A survey of 6000 schoolchildren discovered 36 cases of unilateral and 60 cases of bilateral hallux valgus, defined as a metatarsophalangeal angle of more than 14.5 degrees, measured on standing radiographs. Metatarsus primus varus was found not only in the early stages of hallux valgus but in the unaffected feet of children with unilateral hallux valgus. Adduction of the first metatarsal is not due to differential growth of the cortices of the first metatarsal nor is it a consequence of malalignment of the metatarsocuneiform joint. The intermetatarsal angle did not correlate with the angle of metatarsus adductus nor with the intercuneiform angle

Two siblings with spondylothoracic dysostosis, and two siblings and three unrelated children with spondylocostal dysostosis are described. Both conditions are inherited and characterised by malformed thoracic and lumbar vertebrae. Spondylothoracic dysostosis produces "crab-like" deformities of the ribs, and is usually fatal during early infancy due to respiratory failure. Spondylocostal dysostosis causes short-trunked dwarfism but does not usually reduce life expectancy. These clinical features are distinct from congenital scoliosis, although all three conditions are associated with a particular group of malformations

An alternative to Syme's amputation for congenital absence of the fibula is described in this paper. Nine children have had the ankle reconstructed using the Gruca technique with a very satisfactory result in eight. This procedure is not suitable for every patient and in most unilateral cases the operation can only be regarded as an interim procedure because of progressive leg-length inequality. The decision to remove the foot may be delayed and it allows childhood to be spent without resort to prostheses. However, the procedure can be considered as the definitive operation in cases of bilateral deformity

We present three cases of a previously undescribed condition characterised by unilateral tibia vara associated with an area of focal fibrocartilaginous dysplasia in the medial aspect of the proximal tibia. The three children affected were aged 9, 15 and 27 months respectively. Two required tibial osteotomy, but in one the deformity resolved without treatment. The pathogenesis of the focal lesion remains conjectural; the most likely explanation is that the mesenchymal anlage of the tibial metaphysis has, for unknown reasons, developed abnormally at the insertion of the pes anserinus

Seven children underwent partial meniscectomy for symptomatic discoid lateral meniscus. This procedure, modifying the discoid meniscus to the normal semilunar shape, was indicated only when degeneration or tear was minimal, when the meniscus was not abnormally thickened nor of Wrisberg type, when it was not hypermobile, when the capsular attachment was intact, and when the residual meniscus was free from abnormality. The results were excellent clinically, radiologically and arthroscopically, rehabilitation was shortened to half that required for total meniscectomy and the residual meniscus functioned entirely normally

The Fairbank Collection in the Radiology Department of the Royal National Orthopaedic Hospital contains details of 15 patients in the section labelled "Metaphysial Dysplasia and Dysostosis". This material has been reviewed, long-term follow-up of the patients carried out and the diagnosis revised, where indicated, according to current concepts. Of the 15 patients, all children, seven had recognisable bone dysplasias. The remaining eight, all listed under the heading "metaphysial fragility", had the characteristic radiographic features of "battered" babies

1. Congenital coxa vara and infantile coxa vara must be separated as distinct entities. 2. Infantile coxa vara is likely to be due to distal movement of the head fragment relative to the shaft and neck. This can result either from severe trauma in normal bone or from shearing stress on an abnormal femoral neck. 3. There is no justification for considering infantile coxa vara as congenital, developmental or due to interruption of ossification. The nature of the pathological lesion at the epiphysial line in some children is unknown

We report the results of a new surgical procedure for spastic equinovarus deformity due to cerebral palsy. This is the transfer of the anterior half of the split tibialis posterior to the dorsum of the foot through the interosseous membrane. We performed the operation on 23 feet in 18 children. All patients were assessed before operation and at follow-up at a mean of 8.4 years postoperatively. Using the criteria of Kling et al (1985), excellent results were obtained in 14 feet, good results in eight, and a poor result in only one

Traction injury to the sciatic nerve can occur during hamstring lengthening. The aim of this study was to monitor the influence of hamstring lengthening on conduction in the sciatic nerve using evoked electromyography (EMG). Ten children with spastic cerebral palsy underwent bilateral distal hamstring lengthening. Before lengthening, the evoked potential was recorded with the patient prone. During lengthening, it was recorded with the knee flexed to 90°, 60° and 30°, and at the end of lengthening with the hip and knee extended. In all patients, the amplitude of the evoked EMG gradually decreased with increasing lengthening. The mean decrease with the knee flexed to 60° was 34% (10 to 77), and to 30°, 86% (52 to 98) compared with the pre-lengthening amplitude. On hip extension at the end of the lengthening procedure, the EMG returned to the pre-lengthening level. Monitoring of the evoked EMG potential of the sciatic nerve during and after hamstring lengthening, may be helpful in preventing traction injury

Five children with atlanto-axial rotatory fixation (AARF) in association with fractures of the clavicle are described. It is postulated that the rotary fixation is a direct result of the trauma which produces the fracture. The importance of early diagnosis is stressed, since delayed diagnosis may lead to chronic deformity. Early diagnosis depends on awareness of the possibility of AARF, and either fluoroscoping the patient in order to take appropriate spot films or imaging the atlanto-axial joint by CT. A simple classification of AARF is proposed based on distinct radiological features which differentiate subluxation from dislocation

