Assessment of skeletal age is important in children’s orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods.

Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods.

The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience.

The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified.

Cite this article: Bone Joint J 2014;3:1556–60

This study is a retrospective monocentric analysis of changes in spinopelvic sagittal alignment after in situ fusion of L5-S1 spondylolisthesis. In situ fusion is a safety procedure with good functionnal outcome, but the consequences on the spinopelvic sagittal balance remains unclear. The aim is to evaluate the adaptative changes in the sagittal balance after such treatment.

This is an analysis of 22 patients (mean age 13,5 years) with an average follow-up of 5,2 years (range 1–11 years). This study includes 6 grade II spondylolisthesis, 7 grade III and 9 grade IV. 13 patients were operated with a non instrumented posterolateral arthrodesis and 9 with a circumferential in situ fusion. Among the 13 grade II and III spondylolisthesis, 12 had a posterolateral arthrodesis and only 1 had a circumferential fusion. As for the grade IV spondylolisthesis 8 out of 9 had a circumferential arthrodesis and only 1 had a posterolateral fusion.

Before and after surgery, all patients had lateral standing radiographs of the spine and pelvis. Different parameters were evaluated before surgery: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, thoracic kyphosis, T9 sagittal tilt, L5 incidence, L5 slope and L5 tilt. After surgery, the pelvic parameters were not evaluated because of the difficulty to visualise the upper part of S1 after arthrodesis. The discs were evaluated by MRI.

The functionnal outcome was evaluated with the Oswestry score.

A global evaluation including all the patients doesn’t show any influence of the surgery on the sagittal alignment. But when evaluating the datas after classifying the patients in function of the severity of the spondylolisthesis, some differences raise. On one side, the patients with grade II and III spondylolisthesis keep a normal T9 sagittal tilt while slightly increasing lumbar lordosis and thoracic kyphosis. On the other side, the patients with grade IV spondylolisthesis operated with a circumferential in situ fusion worsen the T9 sagittal tilt, increase the L5 incidence, decrease their lombar lordosis (L4/L5 discal kyphosis) and thoracic kyphosis.

To conclude, we can say that patients with grade II and III spondylolisthesis have good functionnal outcome and keep a balanced spine. Patients with grade IV have a good clinical outcome as well but keep worsening their sagittal balance despite the circumferential in situ fusion. An unbalanced sagittal alignment might theorically compromise the long term clinical results, but the radiological outcome doesn’t seem to be linked to the functionnal outcome. A long term follow-up has to be done in order to evaluate the outcome of these unbalanced spines and compare it to the functionnal and radiological results obtained with reduced high grade spondylolisthesis.

Background: Lower limb buds appear during the second week of embryonic life and are well differentiated by the end of the 8th week. Primary ossification centres of femur and tibia appear by the end of the 8th week and by 12 weeks the cartilaginous anlage is complete. By 14 weeks primary ossification is sufficient to allow accurate ultrasonographic measurement of femoral length.

There are many established database for estimating fetal femoral length ultrasonagraphically. There is little data however on radiological measurements of fetal femoral lengths. The aim of our study was to introduce radiologically measured fetal femoral lengths in order to improve our understanding of normal fetal femoral growth.

Methods: A group of 40 post-mortem foetal radiographs ranging from 14 weeks to 39 weeks gestation were retrieved from our radiology department having excluded all cases with associated lower limb deformation. Femoral lengths were measured and plotted against gestational age. A standard growth curve was constructed and compared to the currently available data on ultrasonographic measurements. A growth velocity chart, growth remaining and an antenatal multiplier chart was also constructed.

Results: At 14 weeks the length of the femur was 14mm and the tibia 11mm. At birth the femoral diaphyseal length was 75mm and the tibia 62mm.

Using the standard growth curve there was a strong correlation between our radiological measurements and previously published ultrasonographic measurements (R2= 0.9492)

The femoral growth velocity curve demonstrated a rapid growth acceleration phase peaking at 12 cm/annum at 16 weeks, followed by a rapid deceleration phase reducing to a growth rate of 5 cm/annum at birth.

The growth remaining was calculated for each week. At 24 weeks the growth achieved is 10% thus giving a multiplying factor of 10. At birth the growth achieved is 20% giving a multiplying factor of 5.

Discussion: Modern 3D and 4D ultra-sonography has lead to an increasingly accurate detection of antenatal deformities. Antenatal orthopaedics is an advancing sub-specialty. The understanding of normal intra-uterine growth is essential knowledge of a paediatric orthopaedic surgeon when advising on antenatally detected deformities. This correlation of ultrasonographic and radiographic measurements further deepens our understanding of foetal femoral growth.

