Purpose of Study:

In situ fixation with cannulated screws, is the most common surgical management of Slipped Capital Femoral Epiphysis. Surgeons are wary of the consequences to the epiphysis with any manipulation of the hip. The purpose of this study, was to evaluate the use of a single cannulated screw, inserted with imaging done in the standard AP position, and gentle positioning for a frog lateral X-ray, and the risk of slip progression.

Introduction:

Sinus histiocytosis with massive lymphadenopathy (SHML) also known as Rosai – Dorfman disease is a disease of bone marrow stem cell origin. It affects lymph nodes primarily. Solitary bone lesions are very rare and can cause diagnostic difficulty.

Introduction

The femoral neck in children is a common site for bone lesions. The majority are benign. However these lesions can cause diagnostic problems

Acute osteomyelitis of the radius or ulna in children is rare and may be associated with complications including pathological fracture, growth disturbance and cosmetic problems.

Purpose

The hip region is the second most common site for tuberculosis following the spine in children

The aim is to describe the variable radiological patterns of presentation and their resemblance to pyogenic infection, tumours and other benign conditions of bone in children.

Purpose

The treatment of children with contractures involving the lower limbs is challenging. Many are confined to wheelchairs for several years till their potential to ambulate is discovered. The aim is to review the treatment and outcome of eight children treated for contractures and deformities of the lower limbs following confinement to wheelchairs.

Unrecognised DDH may present late in older children. The problems lie in reducing the femoral head into the acetabulum, obtaining concentric reduction and obtaining a functional hip. The aim of this paper is to describe our early results with operative reduction, femoral shortening and derotation in older children with DDH.

Ten hips in 9 girls, aged 3–9 years, with DDH, seen over a 10 year period, underwent operative treatment. Pre-operative traction was not used. The femoral head was exposed through an anterior oblique incision, and femoral shortening and varus derotation osteotomy was performed through a separate lateral approach. The hip was fixed with a plate (6 cases) and cross K wires (4 cases) and immobilized in a spica cast for 6 weeks. A neck shaft angle of 90⁰–130⁰ was obtained.

The osteotomies healed in all hips. Minor skin problems were pin tract sepsis and pressure effects from the cast in 2 patients. Follow up ranged from 6 months to 5 years. Functional and radiological assessment was done to assess the outcome. Pain with avascular necrosis occurred in one patient and another had subluxation of the hip. The CE angle ranged from 0⁰–30⁰, neck shaft angle 90⁰–130⁰, leg length discrepancy from 1cm 2.5cm. The results were good in 6, satisfactory in 2 and poor in 2 children. Remodeling of the neck shaft and acetabulum was seen in the majority. Although the follow up period is short, the results of open reduction and femoral shortening in late DDH is encouraging.

The author concludes that the combination of open reduction, femoral shortening and varus derotation osteotomy gave good to satisfactory results in the majority of patients.

Muscular torticollis is rarely seen in our population group. There is controversy regarding the surgical procedure of choice, post operative immobilization and the ultimate results. Several procedures have been described to release the sternocleidomastoid. In children over 5 years correction of secondary deformities are less certain, and complications are scarring and loss of contour of the neck. The aim of this paper is to review the results of bipolar release of the sternocleidomastoid muscle in muscular torticollis.

Between 2000–2006, 3 girls and 1 boy, aged 6–10 years, were treated surgically for muscular torticollis. Spinal abnormalities and other congenital problems were excluded. Through an incision parallel and superior to the clavicle, the sternal and clavicular attachments of the sternocleidomastoid muscle were divided and 2.5cm of muscle was excised. Through a separate transverse incision inferior to the mastoid process, the insertion of the sternomastoid tendon was divided. Post operative traction was used for 5 days, followed by a moulded collar for 3 months.

The children were assessed for function and cosmesis. All scars healed well. The wry neck position improved in all. All children had improvement in movements and cosmesis. There were no visual problems and the lateral band was inconspicuous in the neutral position. Follow up ranged from 1–5 years. Lateral flexion and rotation improved markedly. Two patients reported an increase in height.

Our early results showed that patients over 6 years had marked improvement in cosmesis and movement following bipolar release of muscular torticollis. The improvement in facial asymmetry is being observed with growth. Obviously, the follow up is not long enough to provide adequate long term evaluation. No major complications occurred.

Septic arthritis of the hip remains a serious problem in our environment. The diagnosis is difficult and treatment is challenging. Particularly in patients presenting late, the outcome may be poor.

