Prasit Nimityongskul

The likelihood of injuries when children fall out of bed

Between 1980 and 1985, 76 children from birth to 16 years of age were reported to have fallen out of a bed, crib, or chair while in our hospital; 75% of the incidents occurred in children from birth to 5 years of age. The height of falls ranged from 1 to 3 ft. Most of the injuries were minor (scalp hematoma and facial lacerations). Our data indicate that severe head, neck, spine, and extremity injuries are extremely rare when children fall out of hospital beds. Child abuse should be suspected and ruled out when a child is seen with severe injury from a reported “fall at home”.

Intramedullary Screw Fixation of Lateral Malleolus Fractures

A biomechanical evaluation of intramedullary versus buttress plate and lag screw fixation of lateral malleolus fractures is combined with a clinical evaluation of 44 patients with lateral malleolus fractures who underwent intramedullary screw fixation. The biomechanical study was performed in experimentally produced, Weber B, supination-eversion ankle fractures. The fractures were fixed with one of the two above fixation methods and then placed under a torsional load to failure. Sixteen cadaver ankles were tested as compared with native bone. The intramedullary screw provided 66.5% the resistance of torsion, and the buttress plate and lag screw provided 61.5% the resistance to torsion. There was no statistical difference between these two groups. The 44 fractures treated with an intramedullary screw were reviewed retrospectively. There was one failure of fixation, and one prominent hardware problem. Time to full weightbearing averaged 7.2 weeks. These results suggest that intramedullary screw fixation of noncomminuted lateral malleolus fractures provides stable fixation with good clinical results. This technique has the advantages of providing dynamic intramedullary fixation with limited surgical dissection and no subcutaneous hardware.

Percutaneous Intramedullary Fixation Of Lateral Malleolus Fractures: Technique And Report Of Early Results

Twenty-four patients with Weber B and low Weber C displaced lateral malleolus fractures who underwent closed reduction and percutaneous internal fixation with an intramedullary, fully threaded, self-tapping screw were retrospectively reviewed. Nineteen of these patients were followed for an average of 63.4 weeks. A good radiographic reduction was obtained in 87.5% of patients, a fair reduction in 8.3%, and a poor reduction in 4.2%. The reduction that was obtained was maintained in all patients. Fracture union was achieved in 95.5% of patients, with an average time to union of 8.2 weeks. In all patients the average time to full weight bearing was 6.8 weeks, whereas that in patients with isolated lateral malleolus fractures was 4.5 weeks. There were no deep wound infections or complaints of painful hardware. At latest follow-up, functional results were excellent in 42.1%, good in 42.1%, fair in 5.3%, and poor in 10.5% of patients. If reduction of the lateral malleolus fracture can be obtained in a closed fashion (with the aid of an image intensifier), we believe that fixation may be performed with an axial screw percutaneously. This technique requires minimal soft-tissue dissection, thereby decreasing wound complications and painful hardware sites that are occasionally observed after open techniques. This closed technique also eliminates screw penetration of the ankle joint and damage to the peroneal tendons, which can be risks when a plate or lag screws are employed as internal fixation. Surgical time is also reduced and tourniquet use is optional. If an acceptable reduction cannot be obtained using this technique, open reduction and internal fixation should be performed.

Avulsion fracture of the tibial tuberosity in late adolescence.

Between January 1982 and May 1985, eight patients with avulsion fractures of tibial tuberosity were seen at the University of South Alabama Medical Center. All were boys, average age, 15 years 8 months. Six of eight had a positive history of Osgood-Schlatter disease. Seven patients underwent open reduction and internal fixation, one had closed reduction and cast. Followup ranged from 5 months to 3.5 years, averaging 19.5 months. All, except one who had lateral meniscectomy, regained practically full ROM and reported no pain or limitation of activities. No patient developed genu recurvatum deformity or leg length discrepancy due to the injury. Open reduction and internal fixation is the treatment of choice in displaced intra-articular fractures. Lateral parapatellar incision is a more direct approach to this fracture and is less likely to injure the infrapatellar branch of the saphenous nerve.

Ultrasonography in the management of developmental dysplasia of the hip (DDH).

