Abstracts
Dr. G. Poornanand, Dr. A. Kabeer, Crescent hospital, Alathur, Palakkad.
Aim:To study the functional outcome of 86 displaced extension type supracondylar fracture in children treated by percutaneous crossed kirschner wire fixation.
Materials and Methods:Out of 144 displaced extension type supracondylar fracture of humerus children, 97 treated by closed reduction and percutaneous kirschner wire fixation. 86 patients followed both clinically and radiologically. 40 were type II and 46 type III supracondylar fractures.65 boys and 21 girls. Average age 7.69 years ranges from 3 to 14 years. Mechanism of injury was falling on outstretched hand in 84; two road traffic accidents. 80 patients postermedial displacement and 6 with poster lateral displacement. 32 right and 54 left sided fractures. Three patients had associated ipsilateral limb injuries. Radial pulse was absent in 7 patients, which later reappeared after closed reduction. One case presented with signs of median nerve injury. Average hospital stay of 2.2 days ranging from 1 to 5 days.
Results:Out of 86 patients two had ulnar nerve and one median nerve palsy post operatively, all of which recovered after 2 to 3 months duration. One cubitus varus deformity 78 patients had full range of movements, 5 patients had 5-10 degrees and 3 had 15 to 30 degrees extension loss.Superficial pin tract infections in 7 patients, treated by oral antibiotics and one had deep infection resulted in extension loss of 30 degrees.
Conclusion:Treatment of displaced extension type supracondylar fracture with closed reduction and percutaneous crossed pinning is advantageous in children because it shortens hospitalization time; the elbow can be splinted in safe and comfortable position, and decreases the risk of compartment syndrome.
Keywords:Supracondylar fractures, Percutaneous crossed k-wire.
Focus on Femur or pelvis? Development Hip Dislocations in 2-3 year old
Dr. Ramani Narsimhan, New Delhi
Treatment of (non-teratological) DDH in 2-3 year olds has been recognized as a “grey area”. While open reduction is a constant factor, selection between femoral and a pelvic osteotomy is a dilemma, even after dynamic testing of hip stability with per-op arthrograms. In a preliminary observation in 7 such hips (6 patients) in this age group, it was observed that the anteversion of femoral neck averaged 65º in all. While there are proponents of primary pelvic osteotomy (Salters/Pembertons) in this scenario, we feel that satisfactory per-op stability can be achieved by a controlled derotation osteotomy of proximal femur primarily, with a simultaneous femoral shortening if necessary. We feel that pelvic osteotomy, which carries more morbidity, can be reserved as a back-up surgery for the future.
5-year follow-up of the modified Treatment of Radial Club Hand
Dr. Rujuta Mehta Presenting author: Dr. M. R. Thatte
Bai Jerbai Wadia Hospital for Children. BHIMS Mumbai 400 012
Long-term follow-up studies for treated radial hemimelia clearly point out 2 unresolved issues: growth and recurrence. Out method seeks to redress these as compared with conventional centralization.
We propose that resecting part of the ulna epiphyseal cartilage and the proximal carpal row to create a notch for stabilizing the wrist is un-indicated as it can adversely affect long-term growth. Most of the approaches described earlier involve excision of redundant ulnar skin. We use the bilobed flap described by Evans and a distractor cum fixator. The dorsal deficit and redundant skin are effectively rebalanced affording excellent 360 degrees exposure. The soft- tissue correction and tendon transfer are carried out as per Buck-Gramko.
The external devise distracts pre-op, holds the reduction per-operatively and maintains correction post-op.
28 cases and 36 hands have been treated by this method. Average follow up is 5 years. Good results have been obtained an all carpal bones have been retained.The ulnar head transverse hypertrophy and realignment has been recorded and compared to radial breadth as well as alignment in age-matched controls and found to be equivalent. Recurrence occurred in only 3 hands.
Conclusions:Early results clearly indicate that preservation of all carpal bones and ulnar epiphyses is important for growth and stability in a hypoplastic limb.
Key Words: Radial club hand, fixator, bilobed flap
Follow up study of cubitus varus correction by Vellore technique
Dr Thomas Palocaren, Vinu M George and Dr. Vrisha Madhuri
Department of Orthopaedics, Christian Medical College, Vellore, Tamil Nadu
Malunion of supracondylar fractures of the humerus resulting in cubitus varus is a common complication in our country. We report our experience of a new technique of corrective osteotomy for cubitus varus done over the last four years from our institution.
Ten children with malunited supracondylar fracture of the humerus underwent this new corrective osteotomy. They were aged 5-14 years. The preoperative varus ranged from 5 to 30 degrees. The preoperative assessment of correction was done by on table clinical assessment of the normal and the deformed limb using a long standardized goniometer. The new technique consisted of a low metaphyseal osteotomy done through a lateral approach and fixed with an oblique K wire and a lateral tension band.
The patients were assessed for range of movements, clinical correction of the deformity and the radiological outcome. The mean post op-carrying angle was 13 degrees. There was no under correction.
The children were followed up till complete range of motion was achieved. Two children were seen later for removal of wires.
We attribute the better correction achieved in our group due to the osteotomy being closer to the joint, since no distal screw had to be placed in the metaphysis and better fixation because of the tension bank effect.
Late Monteggia lesion – results of angulation distraction ulnar osteotomy in children
Vrisha Madhuri, P Sivaramakrishna
CMC Vellore
Late monteggia dislocation of radial head presents with cubitus valgus deformity. Many of these were previously diagnosed to have isolated radial head dislocations. However Mubarak and Linton et al have shown that bowing of 1 mm of the dorsal border is suggestive of old ulnar deformity. Historically it has been suggested that Monteggia lesions are asymptomatic and should be left alone in childhood. However we have found that they become symptomatic after a period of time.
A number of surgical procedures have been described. Hirayama has reported good results with osteotomy of ulna over correcting the angulation and restoration of ulnar length.
We have treated 10 patients with neglected Monteggia lesion with distraction angulation osteotomy. Patient’s ages ranged from 1 to 13 m years with a mean of 8.4 years. The lesions were treated 3 weeks to 11 years following initial trauma. There were 4 anterior 3 posterior 1 lateral and 1 type 4 Monteggia lesions. All patients except 2 were symptomatics and had ulnar bowing of greater that 2 mm. Distraction angulation osteotomy with a plate fixation was carried out in all patients. Open wedge osteotomy at the site of maximum angulation was carried out with over correction achieved by prebending the plate. Radial head was exposed and any obstruction to relocation was removed and head allowed relocating.
Post operative full flexion was achieved in all cases except one 3 had mld limitation of full extension Radial head relocated in all patients. 1 patient had a poor result with fibrous ankylosis. This child who had a 3 years old dislocation had a 2 cm shortening and the ulnar length was not adequately restored at the time of surgery.
We suggest that late Monteggia lesions do become sympyomatic and develop weakness and instability and pain and should be treated with relocation of radial head. Relocation is possible even 11 years after injury with satisfactory out come. Restoration of ulnar length is the key to a successful outcome.
