William W. Robertson

Acute osteomyelitis in children: a review of 116 cases.

Summary We reviewed 116 cases of acute hematogenous osteomyelitis (AHO) (without septic joints) from 1979 to 1985 to establish current patterns of clinical presentation, modes of treatment, and success of therapy. We found that patients present early in the course of their disease, and many have no findings other than local tenderness and an elevated sedimentation rate. Sixty-four of the patients were treated nonoperatively. The average antibiotic treatment time was 2 weeks by intravenous (i.v.) administration followed by additional outpatient oral therapy for periods of up to 4 weeks. This treatment regimen applied specifically to acute osteomyelitis led to no known treatment failures.

Growth disturbances of the proximal femur after pinning of juvenile slipped capital femoral epiphysis

Premature closure of the capital femoral physis after pin fixation of slipped capital femoral epiphysis (SCFE) in the juvenile population (at least 1 year less than the established mean) can lead to growth disturbances of the proximal femur. A retrospective review of 21 patients (33 hips) who had a pinning of a juvenile SCFE was performed. Growth disturbances including greater trochanteric overgrowth, coxa vara, and coxa breva were noted in 64% of the hips. An 80% incidence of bilateral involvement was noted in the juvenile group. Consideration should be given to prophylactic pinning of the contralateral hip and use of a smooth pin construct to prevent premature closure of the growth plate in children with significant growth remaining.

Complex femur fractures in children : treatment with external fixation

Summary External fixation was used to treat complex femur fractures in 10 children. These injuries were associated with head trauma, cerebral palsy, epidermolysis bullosa, open wounds, and failed casting. The duration of external fixation averaged 8 weeks, and the mean follow-up was 5 years 8 months. At follow-up, one patient had 2.6 cm of residual shortening, and two had overgrowth. Complications included one refracture. Three children developed superficial pin site drainage. Although most femur fractures can be treated with traction or casting, external fixation may simplify overall care in children with multiple injuries and is effective in controlling unacceptable femoral shortening and angulation.

The relationships of skeletal injuries with trauma score, injury severity score, length of hospital stay, hospital charges, and mortality in children admitted to a regional pediatric trauma center

Thirty-four-hundred and seventy-two children were consecutively admitted for acute traumatic injuries over a 34 month period to the Childrens National Medical Center. The study comprised 805 patients who sustained 953 fractures and dislocations. The male to female ratio was 2:1. Age at the time of admission was evenly distributed over 16 years, with a mean of 8.3 years. Pedestrian accidents and falls each accounted for 34% of the musculoskeletal injuries, whereas motor vehicle accidents accounted for an additional 13%. The femur was the most commonly fractured bone, representing 22% of all fractures and dislocations, followed by the humerus (16%), tibia/fibula (12%), ankle/foot (13%), and radius/ulna (8%). Nine percent of the fractures were open. The average length of hospital stay was 8.6 days, and the average cost per hospital admission was

Compression-plate fixation of femoral shaft fractures in children aged 8 to 12 years.

8,765. The mortality rate was 3%. Central musculoskeletal injuries (spine, clavicle/scapula, and pelvis) in our hospitalized patients were associated with the longest hospital stays and intensive care unit admissions, and lowest Trauma Scores, as well as the highest Injury Severity Scores, hospital charges, and mortality rates.

Single screw fixation for acute and acute-on-chronic slipped capital femoral epiphysis.

Twenty-one patients between the ages of 8 and 12 years with 23 femoral-shaft fractures underwent dynamic compression plating (DCP) between August 1993 and February 1996. Eleven patients had isolated femoral-shaft fractures, five had associated long-bone injuries, and five had multiple organ injuries. A 4.5-mm DCP plate was used in each case. Patients were kept non-weight bearing with crutches for an average of 8 weeks. Hardware failure occurred in two patients at 6 weeks. One was treated with revision plating, and the other, with spica casting. Both healed uneventfully. No other complications occurred. All patients were radiographically and clinically healed at last follow-up.

Congenital clubfoot. Month of conception.

Charts and radiographs of 78 patients with slipped capital femoral epiphysis were reviewed. During the retrospective study period, 1990 to 1993, 16 patients had acute or acute-on-chronic slips; 21 hips were involved. Nine hips were acute and 12 hips were acute-on-chronic slips. No patient reported endocrinopathy or other systemic illness. All hips were fixed with a single 7-mm cannulated screw. No attempts were made for reduction. The lateral head-shaft angle (preoperative, postoperative, and at followup) was measured as was the position of the screw (postoperative and followup). Physeal closure in 19 hips occurred at a mean of 9.6 months. Two additional patients did not return for followup until 30 and 36 months after surgery. At closure, there was no significant change in head-shaft angle from preoperative position. No cases of avascular necrosis or chondrolysis were seen in this series. Seventeen of the 21 hips had an excellent functional result. Three hips had a good result and 1 had a poor result. There was a tendency for poor pin position and less satisfactory results to be associated. It is concluded that single screw fixation is adequate for treating uncomplicated acute and acute-on-chronic slipped capital femoral epiphyses.

FAILURES OF PIN REMOVAL AFTER IN SITU PINNING OF SLIPPED CAPITAL FEMORAL EPIPHYSES : A COMPARISON OF DIFFERENT PIN TYPES

The medical records of 330 children who were born with uncomplicated congenital clubfoot were reviewed retrospectively. To determine their months of conception, the duration of gestation was extrapolated and those which were less than 40 weeks were noted. The years of conception for the studied children were from 1956 to 1994. Months of the year were ascribed angle values and the distribution of conceptions per month were grouped in radial manner. Using a circular analysis for variance a lack of uniform circular distribution was found for the grouped months of conception. There is a significant seasonal variation in the data. The mean month of conception was June. This finding is at variance with the peak months of conception for the population of the United States for the years 1989 through 1993. The theory that congenital clubfoot is caused by an intrauterine Enterovirus may be supported by this data. The summer and fall peak of Enterovirus infections in temperate climates coincide with the stage of embryologic development (> 8 weeks) which would allow an anterior horn cell lesion to lead to a deformity such as congenital club foot.

Primary Hodgkin's disease of bone : a report of two cases in adolescents and review of the literature

We reviewed 75 pin retrievals after in situ pinning of 35 children with slipped capital femoral epiphysis (SCFE). Four types of pins were used. Ten pins in 8 hips could not be removed because of pin breakage or stripping. Our failure rate was significantly related to pin type and size (p < 0.039). As compared with the expected values using the chi-square method of analysis, the non-cannulated large steel pins and cannulated steel pin groups had fewer failures (p < 0.001) as compared with the cannulated titanium and non-cannulated small steel pin groups. We now avoid using cannulated titanium or non-cannulated small pins in treatment of SCFE.

Arthrography in the evaluation of congenital dislocation of the hip.

The presentation of Hodgkins disease as a primary bony lesion is unusual. Seventeen such cases have been reported, only three of which appear in the orthopedic literature. The prognosis for survival in these patients is poor, possibly because of difficulty in arriving at the correct early diagnosis. In two adolescent girls (ages 12 and 17) with primary Hodgkins disease of bone, the diagnosis was made with uncertainty or delay. One of the patients died and the other has progressive disease, two and one-half years after the diagnosis was established. Earlier recognition may lead to better outcomes.