Abstract

The threshold for decompression in acute compartment syndrome is quoted as a pressure difference between the compartment and diastolic blood pressure of less than 30mmHg. This study reports the findings of continuous compartment pressure monitoring in children who underwent tibial osteotomies.

In this prospective observational study, twenty seven children who underwent tibial osteotomies had anterior compartment pressures monitored using a transducer-tipped probe for a minimum of 72 hours following surgery. Pressure data were collected hourly together with evidence of clinical signs, symptoms and patterns of analgesic use. Patients were also reviewed for late sequelae of compartment syndrome.

One case of compartment syndrome were encountered. Pressure differences (diastolic BP - compartment pressure) were found to vary widely, with many children exceeding the threshold for decompression but without manifesting other signs of compartment syndrome. Fasciotomies were not performed in view of the conflicting evidence and subsequent review confirmed the absence of late sequelae. In these children, low diastolic blood pressures were a common but normal feature. The prevalence of compartment syndrome was 3.7% (1/27). The positive predictive value of using the adult threshold was 7.1%; the negative predictive value was 100%.

We conclude that the threshold for decompression as applied to adults is unsuitable for use in children inasmuch as a positive result would lead to a correct diagnosis in only 7.1% of children. A negative test is more useful in correctly excluding compartment syndrome in 100% of the children studied.

Purpose: The aim of the study was to assess the usefulness of ultrasound in the management of Irritable hips in children’s.

Materials and Methods: Retrospective analysis was performed for 168 patients with irritable hip from January 2004 to December 2005. The right hip was affected in 86 patients and the left hip was affected in 85 patients. Bilateral hip affection was seen in 3 patients. All the patients presented with pain in the hip joint. Most had pain on internal rotation. Majority had limp lasting 0 – 3 days. All patients were older than 1 year. White Blood Cell count (WBC), C-Reactive Protein (CRP) and Ultrasound of the hip was performed on all the patients as per the Irritable hip protocol. Temperature and associated medical condition were also recorded. Patients were divided into two groups, Group A who could weight bear involved 146 patients and Group B who could not weight bear had 22 patients.

Results: Ultrasound examination showed no effusion in 77 patients in Group A and 11 patients in Group B. Remainder of patients in both the groups had hip joint effusion ranging from 2mm – 7mm. All the patients were treated conservatively. None needed aspirations of the effusion in the hip joint or secondary operative procedure.

In group A (Weight bearing patients), 30 patients had mild temperature and 1 had moderate temperature. All of these 31 patients had normal WBC, CRP and their ultrasound showed effusion from 0 – 7mm. 12/31 patients had URTI.

In group B (Non weight bearing patients), 5 patients had mild temperature with normal WBC, CRP and their ultrasound showed effusion from 0 – 6 mm. 1/5 patient had URTI.

All the remaining 115 patients in group A and 17 patients in group B had normal WBC and CRP values.

No associated medical problems were found in 102 patients in group A and 12 patients in group B. Upper respiratory tract infection was noted in 40 patients in group A and 9 patients in group B. Gastroenteritis was noted in 4 patients in group A and 1 patient in group B.

Conclusion: Questions are raised with regards to the role of ultrasound in management of Irritable hips. Ultrasound for irritable hips in weight bearing patients with normal WBC and CRP is of no help. Ultrasound may be considered for non-weight bearing patients despite normal parameters.

Significance: Ultrasound is not of much help in management of irritable hip with normal WBC and CRP. Ultrasound is of definite value to surgeon before any operative procedure for the hip joint.