Intraosseus Schwannoma of the fibula A case report
Dipak Maharjan, Thomas Palocaren, Vrisha Madhuri
Christian medical College Vellore
A 14 years old boy presented with a painful swelling of the right leg of three years duration. Clinically there was a hard, non-tender, swelling arising from the midshaft fibula. Radiology and MRI showed an expansile multilocular well-defined radioluscent lesion in the middle third of the fibula with expansion of the cortex in the medial aspect. There was no periosteal reaction or matrix calcification. Soft issue extension was present in the posterior aspect.
Blood investigation showed normal biochemistry.
Needle biopsy of the lesion was suggestive of schwannoma or fibrous dysplasia. En-bloc excision was done the histopathological excision shoed schwannoma.
On short term follow-up the child was able to walk full weight bearing after 6 weeks.
Schwanomma of the bone is a rare benign lesion of the bone with less than 200 reported cases in the literature. The majority of the cases are in the axial skeleton with very few in the peripheral skeleton and children. Only 2 previous lesions are reported in the fibula In our patient MRI and the needle biopsy were diagnostic. A wide excision was curative. The lesion is presented for its rarity.
Role Of The Peri-Acetabular Osteotomy (Pao) In The Management Of Acetabular Dysplasia In DDH
Dr. Alaric Aroojis
Holy Family Hospital & Children’s Orthopaedic Clinic, Mumbai, India.
Various pelvic osteotomies have been described to address the problem of residual acetabular dysplasia in DDH. These include redirectional osteotomies such as Salter osteotomy, acetabular-reshaping osteotomies such as Pemberton osteotomy or shelf procedures. Peri-acetabular osteotomies (PAO) as described by Albee, Dega and the San Diego group have been used extensively for spastic hip dislocation in cerebral palsy but have not been described for DDH. We report 10 cases in which the PAO has been utilized to address acetabular dysplasia during one-stage reconstruction of hip dislocation in children.
Patients& Methods:10 hips in 8 patients ages 1.5 years 4.5 years underwent primary surgical hip reconstruction for untreated DDH. 2 patients had bilateral hip dislocations and these hips were operated sequentially. All patients underwent a one-stage hip reconstruction, which included open reduction, femoral shortening, femoral varus-derotation osteotomy and capsulorraphy. The decision to perform acetabuloplasty was based on pre-op radiological measurements of acetabular indices such as Acetabular Index (AI), pre-op CT scan or MRI measurements in 6 patients, and on intra-op evaluation of femoral head coverage following open reduction and femoral osteotomy. The acetabulum was markedly dysplastic and anteverted in all patients. A peri-acetabular osteotomy was performed at the same sitting and the acetabulum was hinged open anteriorly and laterally by an incomplete osteotomy that rotated at the triradiate cartilage leaving the medial cortex intact entirely.
Results:At follow-up, all hips are well reduced and contained, and the acetabular indices have normalized from a mean pre-op value of 480 to a mean post-op value of 260. There is no evidence of proximal femoral or acetabular growth disturbances.
Discussion:Peri-acetabular ostetomy or acetabuloplasty can be used effectively to treat residual acetabular dyplasia in DDH and the results are excellent. The osteotomy is inherently stable and provides optimum femoral head coverage. The technical steps of performing this osteotomy will be discussed in detail.
Septic arthritis of hip in children: An elusive problem
Dr. Premal Naik, Associate Professor of Orthopaedics
Smt. S C L Hospital & NHL MMC, Ahmedabad, Gujarat, India
Septic arthritis of hip joint is very well known entity described by Tomsmith. Till date the problem remains elusive especially in neonates and infants with many cases presenting late with sequel.
Material and Methods:From February 2000 to October 2004 we examined 33 patients of septic arthritis of hip joint ranging from 7 days to 15 years. Twenty patients were < 3 months old. Four neonates had bilateral hip involvements and 2 had multiple joint involvements. All neonates were either having low birth weight or septicaemia or ventilatory support. Diagnosis was delayed or prolong medical treatment was given for many days in nearly all patients < 1 yr. All neonates were subjected to ultrasound to know the presence of pus and position of capital femoral epiphysis. C reactive protein elevation was found to be raised in nearly all patients.
Twenty patients underwent surgery to drain pus, 2 were operated late for the immediate complications and rest were late for surgery, of this 2 patients operated for complication one had old unsuccessfully treated septic dislocation and other had joint contracture and full thickness cartilage loss following medically treated septic hip. Organisms were identified in 9 patients of whom 2 were fungal infections.
All patients received spica after one week of surgery and abduction brace if there was preoperative subluxation. Antibiotics were given for 10-14 days depending of response to CRP and then oral for 3-4 weeks depending on clinical and serogical response. Postoperative X rays were done to rule out osteomyelitis.
Discussion:Only 2 patients presented in first 4 days of symptoms rest all presented late due to parentral neglect or failure of diagnosis or prolong medical treatment. Organisms could be identified in 9 cases due to starting of antibiotics before collection of the samples. All neonates had some risk factor and many had subluxation of hip or damage to the capital femoral epiphysis.
Conclusions:With advent of advanced imaging facilities and serological investigations septic arthritis of Hip still remains a difficult diagnosis. High clinical suspicion and knowledge of risk factors is important for early diagnosis. CRP and ultrasound were found to be most reliable tools for confirmation of the diagnosis. When in doubt aspiration should be considered without hesitation. After confirming the presence of pus in hip joint earliest surgical removal with joint lavage is mandatory to prevent long-term sequel.
Management of unicameral bone cysts- Is Bone Grafting really necessary?
Dr Sandeep Patwardhan, Dr Parag Sancheti
Unicameral bone cysts are common benign tumor like lesions in children affecting metaphyseo diaphyseal areas of long bones.
The diagnosis is essentially clinico-radiological and biopsy is rarely needed. Presentation varies from incidental finding on X ray to pathological fracture.
Management modalities range from observation only, intralesional steroids, curettage only to curettage and bone grafting.
Bone graft volume may be inadequate in children and maternal grafts, allografts, grafts substitutes have been used to fill the cyst.
Grafting donor site morbidity like pain, bleeding, infection have been well documented in literature, as have problems with allografts and substitutes.
We have studied a series of 12 cases of Unicameral Bone cysts and treated them with closed intra medullary rods to break open the cyst wall and restore intra medullary blood flow, which we feel is responsible for healing of cyst.
We have not done any form of primary grafting in any case. Curettage and rodding was done in 3 cases and intralesional steroid with rodding was done in 9 cases.
We followed cases for 18 months to document radiologic complete ossification of the cyst, which was taken as healing. We found complete resolution of the cyst in 11 cases within 18 months and recurrence in 1 case, which was grafted subsequently.
We find this method to be encouraging in healing of cyst without the morbidity of bone grafting. Longer evaluation till maturity needs to be done.
Unicameral Bone Cyst: treatment by autologous bone marrow injection
Dr A R Bhaskar
K.J Somaiya Medical College and Research Center, Mumbai, India.
Simple bone cyst commonly involves the upper arm and can pose treatment problems. Use of autologous bone marrow (ABM) to promote healing is a well-described treatment method.
Material and Methods:8 patients with simple bone cyst underwent ABM injection over a 2 years period. 6 lesions were present in the humerus and one in the tibia and femur each. The mean age of presentation was 9 years. There were 4 girls and 5 boys in the study. The operative procedure involved percutaneous aspiration of cyst fluid and injection of contrast medium to delineate the cyst wall. Bone marrow was then obtained from the iliac crest and injected into the cyst cavity. Serial x-rays were obtained to document healing. No reaction to the contrast was reported in any patient.
