W. B. Rodgers

Chronic Monteggia Lesions in Children. Complications and Results of Reconstruction

We retrospectively reviewed the results of operative treatment of chronic Monteggia lesions (Bado type I or the equivalent) with anterior radiocapitellar dislocation in seven patients. The mean age at the time of the reconstruction was six years and nine months (range, eleven months to twelve years), and the mean time from the injury to the operation was twelve months (range, five weeks to thirty-nine months). The mean duration of follow-up was four years and six months (range, two years to eleven years and three months). There were fourteen complications, including malunion of the ulnar shaft in one patient; residual radiocapitellar subluxation in two patients (one anterior and one posterolateral); radiocapitellar dislocation (dynamic anterior subluxation of the radial head in supination) in one patient; transient ulnar-nerve palsy in three patients (with residual weakness in two); partial laceration of the radial nerve in one patient; loss of the fixation in two patients; and non-union of the ulnar osteotomy site, compartment syndrome, conversion reaction, and possible fibrous synostosis of the forearm in one patient each. The patients lost a mean of 36 degrees of pronation and a mean of 27 degrees of supination of the forearm compared with the contralateral, uninjured extremity. Two patients demonstrated a loss of flexion of the elbow of 8 and 13 degrees and three had a loss of extension (mean, 15 degrees) compared with the contralateral side. There were three good, two fair, and two poor results.

Incidence of trigger digits in newborns

Trigger digits are uncommon in infants. We prospectively examined 1046 newborns to determine the congenital incidence of this condition. No trigger digits were identified among these children. This correlates by power calculation to an incidence of 0-3 trigger digits per 1000 live births. We then retrospectively reviewed the records of all children who had undergone surgical release of trigger digits at our hospital from July 1989 to July 1992. Seventy-three children underwent 89 trigger thumb releases and 5 children had 11 trigger finger releases. Only seven of these children presented at less than 6 months of age and none presented at less than 3 months of age. This study raises the possibility that trigger digits may represent lesions acquired after birth.

Parturition-induced Pelvic Dislocation: A Report of Four Cases

OBJECTIVE To describe our experience with four cases of severe pelvic dislocation associated with difficult parturition. DESIGN Retrospective case series. PATIENTS Four patients, each with rupture of the symphysis pubis and sacroiliac joints during labor. All injuries were associated with significant initial pain and disability. All developed persistent symptoms related to the sacroiliac disruption. INTERVENTIONS The three patients who had presented acutely were freated with closed reduction and application of a pelvic binder. Two underwent closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. One patient (N.A.), who presented late, had not been treated with a binder. RESULTS All four patients had persistent posterior pelvic (sacroiliac) pain. In two patients a postpartum neuropathy persisted. CONCLUSIONS Severe pelvic dislocations are rare during labor, with conservative treatment reported to be successful in most cases. The persistence of symptoms in our patients emphasizes the need for careful examination and follow-up of these rare injuries. Because the outcome in our patients was poor and results in the literature are equivocal, we suggest the consideration of an operative approach to treatment in patients with symphyseal diastasis of > 4.0 cm.

Femur fractures in children : Treatment with early sitting spica casting

The purpose of this article is to review our experience with early spica casting and determine risk factors for loss of reduction and skin complications. The radiographic and clinical charts of 114 children were retrospectively reviewed. At the time of fracture union, excessive shortening and angular malunion were not significant problems. Loss of reduction and skin complications occurred in 20 and 14% of patients, respectively. In addition to previously described risk factors, we identified spica knee flexion angle < 50 degrees as predictive of eventual loss of reduction and found that > 2 cm of initial shortening was not a contraindication to early spica casting. Factors associated with skin problems included younger age and abuse as a mechanism of injury. In our opinion, early spica casting is the treatment of choice for all isolated, closed femur fractures in otherwise healthy children aged 6 years or younger, regardless of the degree of initial deformity.

Spinal deformity in myelodysplasia. Correction with posterior pedicle screw instrumentation.

Study Design. A retrospective review of transpedicular instrumentation used in a series of 24 patients with myelodysplastic spinal deformities and deficient posterior elements. Objective. To describe the usefulness and efficacy of these instruments in the treatment of complicated myelodysplastic spinal deformity. Methods. The mean preoperative scoliosis was 75.7° (range, 39‐130°) in the 22 patients with scoliotic deformities; 4 patients with thoracic hyperkyphoses averaged 70.5° (range, 46‐90°) and 10 patients with lumbar kyphoses averaged 80.5° (range, 42‐120°). The instrumentation extended to the sacrum in 4 patients and the pelvis in 9; 10 patients also underwent anterior release and fusion and 7 underwent concomitant spinal cord detethering. At an average follow‐up of 4.0 years (2.0‐7.7 years; one patient died at 8 months), all patients have fused (with the exception of two lumbosacral pseudarthroses). Results. At last follow‐up, deformity measured 32.1° scoliosis (range, 6‐85°), 30.8° thoracic kyphosis (range, 24‐35°), and 0.0° lumbar kyphosis (range, 35° kyphosis to 29° lordosis). Three patients lost some neurologic function after surgery; two recovered within 6 months and one has incomplete recovery. No ambulatory patient lost the ability to walk. Five patients required additional surgical procedures; in three cases, there was instrumentation breakage associated with pseudarthrosis or unfused spinal segments. Conclusions. Pedicle screw instrumentation is uniquely suited to the deficient myelodysplastic spine. Compared with historical control subjects, these devices have proven capable of significant correction of both scoliotic and kyphotic deformities. This instrumentation appears particularly useful in preserving lumbar lordosis in all patients and may preserve more lumbar motion in ambulatory myelodysplasia patients.