From January 1998 to December 2002, 27 children were admitted to the paediatric unit with the diagnosis of septic arthritis. Their ages ranged from 2 to 12 years and the duration of symptoms ranged from 3 days to 3 months. Pain, fever and a limp were the main clinical features. Only one child had bilateral involvement. Laboratory investigations revealed Staphylococcus in 20 children, Serratia in one, Pseudomonas in one and Haemophilus influenza in one. In four patients no growth was identified. Initial radiological findings ranged from no abnormalities in 18 children, to capsular distention in six and hip dislocation in three. Ultrasonography, CT scan and bone scan were also performed. All patients underwent surgical exploration. Twelve had septic arthritis, six pelvic osteomyelitis and five proximal femoral osteitis. There were two psoas abscesses, a buttock abscess and a case of inguinal lymphadenitis. Follow-up ranged from 3 months to 5 years.

Only eight children had a good outcome and full range of movement. There were six cases of ankylosis, 10 of avascular necrosis and three of dislocation.

Thorough clinical and radiographic examination is advocated in patients with apparent septic arthritis, as misdiagnosis is common. The infection may be in the pelvis, femoral neck or related soft tissues.

Introduction and Aims: This disease has an insidious onset and develops as a result of increased host resistance and decreased bacterial virulence. The aim of this paper is to describe the spectrum of primary subacute forms of haematogenous osteomyelitis and highlight the difficulties in diagnosis and the importance of histology.

Method: Twenty-five children aged two to 12 years were reviewed between 1990 and 2002. Symptoms and signs were mild. Complaints were present for two to eight weeks; laboratory tests were non-contributory. Bone scans were done in all patients. All patients had biopsy with curettage of cavitating lesions. Microscopy, culture and histology were done in all patients. Four patients had MRI scans.

Results: There were 28 osseous lesions in 24 children. The anatomical sites were: the tibia, 24 lesions, femur three and ulna one. One child had multifocal involvement involving both tibiae and the ulna. The lesions were classified using the system of Roberts et al. Two lesions were in the epiphysis, six in the metaphysis and 20 in the diaphysis. Radiologically, the lesions resembled several benign and malignant conditions such as tuberculosis and fungal infections, Ewing’s sarcoma, leukaemia, osteosarcoma, chondroblastoma and osteoid osteoma. Bone scan was positive in all cases. Histology of bone showed features of subacute osteomyelitis – inflammatory cells, plasma cells and polymorphonuclear leukocytes. Staphylococcus aureus was cultured in eight patients.

All children were treated with Cloxacillin for six weeks. Follow-up ranged from six months to five years. All diaphyseal and epiphyseal lesions healed completely. Residual sclerosis was seen in metaphyseal lesions. No growth disturbance or articular changes were seen in this study.

Conclusion: Primary subacute haematogenous osteomyelitis is uncommon. Metaphyseal and epiphyseal forms are more commonly reported in the literature. The diaphyseal form was the predominant type in this study. Bone lesions mimic benign and malignant conditions. Biopsy is mandatory. The diagnosis is made on histology. Staphylococus aureus is the usual causative organism, but difficult to culture.

Introduction and Aims: Chronic pyogenic osteomyelitis, with pathological fractures, sequestra and subsequent bone defects, is still a major problem in developing countries. The treatment is challenging. Unhealthy skin with discharging sinuses make routine grafting procedures difficult. The aim of this paper is to describe the methods used to treat resulting defects.

Method: Thirty-four children, aged one to 12 years, treated between 1991 and 2002, were reviewed. The tibia was involved in 24 children, femur (five), radius (four), and ulna (one). Twenty-nine children had sequestrectomy and debridement. Five children presented with established bone defects. Bone defects measured 1–20cm. Four methods of grafting were used. Autogenous onlay grafts were used in defects < 2cm in seven children. The Papineau technique was used in cavitating defects in two, bicortical segmented iliac crest grafts (1cm x 1.5cm) threaded over a Kirschner wire were used in 15 defects (< 10cm) and bone transfer was performed in six children – proximal fibula to tibia (five) and radius to ulna (one).

Results: Three children required repeat grafting, one for fracture and three for non-union. All the remaining grafts incorporated by three to six months. Distal procedures including tibio fibular fusion and fibular epiphysiodesis were performed in six children. An above knee caliper was used in 11 cases till graft hypertrophy and consolidation occurred. All patients are ambulant presently. Shortening was treated with a shoe raise. Shortening ranged from 1–10cm. Fibula transfers showed hypertrophy with weight-bearing in all patients. Follow-up ranges from 10 months to 11 years.