Results:Three lesions in the humerus had documented healing within one year. One healed only partially and needed further injection. One lesion in an older child progressed and a humeral nail was inserted to prevent stress fracture. The tibial lesion also failed to heal and needed intramedullary fixation to prevent a fracture. The femoral lesion had healed by one year. All patients with complete and partial healing reported improvement in symptoms. No infection was seen and no complications related to bone marrow aspiration was reported.
Conclusion:ABM injection is an attractive option for treating these cystic tumours as it precludes bone grafting and allows for healing of cyst. Although symptoms decrease, cyst healing may not be complete. Long term follow-up until skeletal maturity is required, as many cyst are known to regress.
Discussion:Unicameral bone cysts are benign lesions occurring mainly in the immature skeleton. Common sites of predilection are the proximal humerus, proximal femur, calcaneum, and other long bones. In the lower extremity these cyst may present as pathological fractures and occasionally healing of the cyst may be seen after the fracture consolidates. In the upper extremity, these cysts may cause aching pain, and easy fatigue especially with use of arm. Stress fractures may be seen following a fall. Treatment varies from being neglect to invasive therapies like ABM injection, curettage and bone grafting injection of sclerosing agents, and continuous drainage using cannulated screws. All have met with limited success. Our study, albeit small, has had some success with ABM injection. A larger study could be carried out by pooling the cases and determining the efficacy of various treatments in the Indian set up.
Role of aspiration in Transient Synovitis of Hip: Does it alter management?
Dr A R Bhaskar
K. J Somaiya Medical College and Research Center, Mumbai, India.
BSES MG Global Hospital, Mumbai.
Transient synovitis of hip is a benign self-limiting condition, which occurs in early childhood. Septic arthritis must be ruled out as it can have devastating sequalae. Joint aspiration is usually performed when the clinical picture suggests sepsis but other parameters are less convincing. A retrospective analysis of two groups is performed, one of which had joint aspiration. A protocol for management of transient synovitis is suggested.
Material and Methods:30 children admitted to the hospital with hip pain and limps were divided into two groups. Group A (16 children) patients underwent routine aspiration of their hip joints and Group B (4 children) patients were observed. There were 19 boys and 11 girls in the study. The mean age in Group A and Group B was 5.68 years and 7 years respectively. Clinical history regarding onset, duration and progress of pain was recorded for all patients. Vital parameters, range of motion of hip joint and severity of pain were also documented. All patients had plain x-rays, ultrasonography of hip joint, and routine blood tests (White Cell Count and Plasma Viscosity and CRP). The mean fluid amount was 9.28 ml in Group A and 8.12 ml in Group B. The patients in Group A underwent routine aspiration of hip joint in the Operation Room. The fluid was sent for Gram stain and culture. Analgesics were given to all patients and no antibiotics were prescribed routinely.
Results:Aspirate in one patient in Group A, who had high-grade fever revealed turbid fluid and he underwent arthrotomy. He also had a positive gram stain for staphylococcus aureus. All other patients had negative gram stain and negative culture. CRP was positive in 3 cases. Only one had proven infection. Plasma viscosity was positive in one case that had the infection. Analgesic requirements were similar in both groups and increased in Group A in the post-operative period. All patients recovered full range of motion and were able to weight bear at discharge. The duration of inpatient stay was 5.92 days in Group A and 4 days in Group B patients. Patients were followed up at 1, 6 and 12 weeks respectively. Only 25 patients (82%) were available for final follow, 5 were lost to follow up.
Conclusion:No obvious benefit of aspiration in clinically benign irritable hips. Aspiration increases analgesic requirements and probably increases in-patient stay. No correlation between amount of fluid and speed of recovery noted in both the groups.
Comparison of free fibula transfer and Ilizarov method for reconstruction of congenital pseudarthrosis of tibia
Dr Durga Nagaraju.K, Dr Dheenadhayalan, Dr Hari venkataramani, Dr Rajasekaran S, Dr Rajasabapathy S.
Ganga Hospital, Coimbatore.
Congenital pseudarthrosis of the tibia remains one of the most challenging conditions in Paediatric orthopaedics because of its diversing natural coarse. The history of congenital pseudarthrosis of tibia is characterized by repeatedly ineffective surgical interventions with the inevitable outcome of severe disability. Most procedures failed to account for the complexity of the problem. With the abandonment of old grafting techniques, in favour of Ilizarov method or vascularized free fibular grafts the final outcome has improved and made the prognosis for patients less cumbersome. Here we are presenting our experience in both methods in the management of this complex problem.
Materials and methods:Nine cases with congenital pseudarthrosis of tibia seen from 1991 to 2001 at our hospital were reviewed. The age of children ranges from one year to four and half years with a mean of 3.5 yrs. Seven patients are male and remaining is female. Right leg was affected in four children and in five children left leg was affected. Five patients had an associated Neurofibromatoses. All were classified under Boyd type II/III suggesting the least favorable prognosis.
Out of nine patients five patients were primarily treated with Ilizarov technique and four were treated by vascularized free fibular graft. Two patients in Ilizarov group were later developed non-union was successfully treated with vascularized free fibular graft.
In Ilizarov technique the dysplastic segment of the tibia was excised and Ilizarov frame was applied. Corticotomy was done at the same time and distraction was started on 8th postoperative day. All patients were serially reviewed radiologically and further decisions like realignment, ring removal, cast application and bone grafting or change to other modalities of treatment were taken. All patients were reviewed at regular intervals with an average follow up of 7.2 yrs.
In vascularized free fibular graft technique, the anterior tibial vessels were first dissected out and safe guarded. The extent of segment was confirmed on `c’ arm. The diseased segment was then excised and the gap was measured. The fibular graft was harvested from opposite side along with the peroneal vessels. Normal appearance of bone on both side of the dysplastic segment was used as the guide for excising the segments. We used intramedullary `K’ wire and external fixator for stabilizing the free fibular graft to the host tibia. `K’ wires were removed at three to six weeks. External fixator was removed after satisfactory radiological union and starting of hypertrophy of fibula. All patients were reviewed radiologically at regular intervals. Average follow up was 3.4 years.
Results:We achieved bone union in all patients of free fibula transfer group and three patients in Ilizarov group. In Ilizarov group average surgical procedures were six (includes frame realignment, bone grafting and change in to free fibular group) In free fibular graft group, only one surgical procedure was done in all patients, which excluding the removal of `K’ wire and external fixator.
| Ilizarov group | Free Fibula group | |
| 1. Bony union | 3/5 | 6/6 |
| 2. Failure | 2/5 | None |
| 3. Average no of surgeries | 6-8 | 1 |
| 4. Time to bony union | 22-26 wks | 10-14 wks |
| 5. Duration of fixator | 24-36 wks | 16-20 wks |
In Ilizarov group two patients required bone grafting procedure at docking site at average of 17 months (14 months and 20 months) due persistent nonunion and union achieved in both the cases at average of 24 weeks (27 weeks and 20 weeks). Two patients in this group changed to free fibular graft procedure due to unsatisfactory bone growth and recurrence of deformity after an average of 8.5 months (8 months and 9 months) duration of presence of fixator in the patient was varying from 8 months to 10 months (mean 9 months) Six patients we treated in free fibular graft procedure, which includes the two patients whom changed from Ilizarov group. Bone union from 10 weeks to 14 weeks (mean 12 weeks) in all patients.
