Assessment and neurologic involvement of patients with cervical spine congenital synostosis as in Klippel-Feil syndrome: study of 19 cases.

We reviewed 19 children and adolescents with cervical spine congenital synostosis as in Klippel-Feil syndrome (KFS), with an average follow-up of 12.5 years. We paid particular attention to neurologic complications associated with cervical spine abnormalities. Five patients were affected by neurologic complications; four underwent a surgical procedure; and 14 had no neurologic finding. Two had hypermobility at one level, and one had hypermobility at two levels. We found that the more numerous the occipito-C1 abnormalities, the more significant the neurologic risk. In contrast, this risk was not related to the number of "mobile blocks" or to age. Various mechanisms of neural complications have been studied in the literature: medullary abnormality, spinal instability, narrowing of the cervical canal, and vascular dysfunction. Surgery is usually thought to be required in cases with neurologic complications. The indication for surgery is, however, less clear in cases of pure instability without neurologic involvement because surgery is likely to increase the future risks at mobile disks either above or below the fuse level. Careful clinical and radiologic observation is necessary in such patients. Magnetic resonance imaging (MRI) with lateral views in flexion and extension seem to be the best method for detecting impingement of the spine on the cord.

[External fixation in fractures of the lower limb in children]. / La fixation externe dans les fractures du membre inférieur de l'enfant.

PURPOSE OF THE STUDY: The indications, morbidity and results of the use of external fixation for fractures of the lower limbs in children is presented. MATERIAL AND METHOD: We studied 72 fractures of the lower limbs (femur: 25; tibia: 47) in 63 children over a seventeen year period. Average age at fracture was 10 yrs 6 mos. (range 4 yrs 5 mos to 14 yrs 6 mos). Forty fractures were open fractures. The indication for external fixation was decided in three different situations: 39 isolated fractures, 11 patients with multiple fractures, and 13 polytraumatized patients. Three different devices were used: Illizarov: 4, Judet: 16, Orthofix: 52. The fixators were left in place until fracture union was demonstrable. RESULTS: Final results were classed into three groups: good, good following reoperation and sequelae. Comparison of the three different series was made using Student's T test. 9 axial deviations or malrotations occurred: 6 times correction was possible with the device in place. Three cases of osteomyelitis occurred at the fracture site. 23 pin tract infections occurred (23 per cent) 5 of which were persistent and 4 required reoperation. The average healing time was different in the three groups: 4.5 mos for isolated fractures: 8.1 mos for multiple fractures and 5.7 mos for polytraumatized patients. Reoperation was required for 4 patients: 2 bone grafts, 1 decortication, 1 bone transport. Ten refractures occurred following removal of the device, 8 times in patients presenting multiple injuries. In 46 patients with a follow-up greater than 18 months, 9 presented an overgrowth between 1 and 2 cm. Following an average follow-up of 2 years 4 months, 7 patients presented sequelae, 56 had good results, 18 following reoperation. DISCUSSION: The use of external fixation remains an irreplaceable method for osteosynthesis of open fractures with severe soft tissue injuries, multiple fractures or in the polytraumatized patient. Some disadvantages such as pin tract infections and refracture following device removal should be taken into consideration before using it for the treatment of simple, isolated closed fractures of the lower limbs in children. CONCLUSION: When external fixation is chosen for treating fractures, it is preferable to use a modular device which allows axial corrections. Local pin site care is essential to prevent early infection. Early weight bearing and dynamization as soon as possible will promote callus mineralization, removal of the device must be progressive and cast protection is recommended.

[Treatment of comminuted fractures of the lower end of the radius with internal osteosynthesis, traction and early mobilization]. / Traitement des fractures comminutives de l'extrémité inférieure du radius par ostéosynthèse interne, distracteur et mobilisation précoce.

Goals for treatment of comminutive fractures of the distal radius include restoration of the articular profile of the proximal part of the joint, while axial loading forces must be avoided as much as possible to prevent secondary displacement. The choice of an internal fixation protected by an external wrist distractor-fixator, with early activo-passive mobilisation, seems to achieve the goal. Twelve patients with a comminuted fracture of the distal radius, including axial articular impigment displacement were reviewed for this study. All fractures were Frykman's type III, IV, VII or VIII. Distraction was done with a specific external apparatus, allowing an internal fixation, using an anterior plate and posterior Kirschner wires for the more complex cases. Distraction was released at the end of the surgical procedure, while the distractor was left in place. The wrist was mobilised early in the post-operative period, and the distractor was removed two months later. At a mean follow-up of 8.5 months, two patients were still painful. Mean motion of the wrist joint was 115 degrees for flexion-extension and 35 degrees for radio-ulnar deviation. Radiological results were good (10 cases), in both planes sagittal and frontal, and stable with time. The radio-ulnar index was correct in 11 cases. Only two cases of Sudeck's atrophy were noted. Authors use a specific external wrist distractor to obtain and maintain reduction in comminuted fractures of the distal end of the radius, using internal fixation in combination. Early motion of the wrist, protected by the wrist distractor seems to lower rates of Sudeck's atrophy.

