We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up

Aims . To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. . Patients and Methods. A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients’ injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. Results. In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Conclusion. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255–60

Although much has been published on the causes of slipped upper femoral epiphysis and the results of treatment, little attention has been given to the mechanism of the slip. This study presents the results of the analysis of 13 adolescent femora, and the attempts to reproduce the radiological appearances of a typical slip. The mean age of the skeletons was 13 years (11 to 15). It was found that the internal bony architecture in the zone of the growth plate was such that a slip of the epiphysis on the metaphysis (in the normal meaning of the word slip) could not take place, largely relating to the presence of a tubercle of bone projecting down from the epiphysis. The only way that the appearance of a typical slipped upper femoral epiphysis could be reproduced was by rotating the epiphysis posteromedially on the metaphysis. The presence and size of this peg-like tubercle was shown radiologically by CT scanning in one pair of intact adolescent femurs

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

1. Epiphysial tilt commonly precedes slipping. 2. This tilt is due to a diminished or arrested growth from compression of the back of the epiphysial plate. 3. The stresses on the upper end of the femur are such that the upper femoral epiphysial plate is peculiarly liable to compression. 4. A primary abnormality of the cartilage of the epiphysial plate renders it susceptible to the effect of compression. 5. Because this abnormality is diffuse, deformities due to a similar pathology may be found elsewhere, notably in the spine

1. During the past twenty-five years there have been admitted to this orthopaedic service twelve children or adolescents having a close relative who previously or subsequently developed slipped upper femoral epiphysis. This represents an incidence of approximately 7 per cent. 2. There is some evidence that the incidence is considerably higher. 3. In addition to those with close relations also with slipped epiphysis, two patients had parents with osteoarthritis of the hip. 4. I believe, therefore, that in slipped upper femoral epiphysis there is evidence of a genetic defect. This is probably due to a recessive gene of low penetrance. The frequency in this region is high because the north-east of Scotland has very definite geographical boundaries and the rural, agricultural population, from which the majority of these cases were drawn, has formed until recently a stable community likely to show a greater than average incidence

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head–shaft slip angle from 53.8. o. (standard deviation (. sd) 3.2). pre-operatively to 9.1. o. (. sd. 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, . sd. 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. . This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre. Cite this article: Bone Joint J 2015;97-B:1718–25

1. An apparatus was designed to determine the shearing strength of the upper tibial epiphysis in the rat. Observations were made with this instrumenton normal animals, on animals receiving growth-hormone, and on animals receiving oestrogen. 2. When the epiphysis separates from the diaphysis, the plane of cleavage is constant, passing through the third layer of the epiphysial plate. 3. Growth-hormone decreases and sex-hormone increases the shearing strength of the epiphysial plate. These changes are due to alterations produced by these two hormones in the thickness of the third layer of the epiphysial plate. 4. It is suggested that these findings may be of significance in providing an anatomical basis for slipping of the upper femoral epiphysis in man, especially when it is associated with the adiposo-genital syndrome or with rapid adolescent growth

The pathogenesis of slipped upper femoral epiphysis is unknown but the condition has been linked with various endocrine disorders. Nine patients with slipped epiphyses in association with primary juvenile hypothyroidism are presented. In all patients, slipping occurred or symptoms developed in the affected hip before the hypothyroidism was diagnosed. A generalised pathology was suggested by the absence of trauma (8 patients), by bilateral slipping (6 patients), and by obesity and short stature in all patients. All cases had delayed skeletal maturation and characteristic metaphysial changes were seen on their radiographs. The clinical diagnosis of juvenile hypothyroidism can be difficult but it merits consideration in patients who have a slipped upper femoral epiphysis in association with short stature, obesity, delay in skeletal maturity, or any one of these