Discussion:Congenital pseudarthrosis of the tibia remains one of the most controversial paediatric entities in terms of biopathogenesis, pathology, treatment and prognosis. The main histopathological change observed was growth of a highly cellular, fibromatosis like tissue, in the periosteum or within the endosteal marrow tissue. Congenital pseudarthrosis of the tibia now commonly treated by Ilizarov or micro vascular free fibular graft methods. In Ilizarov technique advantages of simultaneous correction of deformities and limb length discrepancy can be possible. Bone union achieved by this technique was to 75% to 90% 1,2. But this technique involves more number of surgeries and prolonged treatment course 5. Literatures show that best indications for Ilizarov’s technique in congenital pseudarthrosis were normotrophic and hypertrophic type of pseudarthrosis and after the age of five years 4,6. Micro vascular free fibular graft seems to give high successful results in the congenital pseudarthrosis of the tibia’s management mainly due to shorter union period and lesser number of surgeries 12. This procedure was very useful in patients who undergone multiple surgeries 10. Best results are achieved if this used as a primary procedure 11. Usually fibular graft is taken from contralateral leg, now; if the ipsilateral fibula is normal it also can be used as a graft 9. This procedure also has disadvantages like minimal donor site morbidity, valgus deformity of ankle joint, which can be prevented by tibio fibular synostosis at the time of taking the fibular graft 8. Limb length discrepancy and rotational deformities cannot be simultaneously correctable. These can be treated later or prior to graft procedure by limb lengthening procedures 7.
Conclusion:Ilizarov and free fibular graft techniques are giving good results compared to other surgical procedures. Micro vascular free fibular transfer is now our preferred technique for the management of congenital pseudarthrosis. It provides a reliable bone union compared with Ilizarov technique. Patient compliance is also better. Inability to simultaneously correct leg length and additional deformities of the foot are limitations.
Use of OF Isotope Bone Scanning in Paediatric Orthopaedic Practice
1) Sonali Pande, 2) Sanjeev Panpaliya, 3) Kaushik Chatterjee
Division of Paediatric Orthopaedics, Sushrut Hospital, Research Centre & PGI Orthopaedics, Nagpur, India,
Division of Nuclear Medicine, Rainbow Medinova Diagnostic Services, Nagpur, India
The lsotope Bone Scan is widely used in clinical practice and is the most commonly requested investigation in any nuclear medicine department because of its sensitivity for lesion detection. The indications for bone scan are continuously being extended. This survey was conducted to identify the indications for bone scan in patients under the age of 15 years and its ability to diagnose / confirm the suspected pathology.
Materials and methods:Records of patients under 15 years of age referred for bone scans at the above unit were analysed. The unit is the only center for bone scans in central India. The indications for bone scan; its ability to confirm the suspected pathology and to detect other unsuspected lesion was studied.
Results:Between October 2003 and November 2004, 35 children under the age of 15 years underwent isotope bone scan. The indications recognized were malignancy and metastases (20), Septic arthritis, osteomyelitis and low back pain (3 each), non-infective condition of hip (4), benign bone lesion and metabolic bone disease (2). The youngest patient was 30 days old. In most cases the bone scan confirmed the suspected diagnosis. In 4 cases it was negative for the suspected pathology while in 1 case it picked up abnormality that was not suspected clinically.
Discussion:The clinical indications for bone scan in patients with unexplained bone pain include malignancy, infection, traumatic and non-traumatic conditions and metabolic bone diseases. The number of scans in the children under 15 years of age made up only 4.3% (35/813) of the total scans performed in the above period. The indications noted in the present study are in agreement with the general recommendations.
Conclusion:Isotope Bone Scan is a useful tool in the armamentarium of a paediatric orthopaedic surgeon and paediatric practice in general. In India it is underutilized due to lack of availability and also lack of awareness of its use and potential amongst the clinicians.
Dysplasia Epiphysealis Hemimelica (A report of 3 cases and review of literature)
Ronald I Khanpur, Thomas Palocaren, Vrisha Madhuri
Christian Medical College, Vellore, South India.
Dysplasia epiphysealis hemimelica (DEH), or Trevor disease, is a rare developmental disorder affecting the epiphyses in young children. The first report of DEH in the literature was by French surgeon Albert Mouchet (1869-1963) and Belot in 1926,who described the condition as a tarsal bone disorder and used the term tarsomegalie. In 1950, Trevor reviewed 10 cases of DEH and used the term tarsoepiphyseal aclasis. In 1956, Fairbanks reported 14 cases and coined the term dysplasia epiphysealis hemimelica. Because of the predisposition to either the medial or lateral half of a single limb, he proposed the name “dysplasia epiphysealis hemimelica.
In 1999 less than 160 numbers of cases were reported in the world. Dyplasia Epiphysealis Hemimemelica occurs in the lower limb with epiphysis osteochondroma arising from one side of the epiphysis. The occurrences of multiple lesions in the limbs are reported. We report 3 children who have multiple lesions on the same limb.
Case 1: This 7 years old male was first seen in the OPD at the age of 3 months with complaints of inability to use the right lower limb of 2 weeks duration and deformity of the right ankle of 3 days duration. He was found to have a bony hard non-tender swelling of the right ankle restricting ankle movements. On examination of the knee, ROM was 0-130 degrees. He gradually developed a fixed flexion deformity at the knee of 45 degrees. After initial diagnosis of DEH of tibia, talus and fibula, further lesions were discovered in the lower femur, upper tibia, femoral head and Navicular on the same side. The surgical intervention at the knee and ankle consisted of excision of the osteochondroma initially which failed to check progression of the disease and eventually resulted in a stiff knee and ankle joints consisting of fixed flexion deformity of the knee at 60 degrees along with calcaneus deformity at the ankle. Arthrodesis was done in a functional position at a later stage. The femoral head steochondroma caused mild flexion abduction deformity and limitation of movementsat the hip. No intervention was carried at this site.
Case 2: 6 years old male, with difficulty in squatting and toe walking from the age of 2 ½ years presented to the Orthopaedic outpatient. There was a equines deformity with stiffness of the right ankle. On examination there was 70 degrees equines deformity with jog of movement with increased bimalleolar distance and bony thickening in the navicular. Radiological survey revealed a lesion in the lateral part of the right tibia, talus, femoral condyle. No surgical intervention has been carried out.
Case 3: 6 years old male, born of non-consanguineous parents by normal vaginal delivery at term in a hospital after a protected and supervised antenatal period. Postnatal period was uneventful, immunization was as per schedule. He presented with a symptomatic swelling of the medial aspect of the left foot as a single swelling in the medial aspect of the foot, arising from the bone, which is hard. Skin over swelling is normal, non-tender. Movement of the ankle is normal and no distal neurovascular deficits. He was found to have a lesion in the medial aspect Navicular and head of talus. The growth was excised. These 3 cases of Dyplasia Epiphysealis Hemimemelica are reported for their rarity. In view of the considerable stiffness that results from excision of osteochondroma, judgement has to be exercised when it comes to extent and timing of surgery.
