Bipin Theruvil

Progressive cubitus varus due to a bony physeal bar in a 4-year-old girl following a supracondylar fracture: a case report.

We report a case of progressive cubitus varus deformity caused by a physeal bar following a supracondylar humeral fracture in a 4-year-old girl. Malreduction is thought to be the commonest cause of this deformity, which is nonprogressive. A corrective osteotomy in cases like ours should be deferred until skeletal maturity.

Delayed displacement of a paediatric atlas fracture through the synchondrosis after minor trauma

A 21-month-old boy presented to the Emergency Department reluctant to move his neck. This was preceded by a fall from a cardboard box, the child landing on his bottom with his head flexed forwards. He cried but continued playing after some time. Next morning, he was noted to be reluctant to move his head. Clinical examination was normal. Cervical spine radiographs at presentation suggested prevertebral soft tissue swelling in the upper cervical region, prompting CT scan of the cervical spine. CT showed an anterior synchondrosis of the atlas (which is a recognised developmental variant), but no convincing evidence of fracture (Fig. 2A). Flexion and extension lateral views of the cervical spine were then obtained to assess spinal stability. During this, the child actively extended his neck when the hard collar was removed and appeared to be pain-free. These views did not demonstrate any abnormal movement or malalignment. The hard collar was removed and the child was discharged home. The child presented 6 days later with neck pain. Clinical examination revealed cervical muscle spasm and torticollis, with normal neurology. At this point, open mouth peg views showed a dramatic appearance of lateral overhang of C1 on C2 (Fig. 1) indicating fracture of the atlas. Repeat CT showed separation of the midline anterior synchondrosis and lateral displacement of the lateral masses with a suggestion of additional displacement of the lateral synchondroses (Fig. 2B). The child was treated in Halter traction for a period of 3 weeks. After this he was immobilised in a cervical collar for a further period of 6 weeks, following which the child made a full clinical recovery. A repeat CT scan showed stable appearances.

Distal radio-ulnar joint subluxation following intramedullary nailing of the radius in a child.

We describe a patient with fractures of both bones of the forearm in whom flexible intramedullary nail fixation of the radius alone led to ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy.

Dislocation of Large Diameter Metal-On-Metal Bearings : An Indicator of Metal Reaction?

We report 3 patients who underwent total hip arthroplasty (THA) using large diameter metal-on-metal bearing. These patients initially presented with pain but went on to develop dislocation of the THA while awaiting investigations. Any pain following metal-on-metal bearing THA should be taken seriously and should trigger investigations to identify a metal reaction. If left untreated, these reactions can cause progressive soft tissue necrosis leading to instability. These patients should be considered for early revision of the bearing surface to prevent further soft tissue damage.

Ankle arthroscopy in children

INTRODUCTION Arthroscopy of the ankle has gained acceptance as a procedure for diagnosing and treating chronic and post-traumatic ankle problems. The senior authors perception is that magnetic resonance imaging (MRI) under-diagnoses anterior soft tissue impingement lesions in children. The purpose of this study was retrospectively to analyse the outcome of ankle arthroscopy in the paediatric age group. PATIENTS AND METHODS Between March 2005 and September 2007, 23 children underwent ankle arthroscopy for post-traumatic pathology. The indications for arthroscopy were failure of non-operative treatment for at least 12 weeks or a grade 3 or 4 osteochondral defect (OCD) on imaging. RESULTS At arthroscopy, OCDs were visualised in 12 cases and impingement lesions were seen in 17 ankles. MRI was performed in 8 of these 12 cases and only 1 suggested the possibility of an impingement lesion. Of the 17 cases of impingement seen on arthroscopy, 12 reported mechanical symptoms preoperatively and 4 were unstable on examination under anaesthetic. Eighteen of the twenty-three patients had complete relief of symptoms at 3 months. Eighteen children who were evaluated at one-year follow up had a mean American Orthopaedic Foot and Ankle Society score of 87. 5 (range: 49-100). CONCLUSIONS Ankle arthroscopy has a successful outcome in paediatric patients and the results are comparable with those reported in adult series. MRI was found to be insensitive for the diagnosis of soft tissue impingement of the ankle.

Surgical Treatment of Limb-Length Discrepancy Following Total Hip Arthroplasty

To The Editor: We read with great interest the article “Surgical Treatment of Limb-Length Discrepancy Following Total Hip Arthroplasty” (2003;85:2310-7), by Parvizi et al. The study retrospectively reviewed the cases of twenty-one patients who had had revision total hip replacement for limb-length discrepancy. According to the authors, in six patients (Cases 2, 6, 9, 12, 13, and 20), the primary problem leading to limb-length inequality was excessive anteversion or retroversion of the acetabular component. In these patients, there was no obvious longitudinal malalignment of the cup or of the femoral component (Table I). All of these six patients underwent revision of the acetabular component alone, and the limb lengths equalized in four patients and the discrepancy decreased in the other two. The authors described two different categories of limb-length discrepancy. The six patients mentioned above obviously … Corresponding author: William J. Hozack, MD Rothman Institute of Orthopaedics 925 Chestnut Street, 5th Floor Philadelphia, PA 19107 rihip{at}aol.com