Dennis C. Paterson

Statistical analysis of the incidence of physeal injuries.

The incidence of physeal injuries in nearly 2,000 bony injuries was 18%. They were commoner in adolescents and specifically more frequent in the upper limbs. The incidence of growth arrest was just over 1%, whereas the incidence of serious complication was <1%. The prognosis depends more on the site than the Salter-Harris classification. The proximal tibia is a common site for growth disturbance.

Long-term follow-up of anterior tibial eminence fractures

Summary Most children who have sustained a tibial eminence fracture have objective evidence of anterior cruciate ligament (ACL) laxity at long-term follow-up, but few have subjective complaints. Clinical signs of anterior instability were noted in 64% of patients (32 of 50) examined at an average follow-up of 4 years. Objective evidence of laxity determined with a KT-1000 arthrometer was noted in 74% of patients (37 of 50). Five patients (10%) complained of pain, but no patient complained of instability at follow-up. Assessment of long-term stability showed that the method of management (open vs. closed methods) had no bearing on eventual outcome.

Difficult supracondylar elbow fractures in children: analysis of percutaneous pinning technique.

After treatment with two lateral percutaneous pins, 80 children with grade II-III supracondylar elbow fractures were reviewed. The result was good in 55 patients (68%) and was the same for extension- and flexion-type injuries. These patients had less than 10 degrees change in carrying angle and less than 20 degrees total change in range of motion. This method eliminates risk of iatrogenic injury to the ulnar nerve but is technically very demanding. Redisplacement, joint penetration, and damage to the capitellar side of growth plate can be avoided only by positioning the pins divergently.

ACUTE SUPPURATIVE ARTHRITIS IN INFANCY AND CHILDHOOD

1. A regime of treatment for acute suppurative arthritis in childhood has been proposed. This consists of: urgent arthrotomy of the affected joint, if possible within five days; skin closure without drainage; antibiotics; and immobilisation of the joint for six weeks. 2. Fifty hips have been treated by this regime: all are clinically and radiologically normal The failure to achieve these results with other forms of treatment is due to delay in diagnosis, inadequate drainage together with lack of immobilisation of tile affected joint, and inadequate treatmellt with antibiotics. 3. Early diagnosis determines the ultimate prognosis. It is suggested that in doubtful cases exploratory arthrotomy is indicated. Eleven hips were found to Ilave some other cause for the signs and symptoms, but the children have suffered no ill effects from the arthrotomy. 4. Diagnostic aspiration is an unsatisfactory method, especially ill the case of tile hip, and should be avoided. Incision is preferable. 5. Acute suppurative arthritis of infancy is a serious condition. Diagnosis is difficult and is often delayed, so that the affected joint may be destroyed. In this small series of nine, seven affected joints were destroyed.

Treatment of the missed Monteggia fracture in the child

Eight children with missed Monteggia fracture-dislocations are described. Seven had reconstructive surgery which included resection of scar tissue from the radiohumeral joint, proximal ulnar osteotomy, reduction of the radial head and reconstruction of the annular ligament. One had excision of the radial head. Excellent results were obtained in patients under ten years of age, up to four years after the initial injury.

Ultrasonic features of acute osteomyelitis in children

The ultrasonic findings in 38 children with osteomyelitis of the limb bones were analysed in four time-related groups based on the interval between the onset of symptoms and the ultrasonic examination. Deep soft-tissue swelling was the earliest sign of acute osteomyelitis; in the next stage there was periosteal elevation and a thin layer of subperiosteal fluid, and in some cases this progressed to form a subperiosteal abscess. The later stages were characterised by cortical erosion, which was commonly present in those who had had symptoms for more than a week. Concurrent septic arthritis was revealed in 11 patients, most frequently in association with osteomyelitis of the proximal femur or the distal humerus. Four weeks after clinical cure, ultrasonic examination showed no abnormalities. Ultrasonography is therefore a useful additional method for the diagnosis and assessment of osteomyelitis and its complications.