Literature Review: DEH is thought to be a variant of osteochondroma arising within a joint. It is a rare congenital bone developmental disorder characterized by asymmetrical limb deformity due to localized overgrowth of cartilage, usually involving the lower extremities, the upper ones being rarely affected. The cartilaginous growths histologically resemble osteochondroma. The condition most often occurs in the ankle region and it is always confined to a single limb. Male-to-female ratio is 3 : 1. The aetiology is unknown. The genetic basis, if any, is uncertain DEH is a benign disorder, and no cases of malignant transformation have been reported. The natural history of DEH is a continuous increase in size of the lesion until skeletal maturity. Therefore, the long-term prognosis for untreated lesions involving the weight bearing surface of the joint is often a progression toward pain and arthrosis.
Pelvic Support Osteotomy (Pso) By Ilizarov Technique In Children.
Dr. Ruta M. Kulkarni, Co-Authors Dr. G. S. Kulkarni.
Introduction:A wide spectrum of hip disorders lead to severe hip pain and instability with limb length discrepancy and axial malalignment.In circumstances,where femoral head salvage procedure and total hip replacement are beyond limits, PSO by ilizarov technique provides solution to all these problems simultaneously in one surgery.
Material:This surgery was performed in 19 patients. 12 boys and 7 girls Age range- 7 to 18 yrs. Average limb length discrepancy was 3.5 cm.
| No. Of Cases | |
| 1. Old infantile septic arthritis of hip | 5 |
| 2. Tuberculosis of Hip | 5 |
| 3. Unreduced old traumatic hip dislocation | 2 |
| 4. Old unreduced DDH | 4 |
| 5. Idiopathic chondrolysis | 2 |
| 6. Old healed Perthes disease | 1 |
All patients were evaluated on basis of Modified Harris Hip score.
Method:After excision of femoral head, (In unreduced dislocations head was retained) Proximally subtrochanteric valgus and extension Osteotomy was done which supports against the pelvis. Distally corticotomy was done at planned level, which permits lengthening and correction of valgus and balances the mechanical axis of limb. Stabilization of the Osteotomy is done with ilizarov external fixator.
Results:Follow up ranges from 2 to 5 years. Mean Harris Hip score improved from 43 to 78. Excellent to good results in 14 cases, fair in 4, 1 is Poor. All patients had significant relief of pain and lurch decreased by almost 70 percent.
Conclusion:PSO by ilizarov technique provides relatively stable hip with correction of LLD and Axial malalignments.
Summary:In children, unstable and unsalvageable hips can be reconstructed by PSO. It provides relatively stable hip with correction of LLD and axial malalignment.
The Choice Of Intramedullary Devices For The Femur And The Tibia In Osteogenesis Imperfecta
Renjit AV, Gleeson Rebello, Chandra Kant B, Benjamin Joseph
Paediatric Orthopaedic Service, Kasturba Medical College, Manipal
This study was undertaken to compare the results of three different fixation techniques in the femur and two techniques in the tibia with the hope that the results would enable the surgeon to make a rational choice of the intramedullary fixation device for osteogenesis imperfecta.
Materials and Methods:The results of intramedullary rodding of fifty femoral and twenty-five tibial segments were analyzed retrospectively. The techniques of femoral rodding included single Rush rodding, dual Rush rodding and Sheffield telescoping rodding. Single Rush rods or Sheffield rods were used in the tibia. The frequencies of fractures following rodding and implant-related complications and the interval between initial rodding and rod revision were analyzed. The longevity of the rods was evaluated by survival analysis.
Results:In the femur, dual Rush rods and Sheffield rods were equally effective and both were superior to a single Rush rod with reference to each of the outcome variables. The technique of dual Rush rodding was more demanding than telescoping rodding. In the tibia, a single Rush rod was as effective as a Sheffield telescoping rod.
Conclusion:Based on our results, a single Rush rod would be the preferred implant in the tibia while in the femur, dual Rush rods or a Sheffield telescoping rod may be preferred.
Primary Management Of Idipathic Clubfoot By Ponseti Technique
Dr. Ruta M. Kulkarni. Co-Authors: Dr. G. S. Kulkarni.
Post Graduation Institute of Swasthiyog Pratisthan, Extension area, MIRAJ – 416410.
Ponseti technique consists of gradual gentle manipulation and serial plaster casts and minimal surgery when the child presents early. According to Ponseti clubfoot is subtalar joint at its extreme range of motion. Biomechanics of subtalar joint is used to correct it.
Material:We have treated 68 clubfeet in 48 patients. Bilateral deformity seen in 27 patients and unilateral deformity in 14 patients. 30 boys and 18 girls were affected. Average age of presentation was 3 months (from five days of age till one year two months of age)
Method:Cavus, adductus, varus, equines (CAVE), which are the components of clubfoot deformity are all corrected simultaneously, except equines which is corrected last. Elevation of first metatarsal and supination of forefoot corrects cavus. Simultaneously the forefoot is gently and gradually supinated and abducted under the talus while applying counter pressure against lateral aspect of head of talus. Forefoot pushes the calcaneus into abduction. When calcaneus abducts it also everts and dorsiflexes there by correcting all the deformities simultaneously. This is because of severe obliquity of axis of subtalar joint. Equinus is corrected last by progressively dorsiflexing the foot after achieving 60 to 70 degrees of abduction. However, to facilitate more rapid correction, a percutaneous tendoachilles tenotomy is done in 97 to 99% of patients. Correction is maintained by toe to groin plaster cast with knee in 90-degree flexion. Usually 5 to 6 serial casts correct the deformity. After that foot is splinted continuously for three months and during night for three to four years to prevent relapse.
Results: Assessed with Pirani’s score.
Average pirani score precast was 5.5 and by the end of treatment was 0.5.
Full correction by ponseti technique achieved in 46 patients
Percutaneous TA tenotomy performed in 97% of patients.
Ponseti technique is based on normal biomechanics of subtalar joint and that is why it is very effective for correction of clubfeet.
Recent Advances In Pediatric Orthotics
Presented by:- Aarti Deshpande (Branch Manager)
Endolite P&O Centre Mumbai
Human locomotion is also affected by changes in development such as physiological processes affecting neuromotor control, growing and maturing body segments, variable rotation of limbs and joints about an axis of motion, and changes in posture. The attainment of locomotor skills is a complicated process dependent upon an intact neuromotor and musculoskeletal system. Persistence of primitive reflexes will interfere with volitional changes in posture and tone necessary for locomotion. Postural responses, on the other hand, are critical for maintaining balance in the upright position first in sitting, then in standing and achieving locomotion skills of walking and running. There is much different type of Orthosis available for children’s with disability. The conventional orthosis presently available have limited range of movement at the hip, knee and ankle and the child requires more energy for ambulation. We shall discuss a few advance orthosis their SWASH (Standing Walking And Sitting Hip Orthosis) is a hip stabilization and sitting orthosis which can offer significant benefits for the non-ambulatory child with severe involvement and can work for neuromuscular disorders other than just CP.
