Epiphyseal separations in spastic cerebral palsy

Metaphyseal and diaphyseal fractures have been reported in children with severe spastic cerebral palsy, but there is no reference to epiphyseal separations in these patients. We report nine epiphyseal separations involving the distal femur and proximal humerus in four severely affected children with spastic quadriplegic cerebral palsy. The clinico-radiological features confirmed the cause to be scurvy. These epiphyseal separations have a good prognosis unlike the physeal injuries reported in children with myelodysplasia. Treatment with vitamin C and splintage resulted in rapid healing with excellent remodeling. Scurvy should be considered a potential cause for an epiphyseal slip in a child with severe spastic cerebral palsy. Routine dietary supplementation of vitamin C is recommended for these malnourished and nonambulant children.     

Complete distal humeral epiphyseal separation indicating a battered child syndrome: a case report

BACKGROUND: Complete distal humeral epiphysiolysis is a rare and uncommon injury and may result from severe trauma, e.g. birth injury or battered child syndrome. CASE REPORT: This is a case report of a 5-month-old female child with distal humeral epiphysiolysis. In the course of clinical and radiological examinations, a battered child syndrome could be diagnosed. Open reduction and temporary transfixation of the distal humeral physis were performed. In the middle term follow-up, 1.5-years after the injury, the function of the elbow was nearly normal but the ulnar condyle showed growth disturbance with cubitus varus of 10 degrees . CONCLUSION: Correct diagnosis of complete distal humeral epiphysiolysis may be difficult and misinterpretation of the injury as elbow dislocation should be avoided. This particular lesion is a strong indicator of child abuse. Treatment options and the necessity of operative procedures are discussed.     

Antti Alho: 1935-2000

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured.

The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course.

The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.     

Epiphyseal fractures

The distal humerus and distal tibia are the most common sites of epiphyseal fractures. Epiphyseal detachment was found to occur more often in the region of upper extremities. Treatment of children for epiphyseal fractures is inevitably accompanied by growth disorders. Articular and diaphyseal malpositions are controllable. Fractures in childhood and, consequently, epiphyseal fractures should be grouped by diaphyseal and articular fractures. Epiphyseal detachment should then be associated with diaphyseal fractures, and epiphyseal fractures should be grouped under articular fractures.     

Fracture patterns in Nottingham children

The incidence and pattern of fractures in children less than or equal to 12 years of age living in Nottingham, England, have been reviewed. The annual incidence rate is 16/1,000 children. Fractures are rare in those less than 18 months of age, and incidence increases with age. The most common cause of fracture was a fall in or around the home; the incidence rate of fractures after road traffic accidents was similar in all age groups. Fractures of the distal radius and ulna accounted for 35.8% of all fractures seen, with hand fractures the second largest group (14.7%). The most common fracture type was a green-stick fracture (51.6%), and 18.5% of fractures were epiphyseal injuries. Epiphyseal injuries in children less than 5 years of age, were uncommon whereas spiral/oblique fractures were more common. Rotational trauma is more likely to cause a spiral or oblique shaft fracture in a younger child and an epiphyseal fracture in an older child.     

T-condylar fracture of the distal humerus in a three-year-old child.

A three-year-old girl suffered a T-condylar fracture of the distal humerus. Open reduction and pinning were performed. Three years after injury, there was no functional disturbance or radiographic evidence of avascular necrosis or epiphyseal growth arrest.     

Remodelling after Distal Forearm Fractures in Children: I. The Effect of Residual Angulation on the Spatial Orientation of the Epiphyseal Plates

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured.

The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course.

The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.     

Remodelling after distal forearm fractures in children. I. The effect of residual angulation on the spatial orientation of the epiphyseal plates

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured. The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course. The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.     