We describe a congenital deformity of the foot which is characterised by calcaneus at the ankle and valgus at the subtalar joint; spontaneous improvement does not occur and serial casting results in incomplete or impermanent correction of the deformities. Experience with five feet in four children indicates that release of the ligaments and tendons anterior and lateral to the ankle and lateral to the subtalar joint is the minimum surgery necessary; subtalar arthrodesis may be required in addition. The foot deformity described may occur as an isolated condition or in association with multiple congenital anomalies. The possibility of a neurological deficit should always be excluded

The late results of treatment of 24 legs in 21 children with congenital deficiency of the tibia are presented. A new classification is proposed which correlates well with recommendations for treatment and with the final functional result. Three types of deficiency were recognised: Type I, total absence of the tibia; Type II, distal absence; Type III, distal deficiency with tibiofibular diastasis. The early radiographic appearances, the functional status of the quadriceps and the severity of flexion contracture of the knee were important factors in the selection of the operations likely to give the best function

The term flat foot is surrounded by confusion and there is little to help the clinician to identify cases which require treatment and to avoid treating many children unnecessarily. Research for 25 years has been aimed at elucidating this problem by identifying and evaluating a series of signs and tests. These tests allow the recognition of the abnormal foot as early as possible, when efficient treatment is likely to be most effective. The results indicate that evaluation of the flat foot should be based on a combination of signs, with most emphasis on the result of the great toe extension test

Cubitus varus is the most common complication of supracondylar fracture of the humerus in children. Although function of the elbow is not greatly impaired, the deformity is unsightly. It usually results from malunion, since growth disturbance of the humerus after this fracture is uncommon. The normal carrying angle can be restored by supracondylar osteotomy. This operation was done in 32 patients over a ten-year period, 16 of them using the technique described by French (1959). The results in 27 patients are reviewed in the light of previous reports. French's method proved safe and satisfactory

This paper reports on a prospective study undertaken to determine the natural history of untreated idiopathic hooked forefoot. The progress of 130 affected feet in eighty-three children was followed for an average of seven years. At review 86% of the feet were normal or only mildly deformed and all were fully mobile; 10% were still moderately deformed but were asymptomatic; 4% remained deformed and stiff. It was not possible to detect these resistant cases before the age of three years, but the low failure rate would seem to justify a policy of expectant treatment

1. The management of fractures in five patients with haemophilia is described: two patients had antibodies to antihaemophilic globulin. 2. The principles of management of injured haemophilia patients are described, as are the special problems in patients with antibodies to AHG. 3. Stability of the fragments must be achieved to prevent the hazards of displacement of the fracture, recurrent bleeding and pseudotumour formation which may threaten viability of the limb. 4. Stabilisation of potentially unstable fractures can be achieved at the onset by internal fixation. Plaster casts should be reserved for stable fractures or fractures occurring in young children

1. Previous reports of the role of the quadriceps in producing limitation of movement or dislocation of the patella have tended to implicate one particular part of the complex. Experience gained in thirty-five quadricepsplasties in children has shown that all parts of the quadriceps (except vastus medialis) and the ilio-tibial band also may play a part and that each of these must be attended to if a satisfactory result is to be obtained. 2. A simple technique of operation is described and illustrated. 3. Since this paper was prepared, a patient showing features of particular interest has been seen and treated

1. A rationale of subtrochanteric osteotomy with derotation and varus angulation in the treatment of Perthes' disease is suggested. 2. Three months after operation the child returns to a normal unrestricted life. 3. The anatomical results in twelve such operations with an average follow-up of two years and five months are presented. In five children the results were "very good," in four "good," in one "fair" and in one "bad.". 4. These results seem to compare favourably with those observed after conservative treatment of two, three or more years duration

Failure of massive knee endoprostheses implanted for malignant tumours of the distal femur in children presents a difficult problem. We present the results of rotationplasty undertaken under these circumstances in four boys. They had been treated initially at a mean age of 9.5 years for a stage-IIB malignant tumour of the distal femur by resection and implantation of a massive knee endoprosthesis. After a mean period of eight years and a mean of four operative procedures, there was failure of the endoprosthesis because of aseptic loosening in two and infection in two. Function was poor with a mean Musculoskeletal Tumor Society score of 7.5/30, and considerable associated psychological problems. At a mean follow-up of 4.5 years after rotationplasty there was excellent function with a mean score of 27.5/30 and resolution of the psychological problems

In this prospective study of 18 hips we compared the efficacy of ultrasound with CT in determining the position of the femoral head in a spica cast after closed or open reduction in children with developmental dysplasia of the hip. Ultrasound was performed through the perineal opening of the cast. With a transinguinal approach, the superior ramus of the pubis, the acetabulum, the femoral head and the femoral neck can be depicted in one plane. The CT and ultrasound images were blinded and reviewed by two of the authors. Ultrasound was inconclusive in the first two reductions since the perineal opening was too small to see all the landmarks in one plane. In the following 16 reductions the landmarks were well defined and interpretation of the CT and ultrasound was similar. The perineal opening in the spica cast should be made in such a way that the ultrasound probe can be positioned in the groin so that the landmarks can be shown in one plane