Toe OFF is a new generation AFO. The design absorbs energy at hell strike and returns it at toe-off, restoring a more normal and dynamic gait. The benefits are the ability to walk further… with greater comfort… and with less impairment of gait pattern, if not fully normal. Tamarack Variable Assist Ankle joints provide continuous variable adjustment of ankle. This opens new opportunities for more precisely choosing and maintaining the optimum orthotic solution as patients progress through the changes typically encountered during pediatric development, post CVA recovery, and other diagnoses where the patient’s condition and needs change with time. Lerman Nonlnvasive Pediatric Halo System is a pin less halo system for children with the goal of providing cervical spine immobilization and control similar to a standard halo, but in a less invasive manner. There are others options of modern orthoses; their prescription and their application to patients will be discussed.
Can Spondylo – Epiphyseal Dysplasia Tarda Be Diagnosed Before Symptoms Are Evident?
Vineet Agarwal, Neeraj Goyal, SS Agarwal, Benjamin Joseph
Paediatric Orthopaedic Service
Kasturba Medical College, Manipal
To see if screening tests to diagnose reduction in hip movement can be used to diagnose asymptomatic spondylo-epiphyseal dysplasia tarda.
Background:Every symptomatic patient with spondylo-epiphyseal dysplasia tarda type Handigodu has significant reduction in hip movements and the inability to squat and sit cross- legged are early symptoms in these patients. However, considerable reduction in hip movement may have to develop before they become conscious of the difficulty in adopting these postures.
Materials and Methods:1026 children from schools in villages where Handigodu syndrome is prevalent were screened for limitation of hip movement. Three tests were applied to detect limitation of hip movement:
- to detect limitation of abduction,
- to detect limitation of internal rotation and
- to detect limitation of abduction, flexion and external rotation.
The first two tests have been validated and been found to be very sensitive in detecting limitation of movements in a previous study. If any of these tests were positive, plain antero-posterior and frog-lateral radiographs of the pelvis were taken to see if changes of skeletal dysplasia were evident.
Results:Of 1026 children screened, 5 had limitation of hip abduction, 65 had limitation of hip internal rotation and 5 had limitation of abduction / flexion / external rotation. Only 9 of these children have had x-rays done so far and none of these 9, showed clear radiographic evidence of a skeletal dysplasia. The x-rays of the remaining children with positive tests are being arranged. Irrespective of the radiological findings on the current x-rays, the children are being followed up to see if radiological features of skeletal dysplasia appear in due course.
Conclusions:The screening tests detected limitation of hip movements in children from a susceptible population. In view of the high incidence of the dysplasia in this population early detection of hip involvement may be useful to determine if any intervention can delay the onset of osteoarthrosis.
Does Developmental Dysplasia Of The Hip Cause Delay In Walking?
Dr. Surendra U. Kamath
Department of Orthopaedics, K. M. C. Hospital, Attavar, MANGALORE.
The purpose of this study was to review the age of walking in a series of children with late presenting development dysplasia of the hip and to compare this with a control group of normal children.
Design:Restrospective review of Children presented with late diagnosed developmental dysplasia of the hip and comparing their age of walking with an age and sex matched group of 100 normal children.
Setting:Royal hospital for Sick Children, Yorkhill, Glasgow.
Patients:We reviewed 109 patients who presented with late diagnosed developmental dysplasia of the hip between 1993 and 1997. After exclusion of bottom shufflers, those with a family history of late walking, those with mental retardation or development delay and those who had not started walking at the time of diagnosis, 86 children were available for the study. The age of walking in this group was compared with an age and sex matched group of 100 normal Children chosen from those attending the fracture clinics, in which the same exclusion criteria were observed.
Results:The median age of independent walking in the study group was 13.8 months, whereas in the control group it was 12.5 months. The median time to independent walking was about one month less in the normal control. This was clinically insignificant as they all walked before the age of 18 months.
Conclusion:We conclude that the children with development dysplasia of the hip do not present as late walkers.
Keywords:Development dysplasia of the hip Delayed diagnosis – Walking age – Late walkers
Treatment Of Congenital Muscular Torticollis By Ferkel’s Bipolar Release – A Study Of 18 Cases.
Patwardhan Sandeep Sancheti Parag
Affiliation: Sancheti Institute for Orthopaedics & Rehabilitation, Pune, INDIA
Congenital Muscular Torticollis, Bipolar Release, Deformity Correction, Complications
Introduction:Congenital Muscular Torticollis is a common occurrence with reported incidence of 5 per 1000 live births. Improvement in appearance can be achieved before 2 yrs. of age by conservative methods like Stretching, Strapping and use of Orthoses. However, surgery becomes mandatory after 2 yrs. of age. Multiple methods of treatment have been tried with varying results including tenotomy, Unipolar Sternocleidomastoid release, and bipolar release with Ferkel et al modification.
Materials and Methods:We have studied 18 cases presented to us between 2-30 yrs. of age and evaluated our results over 2 yrs. The aim of the procedure was to achieve deformity correction, improvement in appearance and neck movement. We have used Ferkel’s technique of Bipolar Stemocleidomastoid release in all patients with severe muscular Torticollis with more than 30 degrees of restriction of restriction of movement in lateral plane and facial asymmetry.
Results:
Clinically we have evaluated the patients as Excellent; Good & Fair based using the modified Ling’s criteria
1. Complete correction of the deformity.
2. Improvement in Neck movements.
We had an average follow up of 2 yrs., at which we achieved 70% excellent results, 20% Good results and 10% Fair results. There was 1 complication of facial nerve palsy, which has recovered. Persistence of facial asymmetry at 2 yr follow up was not considered as a complication, which occurred in 6 patients.
Bipolar Sternocleidomastoid release is an excellent procedure for treatment of congenital muscular torticollis after age of 2 yrs with uniformly good deformity correction and improvement in movements. Surgery after maturity is generally thought to be having more complications, but we did not encounter any problems. Facial asymmetry may persist and needs longer evaluation.
Postero-medial release in clubfoot A retrospective study of causes of failures
Dr. Amish V. Sanghvi M. S (ortho.), Assistant orthopedic surgeon, G. T. Sheth
Orthopedic Hospital, Rajkot, Gujarat.
Postero-medial release is the most common surgical procedure used to correct the deformity of clubfoot. It has been seen that despite a good correction immediately following the surgery, the long-term results are not satisfactory.
Materials and methods:A retrospective study was carried out in a total number 52 clubfeet in 36 patients treated by postero-medial release. Inclusion criteria: Patients undergoing postero-medial release alone. Exclusion criteria:patients treated by surgeries other than or in addition to postero-medial release in the same stage. This is to avoid effect of other surgeries on result as the study aimed at determining the causes of failures of postero-medial release as an isolated procedure. The mean duration after surgery was 5.1 ± 1.2 years, mean age at operation was 1.1 ± 0.5 years and mean age of patient at final follow up was 6.9 ± 2.1 years. The results were plotted according to the criteria of Atar, Lehman, Grant and Strong water and were compared with different variables.