The measurements and standardization of humerocondylar angle in children

BACKGROUND: Supracondylar fractures of the humerus in children are very common. However, the literature regarding measurements of normal anatomical relationships of the distal humerus in sagittal plane is sparse. METHOD: We reviewed the radiographs of normal elbow joints in 142 children treated in our hospital over 2 years. No history of previous trauma of distal humerus was found. The children were separated into 3 age groups (<5, 5-10, and 10-15 years old), and measurement of the humerocondylar angle (HCA) in sagittal plane was performed. RESULTS: The mean age of children in group 1 was 3 years 1 month; in group 2, 7 years 8 months; and in group 3, 12 years. There were 99 boys and 43 girls. The mean HCA was 41.6 degrees (range, 30-70 degrees). No statistically significant influence on HCA by age, sex, or side was found. We found a small number of extreme variants in HCA (down to 30 degrees and up to 70 degrees) in children without any history of previous trauma and having a normal range of elbow motion. CONCLUSIONS: We found that HCA is close to the well-accepted figure of 40 degrees. Interestingly, this value remains the same in all age groups. That means that the geometry of the distal humerus in sagittal plane is established very early during the growth and remains constant. Due to significant individual variations of HCA, it alone cannot be sufficient for final decisions in evaluation and treatment of supracondylar fractures.     

儿童侧位肱骺角的测量及其临床意义

目的 测量儿童侧位肱骺角的正常值,探讨其临床意义.方法 对2～13岁双肘无骨折及畸形的骨骺未闭合的志愿者儿童96人192个肘关节进行研究,其中每个年龄组8人,男、女各4人,共12个年龄组.按不同的年龄段分A(2～5岁)、B(6～9岁)、C(10～13岁)三个组,每组32人64个肘关节.所有儿童均摄标准侧位X线片,取肱骨干长轴与肱骨小头骺板线的夹角为侧位肱骺角.在受试者中随机选取每年龄组4人,男、女各2人,单侧共48个肘关节,分别摄肘关节标准正位X线片和球管与肱骨干长轴呈侧位肱骺角的改良投射正位X线片,比较两者所显示肱骨小头骺板线的清晰率.结果 正常侧位肱骺角平均47.84°±6.69°;不同性别及不同侧别肘关节侧位肱骺角比较,差异均无统计学意义;侧位肱骺角与年龄之间具有显著相关性.改良投射正位X线片肱骨小头骺板线显示的清晰率为100%,而传统垂直投射则为14.58%.结论 儿童健侧的侧位肱骺角可作为患侧的参考指标;球管与肱骨干长轴呈侧位肱骺角的改良投射正位X线片可清晰显示肱骨小头骺板线.     

Battered child syndrome simulating myositis

The battered child syndrome is not an unusual problem to be encountered in a clinical orthopedic practice. The manifestations in abused children may be varied and many, necessitating that orthopedists be familiar with the ways in which affected children present to reduce the unfortunate consequences that occur when abuse is not initially recognized. Our purpose in reporting the case of an abused child is to attract the attention of the orthopedic surgeon, who may be the initial physician to see a battered child, to an unusual presentation of this syndrome which simulated myositis. The association of myositis with battered child syndrome has not been previously encountered in the orthopedic literature.     

Neonatal separation of distal humeral epiphysis during Caesarean section: a case report

We report a rare injury of distal humeral epiphyseal separation in a newborn during a Caesarean section. The diagnosis was made using magnetic resonance imaging. Emergency Caesarean deliveries with considerable traction applied to extract the baby can be the risk factor of such an injury.     

Remodeling of angulated distal forearm fractures in children

Seventy children treated for distal forearm fractures were clinically and roentgenologically reexamined with a median follow-up time of 3.5 years (range, 1.5-6.0 years). The angulation of the fractures and of the epiphyseal plates was measured at the time of healing and at the follow-up examination. The patients were divided into three age groups of 0-5 years, 6-10 years, and 11-15 years at the time of fracture. In children younger than 11 years of age with residual angulation after distal forearm fractures, the change of orientation of the epiphyseal plate toward normal seemed to account for nearly all the actual correction at the site of fracture, up to 28 degrees. In children older than 11 years of age the capacity of correction of the orientation of the epiphyseal plate was preserved, but its influence upon the correction of distal forearm fractures decreased. This did not prevent correction of possible residual angulation at the fracture site--up to 18 degrees. This may be because, in this age group, appositional bone formation and resorption are the most important remodeling factors. The importance of the orientation of the epiphyseal plate is related to the distance between the fracture site and the epiphyseal plate and by the age of the patient.     

A rare combination injury of type III Monteggia fracture dislocation and ipsilateral epiphyseal fracture of distal radius in children. Is there a probability of missing the Monteggia component?