Slipped upper femoral epiphysis remains a disease of unknown aetiology. Recent evidence has bolstered speculation that the immune system may play a role in the aetiology or pathogenesis of slipped epiphysis or of one of its complications, chondrolysis. This study reports the finding of immune complexes in the synovial fluid of all but one hip affected with slipped epiphysis in a consecutive series. In seven patients, immune complexes were detected by both the Raji cell assay and C1q-binding assay; in two, by the C1q-assay only; and in one, by the Raji cell assay only. No patients had immune complexes in the serum. Twenty-one patients with synovitis of the knee or hip caused by a variety of disorders served as the control group. Two of these patients had immune complexes in their synovial fluid. It appears that the immune complexes characterise the synovitis found with slipped upper femoral epiphysis as distinct from most other synovitides

We report 16 cases in which the upper cervical spine was approached through the mouth for operative decompression and stabilisation, with or without removal of diseased tissues. The indications are discussed and the technique is described. Results are compared with those of other reported series. We believe that this operation has a place in the treatment of certain conditions affecting the upper part of the cervical spine and the foramen magnum, with or without involvement of the medulla and spinal cord

1. Thirteen cases of traumatic separation of the upper femoral epiphysis have been studied. Four were previously reported and nine new cases are analysed. 2. This is a rare injury occurring in young children and is due to severe violence. 3. Separation occurred at the epiphysial plate, and severe posterior displacement was frequent. The fracture line does not penetrate the epiphysis. 4. Premature fusion, avascular necrosis or non-union (individually or together) occurred in eleven of the thirteen patients. 5. Separation of the upper femoral epiphysis is a serious injury which is likely to lead to permanent deformity

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae

Six patients, aged between 3 and 51 years, with tuberculosis of the upper cervical spine were studied. Prominent features of the disease included pain and stiffness, paralysis, swelling of the retropharyngeal soft tissue, osteolytic erosions, and atlanto-axial subluxation. Cure was obtained with antibiotics, transoral decompression and C1-2 fusion

We reviewed the management of 100 cases of slipped upper femoral epiphysis treated over a period of 26 years. A total of 14 slips was identified as unstable on admission. These underwent reduction and stabilisation within 24 hours of the onset of severe symptoms. Of the 86 stable slips four progressed to avascular necrosis (AVN), which was not seen in the unstable slips. The literature on slipped upper femoral epiphysis suggests that the acute unstable slip is at higher risk of developing AVN. We recommend reduction and stabilisation of unstable slips within 24 hours of the onset of symptoms in order to reduce the risk of AVN

Slipped upper femoral epiphysis (SUFE) with an open physis is rare in an adult and the condition may present without prior diagnosis of an underlying medical condition. We have treated a 29-year-old man with bilateral SUFE associated with autoimmune hypothyroidism. The management was delayed and complicated by co-existing autoimmune chronic active hepatitis. He underwent thyroxine therapy and bilateral pinning in situ with a single ASNIS screw. Closure of the physis occurred after five months on the right side. The left side required a further corrective intertrochanteric osteotomy, and it was only after 13 months that complete fusion of this physis was seen. The case highlights the need to consider endocrine and metabolic conditions in atypical presentation of SUFE

Ten uncemented total hip replacements were performed in 1975 using an implant in which the cobalt-chrome femoral stem was coated to give a porous surface. In all but one case a high-density polyethylene head was used. The radiological changes in the upper femoral shafts were assessed between three and nine years later. Seven showed extensive stress-relieving changes, loss of calcar, stress fractures at the root of the lesser trochanter with subsequent detachment, and osteoporosis followed by avulsion of the greater trochanter. In these seven patients the lower part of the stem appeared to be soundly embedded, although in only one was there evidence of bony incorporation. It is suggested that if the fixation of a fully coated implant of this sort remains sound, gross atrophy of the upper femoral shaft develops after five years. This atrophy, associated with an implant which can be removed only at the expense of further bone destruction, presents substantial problems if revision is needed

We describe a surgical approach to the upper thoracic spine which allows an adequate exposure of the vertebral bodies from T1 to T3. The approach causes little functional disturbance and is especially useful in older patients with spinal tumours causing spinal cord compression

1. The surgical management of two children with congenital hypoplasia of the upper end of the femur is described. 2. Early exploration is advocated to establish the nature and extent of the anomaly and to attempt its correction. 3. The preliminary results are sufficiently encouraging for us to recommend that further attempts at surgical treatment be considered in patients with this disorder