Remodelling after pinning for slipped capital femoral epiphysis

We assessed 70 hips at an average of 7.1 years after pinning for slipped upper femoral epiphysis to determine the frequency of remodelling, what factors influence it and its effect on the clinical outcome. Remodelling was defined by a new classification of the anterior femoral head-neck profile as seen on the lateral radiograph. Remodelling occurred in 50% of hips with a head-shaft angle of 30 degrees or more; the probability of remodelling was significantly less the greater the degree of slip, but was significantly increased if the triradiate cartilage was open at the time of presentation. We found no significant effect for age, sex, weight or length of symptoms. The range of internal rotation was significantly greater in those hips that remodelled. We support the treatment of moderate slips in skeletally immature patients by pinning in situ, since the probability of satisfactory remodelling was 75% for slips of 40 degrees or less.

Skeletal age estimation in leg length discrepancy.

Sixty hand radiographs of children with known leg length discrepancy were reported independently in a “blind” manner by four radiologists using the Greulich and Pyle Atlas. Significant variation was found. Fifty percent of the children were assigned a skeletal age that differed by more than 1 year between radiologists; 10% varied by more than 2 years (p < 0.05). Female skeletal age was considerably understimated by an average of 11 months. Skeletal age estimation is one source of error in the timing of surgery for leg length equalization, especially when a single estimate is used. Skeletal age also appears to be more variable in children with leg length discrepancy.

Slipped capital femoral epiphysis. Incidence and clinical assessment of physeal instability

In an unselected series of 55 cases of slipped capital femoral epiphysis (SCFE) we observed an incidence of 25% of epiphyseal reduction, mostly unintentional. Reduction indicated physeal instability and was associated with an effusion, detected by sonography on admission, and inability to bear weight. The true prevalence of instability may be higher since an effusion was noted in 33 cases (60%) on the initial sonographic assessment. Serial radiographs showed reduction in 12 (22%), with an average change of 15.1 degrees in the head-neck angle. Serial sonography showed reduction in 7 out of 20 cases (35%), with an average change of 3.7 mm in displacement. In two cases reduction was seen on sonography but not on radiography. Of the hips which showed subsequent reduction, 12 had had a bone scan on admission; three showed initial epiphyseal avascularity but only one progressed to symptomatic avascular necrosis. All stable hips had normal epiphyseal vascularity on the initial bone scan. This indicates the importance of injury from the initial displacement in causing avascular necrosis, rather than effusion, vascular compromise or iatrogenic injury from gentle repositioning. Physeal instability in SCFE is common and should be assessed clinically on admission. It is indicated by joint effusion or inability to bear weight. A slip is very unlikely to be unstable in a child able to bear weight and with no sonographic effusion.

Classification in slipped capital femoral epiphysis : sonographic assessment of stability and remodeling

In a prospective study of 26 hips in 21 patients with slipped capital femoral epiphyses (SCFEs), serial sonography was more sensitive than radiography in showing epiphyseal displacement and reduction. Reductions were associated with grossly visible hip joint effusions. The initial slips were reduced by treatment in seven of 11 hips with effusion. The 15 hips without effusion were unreduced. After stabilization and pinning, the effusion did not recur in any case. Sonography is sensitive and free from projectional errors in the assessment of metaphyseal remodeling. If any remodeling is present, the SCFE is at least three weeks in duration. A new classification into acute, acute-on-chronic, and chronic SCFEs is proposed, based on the objective sonographic data. Joint effusion represents physeal instability or recent progression, and remodeling is a sign of chronicity. An acute SCFE is characterized by effusion, whereas a slip without effusion but with remodeling is designated as chronic. An acute-on-chronic SCFE is associated with both effusion and remodeling. Joint effusion suggests that SCFEs should be operatively fixed and that displacement may diminish with traction or intraoperative positioning of the hip.