Conclusion: Onlay grafting was successful in small defects < 2cm. Larger defects up to 10cm can be treated by segmented bicortical iliac crest grafts over a Kirschner wire, providing some stability and increased surface area for incorporation. Bone transfers should be reserved for difficult cases with extensive scarring and as an alternative to ablation in selected cases.

Acute bilateral symmetrical pyogenic osteomyelitis in children is rare. The purpose of this paper is to increase awareness of the existence and severity of this condition.

The clinical records and radiographs of eight children with acute bilateral symmetrical osteomyelitis seen between 1990 and 2003 were reviewed. All had typical clinical and laboratory features of acute osteomyelitis. The duration of symptoms ranged from 7 to 14 days. The age range was 5 to 12 years.

The sites involved were the proximal femora in two patients, the distal femora in two, the proximal tibiae in two, the calcanei in one and the clavicle in one. All patients had fluctuant abscesses and underwent incision and drainage. Staphylococcus aureus was cultured in all cases and treated with cloxacillin for 6 weeks.

Follow-up ranged from 18 months to 4 years. All except the patient with the clavicular lesion had poor outcomes. Patients with femoral neck involvement had avascular necrosis, pathological fractures and ankylosis. The children with distal femoral and upper tibial involvement developed chronic osteomyelitis, with sequestra, sinuses and knee joint ankylosis. The child with calcaneal involvement developed bilateral ankle, subtalar, calcaneocuboid and talonavicular fusion.

Bilateral symmetrical haematogenous osteomyelitis is a severe disease caused by a virulent organism. Symmetrical and simultaneous infection of the same bones is reported mainly in congenital syphilis and chronic recurrent multifocal osteomyelitis, which is associated with skin lesions. All children presenting with acute osteomyelitis should be thoroughly examined to exclude symmetrical and multifocal sites of involvement. A bone scan may be useful in the early detection of involved sites.

Isolated femoral neck lesions in children are rare and the differential diagnosis is wide. This study examines the spectrum of chronic non-traumatic bone lesions seen in the femoral neck region in children and emphasises the importance of tissue diagnosis.

From 1990 to 2003, 23 children aged 1 to 3 years with chronic bone lesions of the femoral neck region were seen. Their case records and radiographs were reviewed retrospectively. Pain and a limp for 4 to 12 weeks were the main symptoms. Most children (18) had right-sided lesions. All had routine blood investigations, radiographs and bone scans. Histological and microbiological studies were done when pus and granulation tissue were found.

We found infections, benign tumours and haematopoetic lesions. There were seven cases of tuberculosis and three of subacute pyogenic osteomyelitis. Six children had simple bone cysts, one a chondroblastoma, one a fibrous dysplasia and three osteoid osteoma. Two had eosinophilic granulomata. All 23 lesions were treated by curettage and biopsied. Bone graft was used in all the simple bone cysts, fibrous dysplasia and chondroblastoma. Internal fixation was used in one displaced fracture and the rest were immobilised in a spica. Follow-up ranged from 9 months to 8 years. All lesions showed healing. Coxa vara occurred in four patients and growth disturbances in five.

Tuberculous lesions caused the greatest diagnostic dilemma as they resembled several benign bony conditions. Thorough examination is essential and biopsy is mandatory.

Introduction and Aims: Solitary osseous lesions of tuberculosis are uncommonly reported in children. Historically, bone lesions were predominantly of the multifocal and disseminated type. The aim of this paper is to describe the protean radiological manifestations of tuberculosis in sites other than the spine and synovium, and their resemblance to benign and malignant bone lesions.

Method: Forty-nine children, aged 1–12 years with histologically confirmed osseous lesions of tuberculosis, were reviewed between 1984 and 2001. Symptoms ranged from two weeks to three months. There were a total of 59 lesions. Forty-three children had solitary, and six had multifocal lesions. Thirty lesions were in the metaphyses, six in the diaphyses and five in the epiphyses. The remainder were in the small and flat bones. Four basic patterns of bone lesions were seen. The majority were cystic in type (34), infiltrative (10), focal erosions (nine) and spina ventosa lesions (6). Several bone lesions resembled pyogenic and fungal osteomyelitis, osteoid osteoma, benign and malignant bone tumors. All patients had biopsy with curettage.