Combined type III Monteggia fracture dislocation and ipsilateral distal radial epiphyseal fracture is a very rare injury. Because of difficulty in performing the proper clinical evaluation of a child in an acute injury state, one of the components of this combined injury may be missed. We report a tenyear-old male child with this kind of injury where the Monteggia lesion was initially missed at the emergency department. Later we found the combined epiphyseal fracture of distal radius and Monteggia lesion in the ipsilateral side of the same limb which was managed by closed reduction and K-wire fixation. Bony union as well as wrist and elbow motion was complete 3 months after surgical intervention.     

Malalignment following injuries of the distal tibia and epiphysis of the fibula]

If the correct treatment is applied, growth disturbances following epiphyseal fractures of the distal tibia are rare. Even if the prognosis is good after the correct treatment of epiphyseal fractures of the distal tibia, the parents and child may have to be informed about growth disturbances. Most frequent is a varus deformity after asymmetric closure of the medial growth plate. If at least 2 years of growth can be expected, a callus resection according to Langenskj?ld is indicated. If this procedure fails, the ideal timing for a correction is the end of the growth. Imminent contractures can be an indication for early correction even if a recurrent deformity can be expected. An open-wedge osteotomy permits all three procedures to be carried out: callus resection, axis correction and leg-length correction. If an incongruence of the joint is present, the closed wedge technique using an external fixator is indicated; correction of the leg length can be postponed. Joint incongruence reacts well to axis alignment. The pre-arthrotic joint can remain free of symptoms for years. We never encountered epiphyseal fractures of the distal fibula, but we did see one case of deformity of the ankle joint as a result of closure of the proximal fibular growth plate.     

FRAX工具不同方法评价北京地区中老年骨质疏松骨折风险的回顾性研究

目的通过应用FRAX骨折风险评估系统联合桡骨远端1/3处骨密度、股骨颈骨密度,探讨FRAX联合不同部位骨密度后分析10年内发生全身骨折风险的概率。方法回顾性分析7488例分别接受DXA桡骨远端、股骨颈检查的体检人群,将桡骨远端骨密度、股骨颈骨密度分别输入FRAX骨折风险评估系统,分析比较两种方法计算出的未来10年骨折风险概率随年龄、性别的变化趋势,采用两独立样本t检验比较两者间的差异。结果 FRAX联合Hologic法股骨颈骨密度及T指数桡骨远端骨密度所得到的未来10年骨折风险概率均整体表现为随年龄的增长呈增加趋势,其中Hologic股骨颈骨密度法女性骨折风险概率随年龄变化最为明显,且持续增加;60岁以后Hologic股骨颈骨密度法男性及T指数桡骨远端骨密度法女性随年龄增加幅度较缓慢;60岁以后男性T指数桡骨远端骨密度法骨折风险概率随年龄增长轻度下降;两种方法骨折风险概率的增加幅度男性均小于女性,不论性别、年龄,骨折风险概率均值T指数桡骨远端骨密度法均小于Hologic股骨颈骨密度法。结论 FRAX分别联合桡骨远端骨密度及股骨颈骨密度评估未来10年骨折风险概率随年龄、性别变化趋势相仿,但采用桡骨远端骨密度的方法可能导致未来10年内骨折风险概率的低估,故不推荐采用,但测量桡骨远端骨密度的方法较股骨颈骨密度更加方便、快捷,故在日常工作中可作为对骨质疏松症的筛查手段之一。     

儿童移位肱骨髁间骨折的手术治疗

目的：回顾性评估切开复位内固定术治疗儿童移位肱骨髁间骨折的临床效果。方法：自2007年3月至2009年2月,我科应用切开复位及内固定治疗了8例移位的肱骨髁间骨折患儿,其中男7例、女1例,平均年龄8．2岁（6-12岁）。按照Riseborough—Radin分型系统,其中Ⅲ型6例、Ⅳ型2例;受伤机制包括：5例滑板车摔伤、1例摩托车摔伤、1例高处坠落伤、1例自行车摔伤。方法为采用Bryan—Morrey后内侧手术入路切开复位内固定术,应用克氏针钢丝或钉板系统内固定治疗。结果：术后无一例伤口感染及尺神经损伤,骨折均解剖对位。7例应用克氏针钢丝固定,1例行钉板系统固定。8例患儿均获得随访,平均随访时间2．2年（1．5-3年）。肘关节X线片显示无一例出现骨折的延迟愈合、不愈合,无一例肱骨远端骨骺坏死发生,2例合并肘关节异位骨化,肘关节屈伸活动度平均-10．6°131．3°,日常生活无明显影响。结论：移位的肱骨髁间骨折患儿,应用Bryan—Morrey后内侧手术入路切开复位内固定术可获得较好的治疗效果。     