Increasing lordosis of the occipitocervical junction after arthrodesis in young children : The occipitocervical crankshaft phenomenon

Five children were treated before age 6 years with occipitocervical fusion for occipitocervical instability. Long-term (average, 11.8 years; range, 8.4-14.5 years) follow-up revealed increasing lordosis across the fused segment in four of the patients, a finding we here refer to as the occipitocervical crankshaft phenomenon. On average, occipitocervical lordosis increased 1.06 degrees per level fused per year until skeletal maturity. Although such a progression might be expected, to our knowledge this is the first report of its occurrence. Compensatory subaxial motion was able to overcome this increase in all of the patients. We recommend occipitocervical fusion in a neutral or slightly flexed position in the very young child to account for this predictable increase in lordosis.

Surgery of the spine in myelodysplasia : An overview

Significant spinal deformity is particularly common in nonambulatory patients with myelodysplasia. Progressive deformity may be caused by congenital anomalies, paralytic collapse, hip contractures, or spinal cord tethering. Existing or projected functional impairment should be the principle indication for treatment. Surgical treatment is complicated by poor soft tissue coverage, associated contractures, lack of sensation, weak bone, and absence of posterior elements. Successful fusion can be achieved by circumferential (anterior and posterior) fusion and current rigid segmental instrumentation. The unique deformities and bony anatomy require individualized techniques to achieve fixation.

Chronic physeal fractures in myelodysplasia: magnetic resonance analysis, histologic description, treatment, and outcome.

Thirteen myelodysplastic children with 19 chronic physeal fractures were treated. All were treated with prolonged immobilization (average, 5.8 months; range, 3-18 months) in either braces or casts; four of the fractures required operative fixation to facilitate healing. All were healed at 4.8-years follow-up but, in four of the fractures, the growth plate closed prematurely. Three of the children underwent magnetic resonance imaging (MRI) of the injured physes, and one underwent physeal biopsy as part of her operative epiphysiodesis. Histologic analysis revealed three distinct zones of physeal pathoanatomy: a normal zone of proliferation; a thickened, disorganized zone of hypertrophy; and a vascularized zone of fibrous tissue adjacent to the metaphysis. On MRI, there was thickening of the physis and irregularity of the zone of provisional calcification. The physeal cartilage and the juxtametaphyseal fibrovascular tissue enhanced with gadolinium. These findings corroborate earlier mechanistic proposals for physeal injury in myelodysplasia: chronic stress or trauma to the poorly sensate limb produces micromotion at the zone of hypertrophy, yielding a widened, disorganized physis, and leading to fracture, displacement, and delayed union.

CHRONIC MONTEGGIA LESIONS IN CHILDREN. COMPLICATIONS AND RESULTS OF RECONSTRUCTION

We retrospectively reviewed the results of operative treatment of chronic Monteggia lesions (Bado type I or the equivalent) with anterior radiocapitellar dislocation in seven patients. The mean age at the time of the reconstruction was six years and nine months (range, eleven months to twelve years), and the mean time from the injury to the operation was twelve months (range, five weeks to thirty-nine months). The mean duration of follow-up was four years and six months (range, two years to eleven years and three months). There were fourteen complications, including malunion of the ulnar shaft in one patient; residual radiocapitellar subluxation in two patients (one anterior and one posterolateral); radiocapitellar dislocation (dynamic anterior subluxation of the radial head in supination) in one patient; transient ulnar-nerve palsy in three patients (with residual weakness in two); partial laceration of the radial nerve in one patient; loss of the fixation in two patients; and non-union of the ulnar osteotomy site, compartment syndrome, conversion reaction, and possible fibrous synostosis of the forearm in one patient each. The patients lost a mean of 36 degrees of pronation and a mean of 27 degrees of supination of the forearm compared with the contralateral, uninjured extremity. Two patients demonstrated a loss of flexion of the elbow of 8 and 13 degrees and three had a loss of extension (mean, 15 degrees) compared with the contralateral side. There were three good, two fair, and two poor results.