Results: Follow-up ranged from nine months to 12 years (average 3.5). All lesions showed clinical and radiological healing by three to six months following anti-tuberculous treatment with rifampicin, isoniazid and pyrazinamide. Cystic lesions healed with slight marginal sclerosis in 12 patients. Growth disturbance was seen in six children with residual shortening of 1–3cm. Avascular necrosis of the femoral head was seen in three hips and coxa vara in two others. Six patients had joint contracture of 100–300. Good remodelling of cystic and spina ventosa lesions was seen in all patients.

Conclusion: The lack of familiarity with the spectrum of bone lesions in tuberculosis can lead to delay in diagnosis. The clinical and radiological manifestations of tuberculosis appears to be changing. Destructive and infiltrative lesions are less commonly encountered. Solitary lesions can mimic various benign and malignant conditions. Biopsy is mandatory.

Thirty-four acute traumatic dislocations in children aged 5 to 13 years, treated between 1994 and 2002, were reviewed retrospectively. All injuries were caused by a fall. Two injuries were compound. Two children had ulnar nerve injuries, one a radial nerve injury, and one median nerve and brachial artery injury. Posterolateral dislocations were seen in 22 children, posteromedial in eight, posterior in one, anteromedial in two and anterolateral in one. Pure dislocations occurred in eight children and 26 had associated elbow injuries, including 11 medial epicondyle, five lateral mass, one olecranon, one radial head and eight combined injuries. In the combined group, six children had associated fractures and two had divergent dislocation of the proximal radio-ulnar joint. Twenty required open reduction. The injury was initially missed in eight.

The child with vascular and median nerve injury had not recovered by four months. Among the others, at follow-up of 4 to 48 months 22 results were excellent to good, 10 fair and one poor. Complications included pseudarthrosis of the medial epicondyle in one child and loss of flexion and rotation of 10° to 30° in 15. Radial and ulnar nerve injuries recovered. A high index of suspicion, good clinical examination and compared radiographs are recommended to avoid missed injuries.

Seven children, aged four to nine years, underwent fibular transfer between 1990 and 2002. Five had chronic osteomyelitis and two had septic compound fractures. Bone defects measured 5 cm to 20 cm. Reconstruction was performed in two stages. Debridement, sequestrectomy, and Gentamycin bead insertion were performed first. Two children required skin grafting and one a gastrocnemius flap.

Fibular transfer was performed as a second stage at four to six weeks, when infection was cleared. Through an anterolateral approach the fibula was divided proximally below the physis and transferred from the lateral to the anterior compartment deep to the tibialis anterior muscle belly. The fibula was fixed with screws to the lateral tibial metaphysis in two children, and placed into the medullary canal and fixed with wires in four. Distal procedures were performed in five children.

Patients were immobilised in a cast for three to six months until bone healing occurred, after which the bone was supported with a calliper. Follow-up ranged from 11 months to 13 years. All transfers united to the proximal tibia by 12 weeks. Fibular hypertrophy occurred in all children. There was shortening of 3 cm to 10 cm. Equinus deformity occurred in two children and varus of the ankle in three. All are ambulant with boots and crutches.

Fibular transfer is a useful salvage procedure and an alternative to ablation in severe tibial infections with defects. It has a free blood supply and hypertrophies with weight-bearing.

This paper reviews the outcome of 13 children with congenital pseudarthrosis of the tibia after intramedullary rodding and autogenous bone grafting.

The oldest patient was aged nine years at the time of surgery. The ages of the others ranged from 12 to 24 months. The oldest patient at follow-up was 18 years.

All 13 had bone defect and angulation. Ten children had clinical features of neurofibromatosis. Ten had pseudarthrosis involving the distal third of the tibia, two the middle third and one the proximal third. Autogenous iliac crest chips were used following excision of fibrous tissue and dense and atrophic bone. Rodding was done across the ankle joint in 10 patients. Postoperatively an above-knee cast was applied for 6 to 12 months, after which an above-knee brace was used to protect the rodding.

At follow-up, which ranged from 10 months to 16 years after surgery, all patients were fully weight-bearing and ambulant. Three patients were lost to follow-up after 2 to 4 years. Complications included refracture and rod breakage (two), rod migration (three), and growth retardation with shortening of up to 5 cm. Ten patients had ankle and subtalar joint stiffness and two had valgus deformities of the ankle. Three patients underwent repeat rodding and bone grafting. Radiological union was observed to be progressing in all patients.