Aims: To describe a new & safe technique of gradual distraction for pollicisation of index finger, to which the blood supply is doubtful. This procedure was used in cases where conventional methods of pollicisation are not possible or are risky. Methods: This technique has been utilised in 5 cases (2 traumatic loss of thumb at carpo-metacarpal joint, and 3 cases of absence of thumb associated with radial club hand). The age group was 3–18 years. The procedure consisted of first stage, a webplasty between second & third fingers, osteotomy of the base of second metacarpal and gradual wide abduction of the index finger by distraction. In second stage, the second metacarpal is recessed and rotated, to the position of thumb. At third stage, tendon transfer may be needed for securing the forceful opposition. Results: In all operated 5 cases, desired position of the thumb was obtained along with good function. Conclusion: Gradual distraction for pollicisation may be used in cases where the blood supply of index finger is not based on known specific blood vessel but depends on collateral blood supply. Conventional methods cannot be used or are risky. This technique provides a safe and economical alternative for reconstruction of the thumb, which is a new addition to the armamentarium in thumb reconstruction.

Aims: To treat posttraumatic stiffness of elbow by distraction arthrodiastasis and mobilisation. Standard operative procedures were combined for 4 patients with bony blocks due to myositis ossiþcans. Methods: We reviewed 8 patients, 5:M, 3:F aged 20–42 years. 3 x 2.5mm k-wires were passed in lower-third humerus from lateral to medial side and 3 x 2.5mm k-wires in proximal ulna. Distractors were applied on anterior and posterior aspect of elbow and hinge-joint at the level of elbow-joint. Elbow was gradually distracted to achieve arthro-diastatic state of joint. Maintaining arthrodiastatic state now elbow deformity is gradually corrected by distracting anterior distractors. Than distractors and hinge are locked for tissue reaction to subside over 2–3 weeks followed by dynamic mobilization. Movement gradually improves over 2–3weeks (sometimes prolonged in severe cases). Than þxator is removed and appropriate dynamic splint is applied to maintain correction while allowing mobility. In 4cases bone block was removed surgically and followed by distraction arthrodiastatic procedure. No steroid in any form was used in any stage of treatment. Results: Average follow-up: 2years (maximum 4years). All elbows were stable and extension increased by 30û and ßexion increased by 50û. One case had minor pin-tract infection, responded to basic treatment. No neurovascular deþcit was not seen post procedure in any patients. Conclusion: This technique may be considered before arthrolysis is undertaken for stiff elbow.

Aims: Osteotomy of ulna with fractional distraction maintains ulnar length and reduced position of radial head via interrosseous membrane. Methods: We reviewed 9patients, 5:M, 4:F, aged 2Ð14years. Interval between injury and surgery ranged 2–36months. All had elbow deformity with radial head prominence. Restricted movement in 6patients. 3 had pain on movements. 2x2mm k-wires each, proximal and distal to ulnar osteotomy. Distal k-wires transþxed in radius in supination (during distraction of ulna, radius is pulled down). ÔZñ/ÔTransverseñ osteotomy performed subperiosteally Ulna lengthened by fractional distraction. Axial k-wire in ulna in selected patients to prevent angular deformity, developing at osteotomy site during distraction. Latency period: 7days, Distraction rate: 0.8mm/day. Radial head position monitored by weekly x-rays. Static þxator time: 2x(distraction time), for consolidation of new-bone. Total þxator time: 6weeks followed by þxator removal. Brace for 2weeks with elbow-joint physiotherapy. Results: Distraction corrected ulnar deformity, restored ulnar length and radial head in anatomical position. Average ulnar length gain: 14mm. Duration of distraction: 17days. Average follow-up: 2years (1.5 Ð 4years). We achieved full, painless, stable elbow ßexion, extension, pronation and supination movements in eight but one patient. Pronosupination movement did not deteriorate over four years of study. No patient developed myositis ossiþcans or neurodeþcit. 2patients had minor pin-tract infection, subsided on treatment. Conclusion: Safe, effective and fully controlled method. This technique may be considered before open procedures for radial head.

