Dennis S. Weiner

Redisplacement after closed reduction of forearm fractures in children

Reangulation and displacement after closed reduction of pediatric forearm fractures were reviewed in 90 patients treated with 1978-1984. All fractures were remanipulated and followed to union. No complications occurred and all had a functionally satisfactory result. Both intrinsic and extrinsic factors were identified as contributing to the complication of reangulation/displacement. Nonepiphyseal fractures were safely remanipulated up to 24 days postfracture, with the majority at 1-2 weeks. We conclude that 7% of pediatric forearm fractures treated by closed reduction are subject to reangulation and/or displacement following routine acceptable primary treatment, and that remanipulation provides a safe, effective means to obtain and maintain reduction.

The management of forearm fractures in children: a plea for conservatism.

A retrospective review was undertaken to evaluate the efficacy of primary nonoperative treatment (closed reduction and long-arm casting) along with pins and plaster as a salvage technique for those reduction failures. A total of 730 closed fractures (1987-1993) was compiled, of which 300 required closed reductions and casting. Excluded from the study were teenagers whose growth plates were closed. Of the 300 fractures requiring closed reductions, 22 went on to require remanipulations, and 12 required the use of pins-and-plaster technique to obtain or maintain satisfactory reduction. Complications in the group treated in this manner included two superficial pin infections treated with antibiotics and two forearms with moderate loss of pronation/supination not requiring treatment. We believe that closed reduction of pediatric forearm fractures remains the accepted standard and the technique of pins and plaster should be considered a reliable alternative for the unstable injuries.

Pathogenesis of slipped capital femoral epiphysis: current concepts.

Since Ambrose Paré in 1572 initially described what is believed to be the first case of slipped capital femoral epiphysis (SCFE), a virtual plethora of unproven theories has evolved in the ensuing years. The most currently popular theories embrace a framework of biomechanical events versus biochemical events having impact at the time of puberty. The zone of slipping always occurs primarily through the zone of hypertrophy in a corrugated undulating fashion. All investigative studies show that the growth plate at the time of puberty is weakened in SCFE. The final common pathway appears to be a mechanical failure of the growth plate, due to a weakened state, to resist displacement. The commonly encountered large body mass coupled with an increasingly oblique physis lying in a relative degree of retroversion creates a mechanical environment that, coupled with delicate alterations in the hormonal balance of thyroid hormone, growth hormone, testosterone, and estrogen, render the plate intrinsically suspectible to displacement by rather innocuous forces occurring in a shear plane. Ultrastructure studies of SCFE demonstrate a significant alteration in anatomy and physiology in all active metabolic areas of the growth plate. It is the authors concept that SCFE is a generalized metabolic disorder of puberty resulting from a series of pubertal mishaps with a multifactorial basis ordinarily caused by a relative imbalance of hormones, coupled with biomechanical events.

The evolving slope of the proximal femoral growth plate relationship to slipped capital femoral epiphysis

We measured the physeal angle (slope) of the proximal femoral physis on the standard anteroposterior (AP) radiographs. Controls consisted of 307 hips in children aged 1–18 years. Similar measurements were made on the affected (slip) and unaffected (nonslip) sides of 107 children with manifest unilateral slipped capital femoral epiphysis. An age-related increase of 14° occurs in the slope of the proximal femoral physis between ages 1 and 18 years, with maximal increase between ages 9 and 12 years. Increasing obliquity of the proximal femoral physis may be yet another factor contributing to slipped capital femoral epiphysis.

Hazards of internal fixation in the treatment of slipped capital femoral epiphysis.

We reviewed the records of 202 patients (308 hips) in whom a slipped capital femoral epiphysis had been fixed with pins or screws. A serious complication that was directly related to the use of internal fixation developed in eighty hips (26 per cent). The rate of complications in the 202 patients was 40 per cent. In thirty-six (18 per cent) of the 202 patients, an additional procedure was done to correct a pin-related complication. Forty-one hip joints had been penetrated by a pin. Other complications included avascular necrosis (fourteen hips), chondrolysis (nine), fracture (one), infection (one), further slippage (one), sciatic-nerve injury (one), and breakage of a screw (eight). Ways of decreasing the incidence of complications of fixation were explored.