Real time ultrasonography, according to the method of Graf, was performed on 113 infant hips because of abnormal physical findings (ranging from hip clicks to frank dislocation). Three parameters were measured on the standard coronal images: alpha and beta angles of Graf and the d/D ratio of Morin. Results indicated that the presence of hip clicks (88 hips) in general is a benign condition and not associated with abnormal anatomy. Hips that were reduced at birth but dislocatable (Barlow hip) showed no significantly abnormal acetabular anatomy. Hips that were dislocated at rest but were reducible (Ortolani hip) showed definite abnormal acetabular anatomy and femoral head coverage. Ultrasonography is beneficial in the management of developmental dysplasia of the hip (DDH); it confirms the clinical findings and eliminates radiation exposure to the infants pelvis, especially in the first 4-6 months of life when standard radiography is not always reliable in diagnosing DDH.

Surgical Treatment of Clubfoot: A Comparison of Two Techniques

Between 1977 and 1989, 28 clubfeet were operated on, with follow-up ranging from 2 to 13 ½ years and averaging 79 months. Group I (16 feet; average follow-up 104 months) underwent a modified Turcos posteromedial release. The functional result in this group was satisfactory in general, but approximately one third of this group required a secondary procedure for persistent intoeing or residual metatarsus adductus. Group II (12 feet; average follow-up 45 months) underwent a modified, complete subtalar release of McKay and Simons utilizing the Cincinnati incision. No patient in this second group required a secondary procedure. In our experience, the more complete subtalar release procedure of McKay and Simons resulted in better correction than the Turco posteromedial release. Although follow-up in group II was much shorter than that in group I, we felt that 2 years of minimum follow-up in group II was meaningful, since most of the recurrence or residual deformities were noticed within 18 months after surgery. The Cincinnati incision allowed better exposure and a more complete release. Skin flap necrosis was not a problem in this series.

Cardiofaciocutaneous syndrome (CFC) with congenital peripheral neuropathy and nonorganic malnutrition : An autopsy study

Many phenotypic manifestations have been reported in cardiofaciocutaneous (CFC) syndrome, but none, to date, are pathognomonic or obligatory. Previous histopathological studies reported findings in skin and hair; no autopsy studies have been published. We report the clinical and autopsy findings of a 7‐year‐old boy with severe CFC syndrome and malnutrition of psychosocial origin. Manifestations of CFC, reported previously, included macrocephaly and macrosomia at birth; short stature; hypotonia; global developmental delays; dry, sparse thin curly hair; sparse eyebrows and eyelashes; dilated cerebral ventricles; high cranial vault; bitemporal constriction; supraorbital ridge hypoplasia; hypertelorism; ptosis; exophthalmos; depressed nasal bridge; anteverted nostrils; low‐set, posteriorly‐rotated, large, thick ears; decayed, dysplastic teeth; strabismus; hyperelastic skin; wrinkled palms; keratosis pilaris atrophicans faciei; ulerythema ophryogenes; hyperkeratosis; gastroesophageal reflux; and tracheobronchomalacia. Additional findings, not previously reported, include islet cell hyperplasia, lymphoid depletion, thymic atrophy and congenital hypertrophy of peripheral nerves with onion bulb formations. Although the islet cell hyperplasia, lymphoid depletion, and thymic atrophy are nonspecific findings that may be associated with either CFC or malnutrition, the onion bulb hypertrophy is specific for a demyelinating–remyelinating neuropathy. These findings implicate congenital peripheral neuropathy in the pathogenesis of the developmental delays, feeding difficulties, respiratory difficulties, ptosis and short stature in this case. Additional studies of other cases of CFC are needed.

Tumoral calcinosis in an infant

Abstract We report tumoral calcinosis, an uncommon disease of uncertain origin, in an infant – only the sixth instance of the disease reported in this age group. The radiologic features are typical as illustrated by three modalities. The clinical, radiologic and pathologic features are discussed along with comments concerning possible etiologies and management.

Plastic deformation of the forearm: a review and case reports.

Plastic deformation of long bones can occur in any age group but it is more common in children. Based on our experience with this condition and the suggested guidelines for treatment in the literature, we believe that significant deformity (15 degrees or more) in children over 10 years of age should be manipulated and corrected. In children 6 to 10 years of age, attempts should be made to correct a severe deformity (20 degrees or more). Children under 5 years of age probably require no treatment, since remodelling most likely will restore the correct anatomy and function.

Septic hip in pelvic fracture with urologic trauma : case report

Urologic injuries occur in 10% of pelvic fractures and hip sepsis is a rare complication. The symptoms of a septic hip are often not as dramatic when found in the setting of an acute pelvic fracture and may be overlooked. A case is presented with a review of the literature. Early recognition and aggressive surgical debridement are important to prevent the long-term sequelae of septic arthritis.