Aims

To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

Fracture of the Tibia in children usually are treated conservatively. Isoelastic intramendullary nails is an excellent method in order to fix the instable fracture of the shaft of the tibia. The method has a low rate of complications and combines the advantages of the closed reduction and internal fixation technique with the conservative method. The technique allows a precocious weight bearing.

Our retrospective study consider the clinical and radiological outcome of the tibia fractures fixed with intramedullary nails by Metaizeau.

From January 2000 till June 2004 over 150 tibia fracture were observed in our Institution.

14 instable shaft tibia fracture were treated with intramedullary nails. Medium follow up is 33.6 months. Mean Age 11.7 years.

All fractures healed in a mean time of 11 weeks.

No infection, no damage of the physis or refracture were observed.

Metaizeau nails give an elastic but in the same time a stable fixation. This point is very important especially when we have to treat a patient with associated lesions.

The technique has a low rate of infections and recurrence.

The correction of axial deviation of the lower limbs in paediatric patients requires complete patient history and clinical examination. The correct approach to the deformity must consider:radiology,evolution,associated joint damage, neurologic diseases and surgical planning. Timing and choice of operation (osteotomy, assimetric epiphyseal distraction, hemiepiphysodesis, epiphysiodesis) are critical.

Thirty-four paediatric patients with an average age of 10 years (range 2–18) were treated with a monolateral external fixator: 16 femoral osteotomies (nine post-traumatic, four congenital, one after radiotherapy for neoplastic diesease, one Ollier’s disease, one multiple exostosis) and 18 tibial osteotomies (eight congential, four post-traumatic, two multiple exostosis, two osteogenesis imperfecta, one neoplasm, one Ollier’s disease) were performed.

The knowledge of normal physiologic values, angles and anatomical and mechanical axes are fundamentally important. In choosing which operation to perfom in patients with post-traumatic deviation, the controlateral limb, functional necessity, symptoms and possible compensation must be considered. External fixation appears to be necessary in the correction of lower limb deformities because of patient comfort in the femur, because it allows osteotomy in the apex of the deformity and because it is possible to perform lengthening and correction when necessary. We suggest performing lengthening and correction osteotomy at the same level when it is possible, whereas it is dangerous to perform it at the distal metaphyseal femur and distal third of the tibia.

Adolescent hallux valgus is a progressive deformity of childhood. Patients with this disorder complain of pain, deformity, redness at the site of deformity, shoewear limitation and altered cosmesis. Surgery to correct the bunion is considered as pain gets worst, deformity increases or significant shoe wear limitation is present. However, there is still not an uniformly satisfying surgical treatment for the adolescent hallux valgus. This kind of surgery has been often associated with a high rate of recurrence and poor results. The adolescent condition often includes significant metatarsus primus varus as a primary element. This is the reason why isolated soft tissue procedures frequently fail. Surgical treatment often combines first metatarsal osteotomy with a soft tissue realignement of the first metatarsal phalangeal joint. Simmonds and Menelaus in 1960 reported their results with an osteotomy of the base of the first metatarsal in addition to McBride’s soft tissue recostruction. The procedure addresses the three main components of the adolescent hallux valgus deformity: the medial eminence, the hallux valgus and the metatarsus primus varus. Although Simmonds and Menelaus did not use any internal fixation to fix the osteotomy site, they performed a complete transverse osteotomy at the base of the first metatarsus. Besides they used an immobilization for six weeks in the post operative period. We describe a modified procedure where the osteotomy is performed incompletely at the base of the first metatarsal bone and we shortened the post operative immobilization period with a cast for three weeks. Simmonds’ procedure does not interfere with the sesamoid bones while in our method a repositioning of the sesamoids below the metatarsal head has been performed.

Materials and methods: From 1997 to 2000, 22 feet in 12 female and 1 male patients were treated surgically with the modified Simmonds-Menelaus bunion procedure. A primary operation was performed on all feet treated. The average age at surgery was 12.4 years (range 10.5 – 14.6 years). Preoperative, postoperative and final follow up evaluation included history, physical examination, record of range of motion of the first metatarsophalangeal joint, anteroposterior and lateral radiograph of the feet in the weight bearing position.

Results: Lenght of follow up averaged 3.9 years. The average pre operative Hallux Valgus Angle (HVA) was 31.2°. The average pre operative Inter Metatarsal Angle ( IMA) was 13.5°. The average HVA was reduced to 17.8°; the IMA was reduced to 11.3°. Of the 22 feet with preoperative subluxation of the sesamoids, all feet were improved after operation and none were worse. In order to assess our outcomes we used the duPont bunion rating score, which incorporates objective and subjective criteria. We had 5 excellent and 17 good results.

There were no fair or poor results.

Conclusion: Our proposed modified procedure is easy to perform and does not need any internal fixation device. The complications linked to the use of the hardware are removed. Our proposed procedure does not interfere with the shape or the length of the first metatarsal and does not preclude the possibility of further surgical correction.