Non-vascularized free toe phalanx transfers in congenital hand deformities--the Great Ormond Street experience

Many options of varying complexity are available for the management of congenital short digits resulting from aphalangia in symbrachydactyly and constriction ring syndrome. We have used non-vascularized free toe phalanx transfers for these children when a vascularized toe transfer has been contraindicated. We describe our technique and experience with 22 children who underwent a total of 64 transfers of the proximal (35) or middle (29) toe phalanges (average 3 per child). The mean age at initial surgery was 15 months, and the mean follow-up was 5 years. Duration of time until epiphyseal closure could not be determined accurately, but total digital elongation averaged 6mm. Complications of this technique include joint instability, premature epiphyseal closure and, in one patient, infection and graft loss. Donor site deformity was determined according to measured growth deficit and toe function. This technique is a simple option for digital elongation and, if performed in the appropriate age group in short fingered and monodactylous subtypes of symbrachydactyly, has the potential to allow growth and function with minimal donor site deficit.     

儿童移位肱骨髁间骨折的手术治疗

目的：回顾性评估切开复位内固定术治疗儿童移位肱骨髁间骨折的临床效果。方法：自2007年3月至2009年2月,我科应用切开复位及内固定治疗了8例移位的肱骨髁间骨折患儿,其中男7例、女1例,平均年龄8．2岁（6-12岁）。按照Riseborough—Radin分型系统,其中III型6例、IV型2例;受伤机制包括：5例滑板车摔伤、1例摩托车摔伤、I例高处坠落伤、1例自行车摔伤。方法为采用Bryan～Morrey后内侧手术入路切开复位内固定术,应用克氏针钢丝或钉板系统内固定治疗。结果：术后无一例伤口感染及尺神经损伤,骨折均解剖对位。7例应用克氏针钢丝固定,1例行钉板系统固定。8例患儿均获得随访,平均随访时间2．2年（1．5～3年）。肘关节X线片显示无一例出现骨折的延迟愈合、不愈合,无一例肱骨远端骨骺坏死发生,2例合并肘关节异位骨化,肘关节屈伸活动度平均-10．6°-131．3°,日常生活无明显影响。结论：移位的肱骨髁间骨折患儿,应用Bryan—Morrey后内侧手术入路切开复位内固定术可获得较好的治疗效果。     

Pediatric elbow measurement parameters: Evaluation of the six angles in inter- and intra-observer reliability

BackgroundSeveral radiographic measurements of the humerus can be used to evaluate the treatment outcome of supracondylar fractures in children. Because of the cartilaginous nature of the immature elbow, interpretation of radiographs around this area is sometimes challenging and can be unreliable. This study was conducted to determine the inter-observer and intra-observer reliability of the six commonly used radiographic measurements of the distal humerus.MethodThe Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle and lateral capitellohumeral angle of the humerus were measured by two observers on the radiographs of uninjured elbows from 58 children. The values between each measurement were compared and correlated using a Pearson coefficient of correlation to determine the inter-observer and intra-observer reliability.ResultsAll of the radiographic parameters showed excellent intra-observer reliability with the correlation coefficient values of the Baumann angle, humero-ulna angle, metaphyseal-diaphyseal angle, radial epiphyseal angle, shaft-condylar angle, lateral capitellohumeral angle as 0.945, 0.95, 0.909, 0.888, 0.961 and 0.975 (p < 0.001), respectively. The inter-observer reliability of the Baumann and humero-ulna angles were also found to be highly correlated at r = 0.843 (p < 0.001) and 0.878 (p < 0.001), respectively. The metaphyseal-diaphyseal angle had poor reliability with r = 0.136 (p = 0.291) while the radial epiphyseal angle, shaft-condylar angle, and lateral capitellohumeral angle demonstrated good reliability with r = 0.675 (p < 0.001), 0.747 (p < 0.001), and 0.686 (p < 0.001), respectively.ConclusionThe Baumann angle and humero-ulna angle measurements of distal humerus showed excellent inter- and intra-observer reliability. Both parameters represent repeatable and reliable methods for determining the outcome of supracondylar humeral fractures in pediatric population.