Richard H. Gross

Causative factors responsible for femoral fractures in infants and young children

The causative factor responsible for producing a femoral fracture was determined in 74 children 5 years of age or younger admitted to Oklahoma Childrens Memorial Hospital over a 5-year period. Almost one-half of the fractures (34/74) were sustained as a result of suspected or confirmed abuse: most (17/26) of the fractures in infants less than 1 year of age were a result of abuse. Seven automobile-pedestrian accidents were causative in children 2 years or older. An accurate history, good record keeping, common sense, and awareness of the incidence of abuse will assist the orthopedist in recognizing abuse when it is likely, and sparing the family when it is not.

Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy

Summary: Rapid progression of hip subluxation was noted in the year after selective dorsal rhizotomy in seven hips (six patients). The hips that subluxed progressed from a lateral extrusion index averaging 25% preoperatively as compared with 50% after rhizotomy. Although preexistent hip dysplasia was a predisposing factor, hips with an intermediate degree of preoperative lateral extrusion (12–25%) had variable results. Ongoing and more frequent evaluation of hip stability is necessary after dorsal rhizotomy.

An Evaluation of Tibial Lengthening Procedures

Twenty-six patients who had tibial lengthening procedures (Anderson) are reviewed. The rate of union may be assessed at an early stage (eight weeks), and early indications for bone-grafting may be realized at that time. Lengthening of over five centimeters is associated with an increased rate of complications. Angulation at the operative site may occur early or late during the treatment routine, and satisfactory bone stability should be present before the lengthening apparatus is removed. Angulation which develops during the lengthening treatment tends to persist. Foot deformities appear to result from preoperative or postoperative muscle imbalance. Ischemia is suggested as a cause for the appearance of muscle weakness in some patients.

Hip surgery in the lumbar level myelomeningocele patient.

The ambulatory status of 74 patients with myelomeningocele, 4 years of age or older (average, 10 years, 5 months) was examined to assess the effectiveness of surgery about the hip in improving function. Seventeen of these 74 patients, all with lumbar levels of function, underwent surgery for the purpose of reducing a subluxation or a dislocation. Reduction of a dislocated hip did not improve function, and the failure rate was high (45% redislocation). There was little difference between the nonoperated and operated groups regarding ambulatory capabilities or the percentage of ambulators with a dislocated hip. The most severely impaired patients were those who had complications following hip surgery. The level of the neural deficit was the most important factor in determining ambulatory function.

A quantitative method for evaluating results of treating Legg-Perthes syndrome.

A new quantitative method of analyzing hip joint architecture in Legg-Perthes syndrome is presented. Outlines of the bony femoral head and acetabular configuration as seen on the anteroposterior (AP) view were traced on a digitizer. Computer analysis provided measures of joint congruity, containment, and femoral head shape. The methods ability to distinguish pathologic from normal hips and to trace the course of the bony deformity of the hip joint was demonstrated in a group of 14 patients. Interobserver reliability was established. The method provides an objective quantification of treatment results and a reliable means for comparison of data between groups of patients.

Afghan Percutaneous Osteotomy

An alternate technique to corticotomy for osteotomies to be used with external fixation is described. Percutaneous subperiosteal dissection is followed by passage of a Gigli saw and bone division. In contrast to corticotomy, the endosteum is divided, but the surrounding soft tissue envelope is less disrupted. In > 50 percutaneous Afghan osteotomies of the distal femur or proximal tibia, prompt healing has occurred in all cases, with no neurovascular complications. Two patients who had previously undergone corticotomy reported less pain after Afghan osteotomy. The technique is not applicable to the mid-femur because of the proximity of the profunda femoral artery.

Musculoaponeurotic Fibromatosis (Extraabdominal Desmoid Tumor) in a Child with Idiopathic Multicentric Osteolysis

Abstract: The fibromatoses are a group of benign proliferations of fibrous tissue with clinical behavior ranging from that of truly malignant tumors to that of benign reactive fibrous proliferations. Some of the superficial fIbromatoses are fairly common, but the deep ones, also known as desmoid tumors or musculoaponeurotic flbromatoses, are rare idiopathic multicentric osteolysis is a rare skeletal disorder of childhood that causes progressive destruction of bones and renal failure. We recently saw a young girt with both extraabdominal musculoaponeurotic fibromatosis and idiopathic multicentric osteolysis. The classification, diagnosis, and treatment of the deep fibromatoses are reviewed, and the possible association between the minor bone changes occasionally reported In musculoaponeurotic fibromatosis and idiopathic multicentric osteolysis is discussed.

Management of the resistant myelodysplastic or arthrogrypotic clubfoot with the Verebelyi-Ogston procedure.

Summary: The Verebelyi-Ogston (V-O) procedure, consisting of subchrondral excision of the talus and cuboid, was used for the treatment of 13 resistant clubfeet secondary to myelomeningocele or arthrogryposis. Nine feet were initially satisfactory, but the condition recurred in both feet of one patient after bracing was discontinued 3 years postoperatively. Three feet were graded as satisfactory after a second V-O procedure, and one after a third. The procedure must be monitored by intraoperative fluoroscopy or radiography, and followed by orthotic support. Despite the theoretical long-term disadvantage of incongruent joint surfaces, we consider the V-O procedure to be a good method for the treatment of this subset of rigid neuropathic clubfeet.

Ringworm resulting from swimming with a polyurethane cast.

A case of ringworm of the arm is described in a 6-year-old child, after swimming with a polyurethane cast. This report illustrates a potential problem when these casts are inadequately dried and worn for prolonged periods in warm climates. Accurate diagnosis depends on demonstration of fungus in the lesion by smear and culture. Topical antifungal therapy led to rapid resolution.

Limb lengthening for stature: another view.

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