Purpose of the study: To analyse 300 supracondylar fractures with major displacement presenting with acute vascular comprimise and to propose an effective therapeutic strategy in a tertiary referral centre.

Material and Methods: Three hundred patients aged 18 months to 14 years were treated for Larange stage IV supracondylar fracture of the humerus in the same centre. Acute vascular compromise was noted in 46 cases (15%). The radial pulse was absent in all patients with two different contexts: ‘pink hand’ with good distal perfusion in 41 cases (13.5%) and ‘white hand’ with ischemia in five cases (1.5%). Nerve injury was associated in half of the cases, predominantly involving the medial nerve (87%). Emergency management included repeated assessment of the vascular and nervous status using a departmental protocol and Doppler control together with oxygen saturation. Emergency anatomical reduction and stable percutaneous fixation, with lateral and medial wires via a minimal medial exposure to control the ulnar nerve, was performed in all cases. Post-operative immobilisation with a posterior splint at 90° of elbow flexion. Repeated postoperative clinical surveillance: distal perfusion, O2 saturation and Doppler assessment.

Results: 90% of the cases with vascular compromise had posterolateral displacement. Post reduction, the radial pulse was restored immediately in 28 cases and secondarily in 10. The three remaining cases with an absent radial pulse but with a pink hand developed ischemia necessitating surgical exploration revealing incarceration of the brachial artery and medial nerve within the fracture site. Release of the brachial artery restored the radial pulse.

The five cases of primary ischemia with absent pulse and a white hand were managed by emergency reduction followed by exploratory surgery and vascular repair which restored the radial pulse, excepting one case which required anterior fasciotomy.

Conclusion: Early vascular complications after stage IV supracondylar humerus fractures are common in children. This study identified the following points: priority is required for reduction of these fracture and emergency stabilisation; posterolateral displacement is associated with a higher risk of vascular complications; these injuries should be treated in a specialised centre; the absence of a radial pulse with a pink hand warrants repeated observation during the postoperative period; it is not an absolute indication for invasive investigation and surgical exploration; the absence of a pulse with a white hand requires surgical vascular exploration.

Purpose of the study: Special care is warranted only for severe forms of Legg-Perthes-Calvé disease (LPCd) (Catterall 4, Herring B and C, Salter B, involvement > 50%). Should we propose specific treatment or simply monitor the inevitable disease course?

Material and method: Among a series of 485 hips with LPCd, 148 (30.5%) with massive involvement were identified. Ninety-six (64.9%)severe forms were analyzed at the end of growth. Magnetic resonance imaging, scintigraphy and arteriography were used to better assess the femoral head and identify hips at risk. These hips were treated surgically: Salter osteotomy (SA), triple pelvis osteotomy (TO), or varus osteotomy (VA). Three groups of infants were identified according to age at diagnosis of LPCd: less than 6 years, 6–9 years, more than 9 years. Outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).

Results: There were 54 hips (56.3%) in the less than 6 years group, 26 (27.1%) in the 6–9 years groups, and 16 (16.6%) in the greater than 9 years group. Outcome was good for 45 hips (46.9%), fair for 22 (22.9%) and poor for 29 (31.2%) hips and was independent of age at onset of treatment. In the less than 6 years group, 54 hips (56.3%) were Catterall 4, Herring B or C, Salter B. Among the 24 Catterall 4 hips (44.4%) treated orthopedically, outcome was good for 15 (62.5%), fair for 7 (29.2%) and poor for 2 (8.3%). Among the 30 Cartell 4 hips treated surgically, outcome was good for 16 (53.3%), fair for 9 (30%) and poor for 5 (16.7%). In the 6–9 year group, 26 hips (27.1%) were Catterall 4, Herring B or C, Salter B. Among the 10 Catteral 4 hips treated orthopedically (38.5%), outcome was good for 3 (30%), fair for 2 (20%) and poor for 5 (50%). For the 16 Catterall 4 hips treated surgically, outcome was good for 8 (50%), fair for 2 (12.5%) and poor for 6 (37.5%). In the greater than 9 years group, there were 16 (16.6%) Catterall 4, Herring B or C, Salter B hips. Among the 10 Catterall 4 hips treated orthopedically, outcome was good for 1 (10%), fair for 2 (20%) and poor for 7 (70%). Among the 6 Catterall hips treated surgically, outcome was good for 2 (33.3%), fair for 0 and poor for 4 (66.7%).

Conclusion: Good outcome decreases with age. Surgery increases the rate of good outcome in all age groups, but before the age of six years, there is no significant difference between orthopedic and surgical treatment. Before six years, spherical heads (Stulberg 1 and 2) were achieved in six out of ten hips in the 6–9 year group and in only two of ten in the group aged over 9 years.