Results:The results were successful in 69.2% & unfavorable in 30.8% patients. A significantly high failures (80%) were found when postero-medial release was done after 3 years of age of child as a sole procedure as compared to 25.5% failures if age was less than 3 years (p(<)0.05). The patient compliance to follow bracing protocol showed significantly high failure rate of 52.4% in non-compliant patients versus 16.1% in compliant patients (p(<)0.05). A significantly high failure were also seen when bracing was not continued beyond 3 years of age (p(<)0.05). Neurological clubfoot had a significantly high failure rate (80%) compared to idiopathic clubfoot (25.5%) (p(<)0.05)A significantly high failures were also noted when infection and skin necrosis lead to skin grafting or flap coverage as compared to those healed with dressings alone (p(<)0.05). No significant effect of sex, laterality and birth order was noted on the outcome of postero-medial release.
Discussion & Conclusion:Postero-medial release achieves best results in patients of less than 3 years of age, with compliance at least up to 3-4 years for bracing and idiopathic clubfoot. Infection in dub foot does not increase the failure rate unless it is severe enough to require plastic coverage. Any deviations from the above significantly increase poor outcomes and hence are the causes of failures of poster medial release.
Natural History and Outcome Analysis in Varied Presentations of Obstetric Palsy
Dr. Rujuta Mehta
Dr. Mukund Thatte
Dr. Rustom Ginwala
Bai Jerbai Wadia Children’s Hospital, Bombay Hospital Institute Of Medical Sciences
Treatment of Obstetrical palsy has significantly changed over the last 2 decades. We present our data of 119 cases treated over the past 6 years. Only 9 cases recovered fully without any surgical intervention, establishing the role of surgical intervention beyond doubt. The ratio of early v/s late presentations has reversed to 60:40 unlike what was believed earlier. Surgical intervention was needed in 27% cases primarily. Explorations between 3-7 mths revealed neuroma-in-continuity in more than 50% cases where conducting neuromas predominated. Our outcomes show that favorable results can be achieved by neurolysis (16% of the explorations). Untreated upper plexus lesions as well as neurolysed total plexus lesions have shown equivalent degree of recovery. Secondary shoulder muscle transfers were necessary in 65% patients and other tendon transfers were required in another 20% patients Prehensile hand function remained poor in global lesions presenting late. Detailed analysis and various co-relations with site, nature of lesion and timing of surgery are discussed and the outcome of intra-operative findings is presented. The importance of surgical decision making with the use of intra-op stimulation is discussed.
Acknowledgement:The authors thank OSIR (Council for Scientific and Industrial Research New Delhi) for financing the post of {Ist Author}.
Key Words:Obstetrical Palsy, neurolysis
“True Popliteal Angle” And Treatment Of Crouch Gait In Spastic Cerebral Palsy
Dr Alanc Arrojis
Holy Family Hospital & Children’s Orthopaedic Clinic, Mumbai. India.
The popliteal angle, which is indicative of hamstring contracture, is frequently mis-reported in patients with spastic cerebral palsy. The true degree of hamstnng contracture is often masked by the anterior pelvic tilt that is commonly seen in patients with crouch gait. Consequently, injudicious lengthening of the hamstnngs is often performed with further weakening of hip extension power. The purpose of this study was to measure the apparent and true popliteal angles in patients with spastic diplegia and quadnplegia and to elucidate the principles of management of crouch gait.
Patients and Methods:The study was conducted in two parts. Group 1. 32 patients (ages 4.2 16 years) with diplegic or quadriplegic cerebral palsy were prospectively assessed by clinical measurements and observational gait analysis using digital video and freeze-frame playback. Patients were classified by GMFCS levels and using the Rodda & Graham classification of spastic diplegia. Clinical parameters studied included apparent popliteal angle, `true’ popliteal angle as described by Gage, SLR and measurement of knee and hip FFD. The difference between the apparent and true popliteal angles was designated as the hamstnrigs shift. Group II : 10 patients with crouch gait were evaluated using the same measurements as the previous group All ten patients subsequently underwent single event multilevel soft tissue procedures according to principles enunciated by Gage. Outcomes were assessed by clinical measurements and observational gait analysis.
Results:In Group I patient’s significant differences were recorded between the apparent and true popliteal angles, indicating presence of occult antenor pelvic tilt. The difference was most marked in order children with established crouch gait. In Group II patients, surgical principles included correction of pre existing lever arm disease, over-the-brim iliopsoas lengthening, judicious hamstrings lengthenings, rectus femoris transfers and post-op orthosis with FROs.
Discussion:Awareness of `True’ popliteal angle precludes injudicious hamstrings lengthening in patients with crouch gait and optimizes the result of single-even multilevel surgery in children with spastic diplegia and quadriplegia.
The Fate Of The Hip In Spondylo-Epiphyseal Dysplasia Tarda – Subtype Mseleni-Handigodu
Vineet Agarwal, Neeraj Goyal, SS Agarawal, Benjamin Joseph
Paediatric Orthopaedic Service, Kasturba Medical College, Manipal
To study the evolution and natural history of radiological changes in the hip in spondyloepiphyseal dysplasia tarda type Mselini-Handigodu
Materials and methods:Radiographs of the pelvis of 140 patients with Handigodu syndrome and 92 normal controls from the same ethnic population were analyzed. Dimensional alterations in the pelvis, acetabulum and proximal femur were noted. Structural alterations in the femoral head and neck arid the acetabulum and articular changes were documented. Each of these variables was analyzed according to the age of the patients.
Results:The femoral head was larger and the acetabulum was larger, wider and shallower than normal. The acetabular inclination was normal. Subluxation of the hip was not seen but femoral head coverage was poorer than normal. The width of the pelvis was normal [but the height of the pelvis was reduced. The femoral head and acetabulum were often misshapen. Most of these changes were evident by the time the patient reached 20 years of age. Subsequently, progressive degenerative changes were noted. About a quarter of the patients developed protrusio acetabulae. By the third decade of life 50% of the patients had osteophytes, 70% had demonstrable reduction of the joint space, 80% had incongruency of the articular surfaces and 100% had subchondral sclerosis.
Conclusions:The structure of hips in spondylo-epiphyseal dysplasia tarda gets altered during growth and virtually all of them run the risk of developing features of osteoarthritis by the third decade of life.
Limitations Of The Herring’s Lateral Pillar Classification In Perthes’ Disease
Renjit AV, Shamsi AH, Benjamin Joseph
Paediatric Orthopaedic Service, Kasturba Medical College, Manipal
Herring, in 1992, classified Perthes’ disease based on the degree of epiphyseal collapse. This classification is now widely used for planning treatment and for predicting prognosis in Perthes’ disease. We undertook this study:
- to determine the reproducibility of Herring’s lateral pillar classification,
- to determine if the Herring’s grading altered with evolution of the disease and
- to determine the prognostic significance of Herring’s classification.
Anteroposterior and frog-lateral radiographs of 100 children with unilateral Perthes’ disease in the stage of fragmentation were assessed independently by two observers on two different occasions. The Herring’s grading of the affected hip was assessed by direct visual estimation and also by measuring the height of the lateral pillar at a defined point on the epiphysis. 87 patients with more than 2 sequential radiographs in the stage of fragmentation were identified. The Herring’s grade was noted in each film. Other radiological changes in the proximal femur and acetabulum were noted on each radiograph. The frequency of hips that showed a change in Herring’s grading between the first and last radiograph in the stage of fragmentation was noted. 60 of these 87 patients had radiographs till complete healing. The final outcome of the 60 hips was assessed using Mose’s and Stulberg’s criteria. The correlation between the final outcome and Herring’s grading was computed.