Intramedullary rodding of the tibia for congenital pseudarthrosis of the tibia is a simple procedure and can be repeated. It avoids prolonged hospital stay and permits early weight-bearing. Careful supervision is necessary, and until there are signs of good bony union, external support is mandatory.

This paper reports the results of pes anserinus insertion as a dynamic transfer for habitual dislocation of the patella.

From 1995 to 2001 five patients were seen, ranging in age from 5 to 13 years. Follow-up ranged from nine months to three years. Through a long lateral incision, the iliotibial band and abnormal superolateral insertion of the vastus lateralis were divided. The lateral capsule down to the lateral border of the patellar tendon was released. Finally the vastus intermedius tendon was divided.

The rectus femoris was lengthened in one patient. Through a medial parapatellar incision, the pes anserinus insertion was detached with a sleeve of periosteum and sutured to the anteromedial aspect of the patella and patellar tendon to act as a dynamic check rein. The relaxed medial capsule was reefed before the transfer. The child was immobilised in an above-knee cast for four weeks after wound closure and later had physiotherapy.

In all patients the results were good. Movement was from 0° to 130° and there were no complications or redislocations. Skyline views showed the patella located in the groove.

Dynamic stabilisation of the patella in habitual dislocations yields more successful results. Preserving the vastus medialis helps prevent the extensor lag that usually occurs after these procedures. Abnormal insertion of the vastus lateralis and a tight iliotibial band were identified as the main causes of the dislocation. The failure of reconstructive procedures is perhaps due to the inadequate strength of the soft tissue used as a static medial stabiliser of the patella.

Congenital vertical talus is a rare deformity. Many different surgical procedures have been described, and there is debate about whether the correction should be done in one or two stages. We review the results of single stage surgical correction of congenital vertical talus.

Between 1992 and 2000, five boys and seven girls were treated, ranging in age from eight months to two years. In six children both feet were involved, so there was a total of 18 feet. One child had spina bifida, four had arthrogryposis multiplex congenita and three had syndromes and chromosomal abnormalities. Four cases were idiopathic.

Dorsolateral and medial incisions were used. Through the dorsolateral the sinus tarsus, calcaneocuboid and talonavicular joints were released and the extensors lengthened. Through the medial incision the navicula was reduced onto the talus, the tibialis posterior and talonavicular capsule were reefed and the tendo Achillis lengthened. The talonavicular and calcaneocuboid joints were pinned. The tibialis anterior was re-routed through the talar neck. Plasters were changed after two weeks and serial plasters were applied for four to six months.

Follow-up ranged from one to seven years. Results were assessed clinically and radiologically, using the Adelaar 10 point scoring system. There were no wound complications or cases of avascular necrosis of the talus. Further surgery was required to correct cavus in two feet, to correct forefoot abduction in two, and to correct hindfoot valgus in one. Results were rated good in 12 feet and fair in six. Radiologically there was notable improvement in the anteroposterior and lateral talocalcaneal and tarso-first metatarsal angles. All patients were ambulant at last follow-up.

In treating congenital vertical talus, good clinical and radiological results can be obtained with single stage correction of the hindfoot and midfoot deformities.

The treatment of large bony defects following osteomyelitis and trauma with skin damage is challenging. This paper reports the results of fibular transplant for tibial defects.

Between 1990 and 2000, five children aged four to nine years were treated. Four had pyogenic osteomyelitis and one a compound fracture with bone loss. All had large wounds on the medial aspect of the tibia. Before reconstruction, conservative treatment lasted five to six months. Sequestrectomy and debridement were performed before fibular transfer.

At surgery the fibula was divided below the physis and transferred to the remaining tibia, deep to the tibialis anterior muscle belly. In two cases the fibula was fixed to the lateral aspect of the tibia with screws, and in three into the metaphysis with K-wires. Bone graft was packed around the transfer. Immobilised in a cast for four to six months, the leg was later protected with a calliper.

Follow-up ranged from 9 months to 10 years. All children are ambulant, four with callipers and one independently. The latter shows evidence of tibialisation of the fibula. Follow-up continues and the remaining four transfers show solid union and signs of fibular hypertrophy.

Osteomyelitis remains a crippling condition that results in bone defects. Fibular transfer is a salvage procedure and an alternative to ablation in cases of severe bone loss with infection and scarring. It should be reserved for difficult cases with extensive defects where conventional bone grafting is not possible.