John C. Wilson

Intervertebral Disc-Space Inflammation in Children

1. Forty-five cases of disc-space inflammation in children are presented. 2. The average age at onset was six and one-half years with an average duration of symptoms of four and one-half weeks. Back and hip pain with refusal to walk were the most prominent symptoms. An elevated erythrocyte sedimentation rate was present in 91 per cent. Disc-space narrowing usually in the lumbar area was the first roentgenographic sign. Treatment consisted of immobilization and antibiotics if a positive culture was obtained. 3. Fifteen biopsies of the disc space were performed yielding four positive bacteriological cultures and eight specimens showing inflammation. 4. Long-term follow-up showed that the patients were relatively asymptomatic. Forty-two per cent of the patients had a mild scoliosis with minimum rotation; nearly 25 per cent had partial or almost complete interbody ankylosis. 5. A review of the literature and the present series suggests an infectious etiology for disc-space inflammation in children.

TRAUMATIC POSTERIOR (RETROGLENOID) DISLOCATION OF THE HUMERUS

1. Posterior dislocation of the shoulder is an infrequent injury. It may result from trauma or from convulsive seizure. 2. Because of the infrequency of this injury, and because of the failure to obtain both anteroposterior and lateral (axillary) roentgenograms of the shoulder joint, the dislocation is frequently unrecognized for a long period of time. 3. Prompt recognition and treatment of posterior dislocation of the shoulder by closed manipulation yield excellent results. 4. Even with early prompt reduction, however, the replacement is unstable and there is great danger of spontaneous redislocation. 5. The danger of redislocation can be avoided by the simple expedient of transfixing the reduced humeral head to the acromion process with cruciate wires. This does not require an open operation. 6. Failure of early recognition necessitates open operative intervention. The results of late treatment are poor.

Fractures Of The Lower End Of The Humerus In Children

Contrary to prevailing opinion, supracondylar fractures can produce serious growth disturbances if the fracture lines extend into the epiphyseal centers. Cubitus varus and cubitus valgus are not considered serious disabilities, if flexion and extension are complete. However, if the deformity is progressive and is caused by disturbances in the growth centers, disabilities and limitation of motion may occur years after the initial injury. A satisfactory reduction is one in which the alignment in both planes is good. An anterior or posterior displacement of the fragments, in which the articular surfaces are displaced to a corresponding degree, will produce permanent limitations of flexion and extension. Lateral displacement above the epiphyses will produce valgus and varus deformities, but a good functional elbow may still result. Supracondylar fractures in which the fracture line, or part of it, extends into the epiphyses may produce growth disturbances similar to those which result from fractures of the lateral and medial condyles. If the fragment is intra-articular and not attached to overlying bone and soft tissue, it will undergo avascular necrosis. Supracondylar fractures of this type should have an accurate anatomical reduction; and, if the fragments are displaced and rotated, an open reduction is probably the best method of obtaining accurate alignment. A series of lateral condylar fractures, in which there were poor results in 50 per cent, of the cases treated by closed reduction, speaks for the ineffectiveness of this method. Early open reduction with minimal trauma to soft tissues will give the best results. Avascular necrosis of the capitellum will occur if the fracture line separates the epiphysis from the overlying bone and soft tissues. Fractures of half of the capitellum occurred in two patients with lateral condylar fractures. One had poor apposition by open reduction, and avascular necrosis occurred in one year. In the other, the separation was not complete, the position was good, and healing was uneventful. Avascular necrosis of the trochlea may occur later, despite a good reduction of a supracondylar fracture. It can cause stiffness at the joint, due to thinning of the cartilage and distortion of the articular surface of the humerus. Delayed ulnar palsy may cause progressive growth disturbances, and was present in two cases of severe cubitus valgus deformity. Fracture of the medial epicondyle will not cause a serious disability unless the fragment enters the joint cavity. Non-union is difficult to avoid in closed reduction.