Results and Discussion:Actual measurement of the height of the lateral pillar for estimating Herring’s grade was more reproducible than visual estimation (kappa = 0.9 vs 0.65 for intra-observer and 0.66 & 0.51 for inter-observer). In 29% of patients, a change in the Herring’s grading occurred with evolution of the disease, implying that the initial Herring’s grade could be misleading as further collapse of he lateral pillar can occur. The short-term outcome did not correlate to the extent of epiphyseal collapse.
Conclusion:The Herring’s classification of Perthes’ disease has the following limitations,
- The visual method of assessment as proposed by Herring is not highly reproducible.
- The Herring’s grade does change with disease progression in a significant number of patients
- The Herring’s grade is not a reliable predictor of final outcome in Perthes’ disease in our patient population.
These limitations undermine the usefulness of this classification.
Monteggia Fracture Dislocation in a Neonate Resulting from Birth Trauma- A
PN Gupta, Rishi Kaushal, Sudhir Garg, Ravi Gupta, Raj Bahadur
Department of Orthopedics, Govt. Medical College & Hospital, Chandigarh, India.
Birth injuries in an uncommon location may be missed initially and result in a significant morbidity. We came across a case of a Monteggia fracture dislocation resulting from birth trauma, previously riot reported in the literature.
Case report:A 7 day old, 2nd born vaginally delivered infant presented to the Orthopaedic department of the author’s institute with complaint of decreased movements of (R) elbow. Clinical examination revealed lateral displacement of radial head & Radiographs revealed a Bado’s type 3 Monteggia fracture dislocation. A closed reduction was attempted but failed. Subsequently an open reduction & fixation of ulnar fracture with K-wire was done. The radial head got spontaneously reduced. Union of fracture was achieved at 6 weeks when POP slab given after surgery was discarded and K-wires removed. Follow-up at 10 months show no restriction of elbow movements.
Discussion:The clavicle is reported to be the commonest bone to fracture as a result of birth trauma though fractures of femoral and humeral shafts are also common. Birth injury to bones beyond the elbow and the knee are exceedingly rare. Literature reports that about half the patients with birth fractures are diagnosed after a delay period of about 3 to 7 days and in these cases one must to allowed child abuse. Failure of closed reduction in patient of Monteggia fracture dislocation is known and may be due to interposition of orbicular ligament or osteochondral fragements in the joint; but in our patient, failure of closed reduction can be attributed to delayed presentation and attempted union, making the fractures less mobile, due to rapid rate of union in children.
Conclusion:A high index of suspicion and routine screening of all newborns, especially hush rush ones should be done to detect and treat birth fracture at onset. A delay to even few days may prove to be detrimental for this usually non-operatively managed fracture, which will then require operative intervention with its possible attendant morbidities.
The Choice Of Intramedullary Devices For The Femur And The Tibia In Osteogenesis Imperfecta
Renjit AV, Gleeson Rebello, Chandra Kant B, Benjamin Joseph
Paediatric Orthopaedic Service, Kastuba Medical College, Manipal
This study was undertaken to compare the results of three different fixation techniques in the femur and two techniques in the tibia with the hope that the results would enable the surgeon to make a rational choice of the intramedullary fixation device for osteogenesis imperfecta.
Materials and methods:The results of intramedullary rodding of fifty femoral and twenty-five tibial segments were analyzed retrospectively. The techniques of femoral rodding included single Rush rodding, dual Rush rodding and Sheffield telescoping rodding. Single Rush rods or Sheffield rods were used in the tibia. The frequencies of fractures following rodding and implant-related complications and the interval between initial rodding and rod revision were analyzed. The longevity of the rods was evaluated by survival analysis.
Results:In the femur, dual Rush rods and Sheffield rods were equally effective and both were superior to a single Rush rod with reference to each of the outcome variables. The technique of dual Rush rodding was more demanding than telescoping rodding. In the tibia, a single Rush rod was as effective as a Sheffield telescoping rod.
Conclusion:Based on our results, a single Rush rod would be the preferred implant in the tibia while in the femur, dual Rush rods or a Sheffield telescoping rod may be preferred.
Congential upper limb Registries
Dr. Kanwarjot Singh, Co-Authors: Dr. Jaganath Kamath Asso. Professor. KMC.
KMC, Mangalore City, Mangalore, Karnataka, INDIA.
Congenital upper limb anomalies are Relatively common 1.6 out 1000 children according to flat series and they’re association with syndromes and others systemic anomalies is known. In our series classification used by swanson et al recommended by International federation of Surgical Society of the hand and American Society of hand has been used.
Material and Methods:Aims & Objectives To find out Prevalence of congenital upper limb Registries
- Relative frequency of Different congenital upper limb anomalies
- Association with Syndromes
- Male, Female, Laterality, Mother’s age, association with caesserian section.
This study was conducted among total population of 26,000
Results:Prevalence found out was 1.84 per 1,000 population and most common type of registry found Out was Failure of Differentation of parts 43.75% - syndactyly, clinodactyly, camptodactyly. Second most common anomaly found out was type III – Duplication-25%. Among failure of formation of Parts – Radial Club Hand was Found to be most common and mostly associated with syndromes 50% of the total Regestries found were associated with Syndromes.
Discussion:Our series goes in agreement with the other studies done by flat, yamaguchi, ogawa, Leusterberg, Henk Giele et al etc
Conclusions:- Classification and Prevalence calculation is important for planning. Research and treatment of various anomalies.
- Most common type found is failure of Differentration of parts-Type II 43.75%
- 50% of the total Registries are associated with syndromes/anomalies
- Registries more associated with c-section as compared to vaginal Deliveries.
The Roentgen Spectrum In Osteoarticular Tuberculosis With Special Referance To A typical Manifestations
Dr. Vivek, Dr. Arun Goel, Dr. R. Kanojia
Lhmc & Associated Group Of Hospitals, New Delhi.
Moolchand Hospital, New Delhi
Key Words: Atypical Radiographic, Osteoarticular Tuberculosis.
Diagnosis of osteoarticular tuberculosis is often difficult. Although positive tuberculin skin test or a positive chest radiograph supports the diagnosis, negative results do not exclude osteoarticular tuberculosis. Early manifestations are subtle, and advanced disease mimics other infections, granulomatous disease and malignancy. However, recognition and understanding of the radiographic findings of oseoarticular tuberculosis can help in earliest possible diagnosis. This is even truer now that ultrasound, CT, and MRI have allowed the imaging appearance of osteoarticular tuberculosis to be explored. More importantly, the application of newer imaging modalities should enable osteoarticular tuberculosis to be diagnosed at an earlier stage before the radiographic changes become florid. We studied the radiographic manifestations of 575 cases of biopsy proven osteoarticular tuberculosis presented to out hospital since 1976. The purpose of this presentation is to describe some radiographic features of osteoarticular tuberculosis that we do not believe have been adequately addressed. Atypical radiographic manifestations in the management of this disease can’t be over emphasized.