Children presenting with Perthes’ disease before their sixth birthday are considered to have a good prognosis. We describe 166 hips in children in this age group. The mean age at onset of the disease was 44 months (22 to 72). Mild forms (Catterall I and II) were treated conservatively and severe forms (Catterall III and IV) either conservatively or operatively. The aim of the former treatment was to restrict weight-bearing. Operative treatment consisted of innominate osteotomy and was indicated by a Conway type-B appearance on the bone scan. All the patients were followed to skeletal maturity with a mean follow-up of 11 years (8 to 15).

The end results were evaluated radiologically using the classifications of Stulberg and Mose. A total of 50 hips were Catterall grade-I or grade-II, 65 Catterall grade-III and 51 Catterall grade-IV. All hips with mild disease had a good result at skeletal maturity. Of the hips with severe disease 78 (67.3%) had good (Stulberg I and II), 26 (22.4%) fair (Stulberg III) and 12 (10.3%) poor results (Stulberg IV and V). Of the Catterall grade-III hips 38 were treated conservatively of which 31 (81.6%) had a good result, six (15.8%) a fair and one (2.6%) a poor result. Operative treatment was carried out on 27 Catterall grade-III hips, of which 21 (77.8%) had a good, four (14.8%) a fair and two (7.4%) a poor result. By comparison conservative treatment of 19 Catterall grade-IV hips led to ten (52.7%) good, seven (36.8%) fair and two (10.5%) poor results. Operative treatment was carried out on 32 Catterall grade-IV hips, of which 16 (50.0%) had a good, nine (28.1%) a fair and seven (21.9%) a poor result.

We confirm that the prognosis in Perthes’ disease is generally good when the age at onset is less than six years. In severe disease there is no significant difference in outcome after conservative or operative treatment (p > 0.05). Catterall grade-III hips had a better outcome according to the Stulberg and Mose criteria than Catterall grade-IV hips, regardless of the method of treatment.

Purpose of the study: The appropriate treatment for Legg-Perthes-Calvé disease (LPCd) remains a subject of debate. Certain teams consider orthopedic treatment adequate. Others advocate surgery to improve prognosis. Is surgery necessary? When is the proper time? We reviewed retrospectively 91 surgically treated hips (Salter osteotomy or triple pelvis osteotomy) at the end of growth.

Material and methods: Among 485 hips with LPCd, 349 (71.9%) presented massive involvement (Catterall 3 and 4, Herring B and C, Salter B). Ninety-one patients with severe disease were reviewed at the end of growth. Complementary explorations included magnetic resonance imaging, scintigraphy and arteriography using the Dias protocol which enables an assessment of the excentration and the femoral head deformation and identifies hips at risk. Surgical treatments were Salter osteotomy (SA) or triple osteotomy (TO). Three groups were identified depending on the age at disease diagnosis: less than 5 years, 5–9 years, more than 9 years. Using the Stulberg and Mose classifications, outcome was considered good (Stulberg 1 and 2, Mose good), fair (Stulberg 3, Mose fair), or poor (Stulberg 4 and 5, Mose poor).

Results: There were 50 Carttell 3, Herring B, Salter B hips and 41 Catterall 4, Herring B and C, Salter B hips (80% boys). Distribution by group of age at diagnosis was: 34 (37.4%) less than 5 years, 48 (52.7%) 6–9 years, 9 (9.9%) more than 9 years. Salter osteotomy was performed on 32 hips (35.2%) and triple pelvic osteotomy on 59 (94.8%). Outcome at end of growth was: less than 5 years Catterall 3: 77% good, 15.4% fair, 7.6% poor; Catterall 4: 52.4% good, 33.3% fair, 14.3% poor; 6–9 years: Catterall 3: 70% good, 20% fair, 10% poor; Catterall 4: 55.5% good, 22.2% fair, 22.2% poor; more than 9 years: Catterall 3: 42.9% good, 42.9% fair, 14.2% poor; Catterall 4: 50% good, 50% poor.

Conclusion: Outcome worsens with increasing age at diagnosis. Despite surgery, a spherical femoral head (Stulberg 1 or 2) is achieved in only one hip Catterall 4 hip out of two. This result is observed in Catterall 3 hips only in children whose diagnosis is established after the age of nine years. Prognosis is better in Catterall 3 hips.

Poor results increase in older patients. After Orthopaedic treatment 60% of hips in children with LPC Disease appearing before the age of 6 find again its sphericity (Stulberg 1 or 2). About 30 % of hips in children with LCP Disease appearing between 6 and 9 years of age became “normal” (Stulberg 1 or 2) at the end of growth/Only 1 hip out of 10, in the oldest group of children (over 9 years), became spherical at the end of growth. Surgery increases the percentage of good results in all groups of patients.