). DESIGN: A chart review. SETTING: A university-affiliated children's hospital. PATIENTS: Two hundred and forty-three children, 191 with early DDH and 52 with late DDH. MAIN OUTCOME MEASURES: Sex, side involved and prevalence of bilaterality. RESULTS: There were significant differences between the two groups with respect to side involved (p < 0.0002) and bilaterality (p = 0.006) but not in relation to sex. Left-sided dislocations were predominant in the early group and right-sided dislocations in the late group. Bilaterality was more common in the late group. CONCLUSION: There is circumstantial epidemiologic evidence that late DDH may be a different entity from early DDH.

Extra-articular triplane fracture of the distal tibial epiphysis.

We describe an extra-articular triplane fracture of the distal tibia in the skeletally immature patient. This variant of the triplane fracture has been largely ignored in the literature. The clinical significance of recognizing this fracture is that, although it constitutes an epiphyseal fracture, it remains extra-articular. Unlike the standard triplane fracture that exists through the tibiotalar joint, this variant can be treated acceptably with less than an anatomical reduction, therefore often avoiding the need for surgical management.

Unusual burst fracture in an adolescent involving the apophyseal plate.

A 12-year-old girl sustained an unusual burst-type fracture of her first lumbar vertebrae. The main fracture occurred through the anterior ring apophyses and the pedicle-body junction. The anterior ring apophyses were left close to their anatomic position. However, the whole vertebral body with minor internal fracturing was retropulsed into the spinal canal, resulting in incomplete paraplegia. Initial radiographs were complicated by a fracture-dislocation. However, a computed tomography scan elucidated the above-stated fracture pattern. This pattern has not been previously reported to our knowledge. Treatment consisted of intravenous steroids, anterior decompression, anterior fusion with instrumentation, and postoperative thoracolumbar-sacral orthosis. Neurologic improvement has occurred. The patient can now walk independently, but still has absent bladder/bowel function 3 months postoperatively.

Comparison of three noninvasive methods for measuring scoliosis.

The premise behind most noninvasive techniques for the measurement of scoliotic conditions of the spine is that the lateral distortion of the spine relates directly to transverse rib cage deformity within the transverse plane. The focus of this study was to examine this assumption by comparing different noninvasive methods for the assessment of scoliotic curves. The three techniques examined were (1) use of the Scoliometer (SCOL), (2) use of the back-contour device (BCD), and (3) use of moiré topographic imaging (MTI). Fourteen subjects (10 female, 4 male) with idiopathic adolescent scoliosis were measured. Posterior-anterior radiographs were obtained for the clinical assessment of all subjects and were subsequently used to determine Cobb angles. Significant correlations between axial trunk rotation and Cobb-angle measurements were observed in the thoracic region (MTI, r = .80, df = 10, P less than .005; BCD, r = .70, df = 10, P less than .025; SCOL, r = .59, df = 10, P less than .025) but were not found within the lumbar region (MTI, r = .42; BCD, r = .17; SCOL, r = .20). Factors other than trunk deformity, such as the posture assumed by the subject during measurement, may have influenced axial trunk rotation. Hence, the techniques appear to provide valid estimations of lateral curvature of the spine in the thoracic region of the trunk but not the lumbar region. The results suggest that the measurement techniques cannot be used interchangeably in clinical recording.

Work and power in hemiplegic cerebral palsy gait.

The purpose of this descriptive study was to quantify the work that is accomplished by major muscle groups of the affected limb of 10 children with spastic hemiplegia secondary to cerebral palsy during walking. Cinematographic film and force-plate data were used in a biomechanical link-segment model to calculate the positive and negative work performed by the muscles around each joint. The results revealed that the ankle plantar flexors produced just over a third of the positive work for the affected limb instead of the normal two thirds. The greatest proportion of positive work was performed by the hip muscles. More research using work and power analyses will assist in prescribing and determining the effectiveness of treatments.

Mechanical energy patterns in gait of cerebral palsied children with hemiplegia.

The mechanical energy costs of walking were studied in 10 cerebral palsied children with hemiplegia to determine whether their values were substantially different from normal and, if so, to discover the movements that were responsible. A two-dimensional, sagittal-plane cinematographic analysis of the subjects' normal walking was undertaken. This technique provided continuous information about the mechanical energy costs of the whole body and each of its parts, the energy types involved, and the amounts of energy conserved. In most cases, the energy costs were above normal and were attributable to poor patterns of exchange between the potential and kinetic energy types of the head, arms, and trunk segment; to very low levels of kinetic energy that precluded exchange; or to both. We concluded that attention should be directed to restoring the sinusoidal pattern of motion and to the fluctuating speeds during each gait cycle when energy costs are a therapeutic consideration.

A reemphasis-Germ tubes diagnostic for Candida albicans have no constrictions.

Descriptive and illustrative material in several recent diagnostic manuals for medical mycology are unclear with respect to proper designation of germ tubes formed by Candida albicans. Because of the increasing significance of this and other yeast species in human disease, mycologists should be aware that germ tubes, unlike buds or pseudohyphae, do not have constrictions at the point of origin. Light and scanning electron micrographs are presented to emphasize this diagnostic characteristic.