Occult subluxation of the subtalar joint in clubfoot (using computerized tomography).

Routine radiographic analysis does not visualize the posterior aspect of the hindfoot (posterior facet of the talocalcaneal joint). To help evaluate patients with persistent hindfoot abnormalities, computerized tomographic coronal sections in 22 clubfeet were studied. Seventeen feet (77.3%) had a lateral subluxation of the calcaneus. Of 14 feet with acceptable radiographic analysis, 12 (85.7%) had a lateral subluxation of the calcaneus. This study is evidence that a lateral subluxation of the calcaneus can exist, through a horizontal rotation, in the presence of acceptable radiographic analysis, reinforces the necessity for a posteromedial lateral release, and emphasizes that routine radiographic analysis should be supplemented with computerized tomography in evaluation of the resistant hindfoot deformity.

The role of computed tomography and radionuclide scintigraphy in the localization of osteomyelitis in flat bones.

The combined use of radionuclide scintigraphy and computed tomography is recommended for evaluating children with laboratory and clinical data suggestive of flat bone osteomyelitis despite normal conventional radiographs. In addition, computed tomography may be helpful in the presence of abnormal radiographs in determining the exact location of the focus of osteomyelitis and the most suitable route for appropriate drainage or to obtain culture material.

Scintigraphic localization of bone lesions during surgery.

Nuclear medicine provides several methods for increasing the accuracy of surgical removal of bone lesions with focally increased uptake. In this paper, three intraoperative procedures are discussed: remote control by imaging, intraoperative control by imaging, and intraoperative control by scintillation probe. All techniques require preoperative injection of bone imaging tracer. Remote operative control calls for a gamma camera to mark the skin over the lesion prior to surgery, providing optimal preoperative localization and imaging of the excised lesion to ensure complete removal. Intraoperative control procedures require that a portable camera or a scintillation probe be used in the operating room; these permit direct monitoring of localization and resection. Our experience with 18 procedures performed on 15 patients suggests that these techniques are worthy of continued use.

Evaluation of tarsal coalition by computed tomography.

Three cases of talocalcaneal and two calcaneonavicular tarsal coalitions were evaluated with plain radiography and computed tomography (CT). Four of five of the patients' plain films were read as normal. Two of three patients had a Harris view performed for the talocalcaneal middle facet coalitions. One was read as negative, the second as positive after five attempts at obtaining the correct angle. In addition, two of three patients with talocalcaneal middle facet coalition had conventional tomography. One was read as positive, the other as negative. Arthrography was done in one case of calcaneonavicular coalition and was suspicious for the coalition. CT was diagnostic in all five cases. It provided an accurate depiction of the coalition site. In addition, the width of the bony bar at the coalition site could be determined to help plan surgical treatment. In patients presenting with painful feet, in whom tarsal coalition is suspected, plain radiographs should be the initial screening procedure. If secondary signs are present, CT is recommended as the best imaging modality to investigate further for tarsal coalition. Also, if plain films are normal but the index of suspicion is high, CT is thought to be the next most valuable test for diagnosing tarsal coalition.

Computed tomography in the evaluation of the gluteal region.

The role of computed tomography (CT) in the evaluation of the gluteal region was assessed. Six cases of gluteal masses were studied preoperatively by CT; several were also studied with conventional radiographic methods, including barium enema, cystogram, and intravenous urogram. Our case material included an epithelioid sarcoma, Ewing's sarcoma, endodermal sinus tumor, cystic hygroma, neurofibromatosis, and a normal variant. The conventional radiologic studies were normal or demonstrated nonspecific soft tissue density mass effect. By comparison, CT, with its cross-sectional imaging capability, provided unique diagnostic information. CT depicted the presence and origin of a mass, provided tissue characterization, and showed the extent of the lesion, often demonstrating the gluteal mass as an extension of an intrapelvic lesion. CT was valuable in monitoring tumor response to therapy, detecting recurrences, and excluding normal variants as the cause for a gluteal mass. The information provided by CT was important in treatment planning.

Hip CT in congenital dislocation: appearance of tight iliopsoas tendon and pulvinar hypertrophy.

The iliopsoas tendon can interpose between the femoral head and the acetabulum, preventing reduction or stability of reduction of a dislocated hip by a closed method. The tendon produces an infolding of the capsule and labrum. This infolding of the capsule and labrum creates an "isthmus" between the capital and the acetabular parts of the capsule. This deformity of the capsule was recognizable on computed tomography (CT) in 10 patients, all of whom had surgical confirmation of the findings. The presence of hypertrophied pulvinar can also be recognized by CT.

Radiographic changes in unicameral bone cysts following direct injection of steroids: a report on 14 cases.