Maturation factors in slipped capital femoral epiphysis.

Several maturation factors relative to growth and epiphyseal development were reviewed retrospectively in 191 patients with slipped capital femoral epiphysis, including bone age, height and weight, thyroid functions, sex hormone levels, and growth hormone levels. Seventy-one percent of 138 patients had weights above the 80th percentile. Active thyroid (T3) was significantly low in 25% of 80 patients studied. Testosterone levels were markedly depressed in 76% of 64 patients tested. In this same group, 87% had low growth hormone levels. The consistently low testosterone and growth hormone levels, along with a tendency toward hypothyroidism, lend support to the biochemical theory of a delicate hormonal imbalance in slipped capital femoral epiphysis.

Complications in proximal tibial osteotomies in children with presentation of technique

Proximal tibial osteotomies in children have been associated with a number of complications, including peroneal nerve palsies, compartment syndromes, deep and superficial infections, vascular injuries, iatrogenic fractures, apophyseal or growth plate damage, and recurrence of deformity. A retrospective review of the results of 22 children who had 30 primary and seven repeat proximal tibial osteotomies was performed to assess the frequency of complications at our institution. Using a specified technique that included prophylactic anterior compartment fasciotomy and distal fibulectomy, there were three superficial wound infections and one delayed union but no peroneal nerve palsies, vascular injuries, compartment syndromes, or fixation failures. There were no sequelae from the superficial infections. This is a lower rate of complications than previously reported in the literature and suggests a relationship to our current surgical technique and attention to detail. We believe that proximal tibial osteotomies can be performed successfully and safely in children when the surgeon recognizes the potential problems and takes steps to prevent them.

Relationship between femoral anteversion and osteoarthritis of the hip

The purpose of this study was to establish a relationship between the magnitude of femoral anteversion and osteoarthritis of the hip. Sixteen osteoarthritic subjects were compared with 18 control subjects by an improved computed tomography (CT) scanning technique. Femoral anteversion was accurately determined with little radiation exposure. There was no significant difference in femoral anteversion between arthritic subjects and a “normal” control population. There was no significant difference in femoral anteversion between the involved and the uninvolved hips of these subjects with osteoarthritis. These results suggest that performing a derotational femoral osteotomy to prevent osteoarthritis is not indicated. The cause of primary osteoarthritis is multifactorial and does not depend solely on preexistence of higher femoral anteversion.

Severely displaced proximal humeral epiphyseal fractures : A follow-up study

Forty-eight patients with severely displaced proximal humeral epiphyseal fractures were reviewed. Twenty-one patients were followed up for an average of 9 years after injury with a personal interview, examination, and radiographs. Average age was 14.1 years, half of whom were age 15 years or older. Initial head-shaft displacement averaged 80%, and 31 fractures were displaced by > or = 80%. All underwent attempted closed reduction. Radiographs for all except three were sufficient to judge the adequacy of reduction. Twenty-six of 45 attempted closed-reductions failed to improve displacement significantly. Nine patients underwent operative treatment, and the remainder had a closed reduction. In the operative group, complications occurred in three of nine patients. No complications occurred in the nonoperative group. No patients seen at late follow-up identified any activity or employment restrictions as a result of their injuries. Several patients incurred humeral shortening or imperfect radiographic remodeling, but this did not correlate with clinical outcome. Comparing the operative complications with the excellent late results after nonoperative treatment in this series supports previous recommendations to avoid operative intervention with few exceptions. The magnitude of displacement alone does not appear to justify operative treatment.

Surgical treatment of symptomatic accessory tarsal navicular

We report a retrospective review of 50 consecutive patients (75 feet) with chronically symptomatic accessory tarsal naviculars that failed to improve with conservative treatment. Surgical treatment consisted of excision of the accessory tarsal navicular or medial protuberance of a prominent cornuate-shaped navicular combined with simple replication of the tibialis posterior tendon without altering its course. Good and excellent results were obtained in 45 (70 feet) of the 50 patients (90%). The procedure has a low rate of minor complications, is easy to perform, and is extremely well accepted by the patients.