[Orthopaedic treatment of colles' fractures according to judet's method]. / Le traitement des fractures de Pouteau-Colles selon la technique de Judet.

Revision of 109 Colles' fractures treated by Judet's method confirm the safety of that technic and the overall good results (73% of anatomical results). The authors show that the results are quite different in presence or in absence of metaphyseal comminution (50 to 90% of anatomical results) and when anterior cortex of the distal fragment has crossed the anterior cortex of the proximal fragment. They also emphasise the necessity of pre-operative Xrays under traction to assess that comminution, and sometimes to correct the wrong diagnosis of strictly extra-articular fractures.

[Limits and insufficiencies of the treatments of recent double-break articular fractures of the lower fourth of the radius]. / Limites et insuffisances des traitements des fractures récentes à double trait articulaire du quart inférieur du radius.

The authors present a series of 39 intra-articular fractures of the distal part of the radius classified as Frykman VII and VIII. Clinical results showed 77% of good and very good results. Radiographs showed 71% of reduced articular surfaces but only 37% of radiuses were considered to be anatomical. The authors emphasize the high rate of secondary displacement due to the epiphyseal comminution, and the importance of pre-operative radiographs obtained under traction, allowing good analysis of the fracture and evaluation of the comminution.

[Synostosis and tarsal coalitions in children. A study of 68 cases in 47 patients]. / Synostoses et coalitions tarsiennes chez l'enfant. Etude de 68 cas chez 47 patients.

INTRODUCTION: The authors report their experience with tarsal coalitions in children. The purpose of this study was to discuss the origins of the << too long anterior process >> of the calcaneum, and to propose a simple therapeutic strategy for diagnosis and treatment. MATERIALS AND METHODS: The study included 47 children (68 feet), with one or more idiopathic tarsal coalitions. All patients had physical examinations to record symptoms, morphology of the foot, mobility of the foot, gait analysis, standard radiographs, and in some cases CT scans or MRI. The average age of the patients was 11.5 years old, 7 patients had a positive family history for tarsal coalitions. 66 per cent of the patients had mild tarsal pain or a history of repeated ankle sprains. The conservative treatment concerned 28 feet: 3 casts, 2 injections of corticosteroids into the subtalar joint, insole-shoes in 3 cases, and abstention in 20 cases. The operative treatment (40 feet) consisted of resection of calcaneonavicular coalitions (24 feet) resection of talocalcaneal coalitions (3 feet), mediotarsal and subtalar arthrodesis (8 feet), resection of calcaneonavicular coalition combined with the ""Cavalier'' procedure described by Judet (3 feet), calcaneal osteotomy (2 feet). RESULTS: The mean follow-up was 42 months. The morphology of the involved foot was normal in 33 cases, flat foot was seen in 24 cases (4 peroneal spastic flat feet), pes cavus in 3 cases, club foot in 2 cases, pes varus in 4 cases, ""Z'' shaped feet in 2 cases. The radiological examination was demonstrative of tarsal coalition in 61 feet. 7 tarsal coalitions were seen during operative procedures. The location or the coalition was calcaneonavicular (57), talocalcaneal (16), talo-navicular (8), calcaneo-cuboid (7), naviculo-cuneiform (4). The secondary radiographic signs were studied for each foot. In the conservative group, 2 patients degraded their clinical status, one developed a spastic flat foot. In the surgical group, all except 2 patients had good clinical and functional results. One patient had persistent pain in the subtalar joint after a technically correct calcaneonavicular resection. One patient had recurrent spastic flat foot following isolated talocalcaneal resection in a foot presenting multiple tarsal coalitions. This patient was reoperated by a mediotarsal and subtalar arthrodesis with a good result. DISCUSSION: The authors believe that tarsal coalitions have to be recognized based on a history of repeated ankle sprains or subtalar pain. Pain radiographs are diagnostic in most cases. CT scans and MRI are useful when radiographs are negative, especially in young children, or for talocalcaneal coalitions. The authors believe that the ""the too long anterior process'' of the calcaneum in calcaneonavicular coalition has the same embryologic origin. Operative treatment is suitable, when tarsal coalitions are symptomatic or after failure of conservative treatment. Resection gives good results with calcaneonavicular coalitions and selected talocalcaneal coalitions. The mediotarsal and subtalar arthrodesis is suitable in spastic flat foot, or when the bony-bridge is too big, or when the involved joint presents degenerative changes in these cases, the MRI is very useful to select patient for resection or for arthrodesis. CONCLUSION: Evocative history and plain radiographs are diagnostic of most tarsal-coalitions. Modern imagery is useful for difficult diagnostics, for young children, or for evaluation of a joint before resection or arthrodesis. Resection is a good treatment for calcaneonavicular coalitions and gives good results for talocalcaneal coalitions in selected patients.