Twelve children (9 boys and 3 girls, ages 1 1/2-12 yrs.) with unicameral bone cysts were treated with triamcinolone acetonide (4 patients) or methylprednisolone acetate (8 patients) injected directly into the cyst cavity. Postinjection radiographic changes that indicate healing were noted in eight patients and included: reduced size of the cyst cavity, increased internal density, cortical thickening, and remodeling in the vicinity of the cyst. Additional injections were required in three patients because of delayed or partial healing. Recurrence of the cyst (1 case) was signaled by renewed rarefaction and bone expansion.

CT determination of femoral torsion.

Femoral torsion has been measured in infants and children by computed tomography. The method requires two scans, one through the femoral neck, another through the femoral condyles. A specially designed device and packing about the knees assures immobilization of the legs. Slight variations in the positions of the sections in the neck and condyles do not alter the measurement significantly. Intraobserver and interobserver errors are low, 2 degrees and 3 degrees mean error, respectively. The radiation required involves small tissue volumes at about 1.7 R (4.4 x 10(-4) C/kg). Measurements are more difficult when the femoral necks are short or vertically oriented. The method appears to have sufficient accuracy for clinical purposes.

Premature closure of the triradiate cartilage. Report of a case.

A case of early closure of the triradiate cartilage, probably secondary to neonatal septic arthritis of the right hip, is reported. Tomograms of the hip showed the triradiate cartilage closed posteriorly, with the anterior portion still open. These findings were confirmed at operation. An arthrogram and a CT scan of the right hip showed subluxation of the femoral head. This unique complication, after an episode of septic arthritis of the hip, has not before been reported in the literature.

Physeal injuries of the ankle in children: classification.

Seventy-one cases of ankle fractures in children were studied. An analysis of the fracture lines involving the distal tibial and fibular epiphyses were done. A new classification is proposed based on the position of the foot at the moment of trauma and the direction of the abnormal force. Four mechanisms were considered, grades were described for each mechanism and each grade always occurred in the same order. In almost half of the cases, the supination-inversion mechanism was responsible for the injury. A correlation with the physeal injury classification of Salter and Harris is imperative, since complications such as varus deformity of the ankle are common when a Salter-Harris III or IV injury is present. The proposed classification has an important practical use. It facilitates closed reduction, because once the mechanism of injury is known, reduction is obtained by reversing the direction of abnormal force and immobilizing the foot in the opposite position given by the mechanism.

Plastic bowing, torus and greenstick supracondylar fractures of the humerus: radiographic clues to obscure fractures of the elbow in children.

The anterior humeral line is a valuable aid in the search for supracondylar fractures in children. When it is abnormal other signs of fracture should be carefully sought. The AHL was normal in only 5.8% of the cases reviewed (4 of 68 cases). There was other evidence of fracture in each case. Comparison of the AHLs on both sides is helpful when the AHL is normal since it may disclose subtle displacement of the line on the affected side. In children younger than 2 1/2 years the AHL may pass through the anterior third of the capitellum due to the small size of the ossification center; in these patients comparison with the opposite side may also be helpful.

Injuries of the medial epicondylar ossification center of the humerus.

The complex nature of the ossification centers makes elbow injuries in a child or adolescent difficult to evaluate. The medial epicondylar ossification center is involved in a significant proportion. Injuries vary from simple avulsions to wide displacement with entrapment in the elbow. When entrapment occurs, it may be mistaken for the trochlear ossification center and the true nature of the injury overlooked. Radiographic findings are presented. The anteroposterior view was found to be diagnostic in minimal or marked avulsions of the medial epicondyle because of the characteristic inferior displacement. The anteroposterior view may not always be diagnostic in cases of entrapment of the medial epicondyle; the lateral view is usually diagnostic. In elbow dislocation, the presence and position of the medial epicondyle must be ascertained. Comparison and oblique views are often of value.

Pathology of the limbus in untreated teratologic congenital dislocation of the hip. A case report of a ten-month-old- infant.

A dislocated hip in a 10-month-old infant with multiple congenital anomalies was examined postmortem. The true acetabulum was filled with areolar tissue and the acetabular articular cartilage was covered by fibrous pannus. The secondary acetabulum consisted of fibrous capsular tissue lined by synovial cells. A lip of new fibrous tissue, the limbus, grew over the cartilaginous labrum of the true acetabulum in juxtaposition to the dislocated femoral head.

[Treatment of flexion-pronation contracture of the wrist in hemiplegic children]. / Traitment de la flexion pronation du poignet chez l'enfant hémiplégique

Thirty-three cases of infantile spastic hemiplegia have been treated surgically for wrist deformity in flexion, pronation and ulnar deviation. The authors used Green's technique in most of the cases (transplantation of flexor carpi ulnaris to the extensores carpi) either in isolation or in association with lengthening of the pronator teres. The indications for surgery are given and the details of surgical technique and postoperative care are described. The complications are described and the factors affecting prognosis are analysed. Half of the cases had good or excellent results; five were failures.