Aims: To correct cubitus varus deformity by wedge resection and compression by external þxator for rapid osteogenesis. Methods: We treated 6patients with cubitus varus deformity secondary to malunited supra-condylar fracture of humerus. 4:M, 2:F aged between 8–14years. Duration between injury and surgery averaged 20months (1.4–2.4years). Preoperative humeroulna angle on x-ray averaged Ð18.5¡ (−12¡ to −28¡) and on contralateral limb averaged 12.4¡ (8¡−18¡). All patients had full elbow movements preoperatively. 2x2mm k-wires passed in lower humeral metaphysis parallel to joint line and 2x2mm k-wires passed in lower diaphysis perpendicular to humeral shaft. Laterally based bone wedge equivalent to preoperatively calculated template including 5¡ of over-correction was removed in between the wires. A compression distraction rod was applied to close the wedge by compression. Elbow was mobilized after postoperative pain relief in þrst week with dynamic elastic sling. Fixator was removed at 6weeks. Results: All patients achieved full elbow movements and complete cosmetic correction. Osteotomy united faster under compression. No neurovascular complication was seen. One patient had minor pin tract infection, subsided on treatment. Conclusions: Any residual corrections postoperatively are fully adjustable. Literature reports poor results of up to 30% due to loss off or inadequate correction. Stability achieved by þxator allowed early postoperative elbow mobilization. Extremely reliable, ßexible and fully controlled method.

Aims: In reconstruction of brachydactyly, either post-traumatic or congenital, we present our method of skeletal lengthening by distraction. Methods: We treated 32 short digits in 15 patients. Posttraumatic: 10patients and Congenital shortening: 5patients (Average age 5years (3.4 – 7.7 years) in congenital group). For traumatic amputation duration between injury and surgery: average 14weeks (10–19.5weeks). Concerned phalanx exposed through dorsal approach. Transfixing k-wires passed perpendicular to phalangeal shaft above and below proposed osteotomy and connected on either side to a distractor. Latency period: 5days. Distraction rate: 0.8 mm/day. Serial x-rays at 3weekly intervals. In 6patients with deficient new bone, bone grafting was done using iliac crest graft. Fixator left in situ till radiological evidence of bony healing than wires removed under local anaesthesia and patients were started on vigorous physiotherapy for gaining range of movements. 8patients required deepening of the web space in addition to above-mentioned procedures. This procedure was required in cases having more than one short digit. Results: Average length gained: 18mm. Average duration of distraction: 42.26days. Fixator in situ: average 92days (80–136days). Initial stiffness of digits was seen in 50% of cases, which eventually responded to physiotherapy, & all patients had an excellent range of motion. Conclusions: This method provides patients with good function and cosmetic hand. Any surgeon not familiar with microvascular surgery can use this technique.

Osteotomy of ulna with fractional distraction maintains ulnar length and reduced position of radial head via interrosseous membrane.

We reviewed 9 patients, 5:M, 4:F, aged 2–14 years. Interval between injury and surgery ranged 2–36months but in seven patients the repositioning was performed within 6 months. All had elbow deformity with radial head prominence. 6 patients had restricted movements of elbow. 3 had pain on movements.

2 x 2mm k-wires each, proximal and distal to ulnar osteotomy. Distal k-wires were transfixed in radius in complete supination (during distraction of ulna, radius is pulled down). ‘Z’/‘Transverse’ osteotomy was then performed subperiosteally. Ulna lengthened by fractional distraction. Axial k-wire in ulna was used in selected patients to prevent any angular deformity from developing at osteotomy site during distraction. Latency period was 7 days, Distraction rate was 0.8mm/day. Radial head position was monitored by weekly x-rays. Static fixator time was 2 x (distraction time) so as to allow time for consolidation of new-bone. Total fixator time was 6weeks followed by fixator removal and brace for 2weeks with elbow-joint physiotherapy.

Distraction corrected ulnar deformity, restored ulnar length and repositioned radial head in anatomical position. Average ulnar length gained was 14mm. Duration of distraction was 17 days. Average follow-up was 2 years (1.5 – 4years). We achieved full, painless, stable elbow flexion, extension, pronation and supination movements in eight but one patient. Pronosupination movement did not deteriorate over four years of our study. No patient developed myositis ossificans or neurodeficit. 2 patients had minor pin-tract infection, which responded to basic treatment.

Safe, effective and fully controlled method. This technique may be considered before open procedures for radial head is undertaken.