Clinical criteria for using radiography for children with acute knee injuries.

OBJECTIVE: To evaluate clinical criteria for selective radiography for knee injuries in children. DESIGN: Retrospective chart review. SETTING: Emergency department (ED) of a children's hospital. PARTICIPANTS: All patients evaluated by radiography for an isolated, acute knee injury during 12 months. Patients were excluded for injuries: >1 week; isolated to superficial lacerations/abrasions; with prior knee surgery; being reassessed. RESULTS: Two hundred fifty-four patients (60% male; 12.7 years median age) were included. Twelve patients (4.7%) sustained a fracture. Evaluated criteria were point tenderness, inability to bear weight in the ED, and inability to flex the knee to 90 degrees. Point tenderness was not statistically associated with fracture, P = 0.7. Inability to bear weight in the ED (37% fracture rate, P = 0.001) and inability to flex to 90 degrees (52% fracture rate, P < 0.001) were associated with the presence of fracture.[table in text] Applying a rule combining nobearwt and noflex90 would decrease the number of x-rays by 73%, with no missed fractures. CONCLUSIONS: Point tenderness was not a good predictor of knee fracture in children. Using the clinical criteria to select patients requiring knee radiography may greatly reduce the number of unnecessary x-rays.

Madelung deformity in skeletally immature patients: morphologic assessment using radiography, CT, and MRI.

PURPOSE: The purpose of this study was to define the pathoanatomy of the distal radius and surrounding soft tissues, identify the factors that may contribute to diminished forearm rotation, and relate these findings to alterations in wrist motion in skeletally immature patients with the Madelung deformity. METHOD: Four skeletally immature female patients with bilateral Madelung deformities (eight wrists) underwent evaluation of each wrist with radiography, CT, and MRI to assess the morphology of the deformity. Two patients (four wrists) had isolated idiopathic Madelung deformities, and two patients (four wrists) had Madelung deformities secondary to dyschondrosteosis. RESULTS: Radiographically, all wrists demonstrated dorsal bowing of the radius, marked ulnar tilting of the radius and radial tilting of the ulna, volar tilting of the distal articular surface of the radius, and triangulation of the epiphysis. On CT, patients with the idiopathic deformity demonstrated dorsal ulnar subluxation and relative supination of the carpus with respect to the distal radius. Patients with dyschondrosteosis demonstrated no ulnar subluxation and relative pronation of the carpus. All wrists demonstrated a fixed pronated deformity of the distal radius. On MRI, a physeal bar that bridged the distal metaphysis of the radius to the epiphysis was identified in all eight wrists, located on the volar aspect of the radius at the lunate facet. An anomalous volar ligament, a volar radiotriquetral ligament, and the short radiolunate ligament were hypertrophied in seven wrists. CONCLUSION: Based on its location, it is likely that a physeal bar impedes the normal development of the distal radius ulnarly. Hypertrophy of the short radiolunate ligament may be an important contributing factor to carpal pyramidalization owing to tethering on the volar pole of the lunate. Diminished forearm rotation is likely related to carpal malalignment, a fixed pronated deformity of the distal radius, and dorsal bowing of the radius.

Arthroscopic treatment of septic arthritic knees in children and adolescents.

Septic arthritis of the hip and knee is very common in children and adolescents. Sixteen consecutive patients were treated for septic arthritis of the kee with arthroscopic lavage and debridement. Ten of the 16 knees were culture positive on preoperative aspiration. The average duration of antibiotic treatment was 19 days. The mean immobilization period was 1 1/2 days and the time to full and painless range of motion averaged 2.8 weeks. All patients resumed normal activities by 3 weeks, no infections recurred, and postoperative morbidity was minimal.

Comparative review of surgical treatment of the idiopathic clubfoot by three different procedures at Columbus Children's Hospital.

Ninety-nine feet in 54 children were both clinically and roentgenographically evaluated following one of three different procedures of soft tissue clubfoot release. A new rating system that weights dynamic functional results more heavily was used to compare results. Roentgenographic complications included both over- and undercorrection at the talonavicular articulation, avascular necrosis of the talus, navicular, and calcaneus, and talar dome flattening. Recommendations concerning technical aspects of operative approach to clubfeet include (a) more physiologic orientation of the bimalleolar axis, (b) anatomic alignment at the talonavicular joint, and (c) use of the hinged ankle cast brace to increase final ankle range of motion (ROM).