Aims

To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP).

A study of 130 scoliotic children with curves measuring 10 degrees or more has been performed in order to elucidate the importance of stature, growth and development. Girls with adolescent idiopathic curves measuring 15 degrees or more were taller than girls with smaller idiopathic curves and taller than those whose scoliosis was secondary to leg-length inequality (pelvic tilt scoliosis). No differences were observed as regards growth velocity or development. The increased standing height may be genetic but the uncoiling effect of the normal kyphosis to give a flat lateral profile is a more likely cause. The familial trend in idiopathic scoliosis may therefore be explained by the genetically determined shape of the spine in the median (sagittal) plane

The surgical treatment of Perthes’ disease by femoral or innominate osteotomy is not as effective in those over the age of eight years as it is in the younger child. This has prompted the search for other types of management in those who are older. The preliminary results of the use of a lateral shelf acetabuloplasty for such cases have shown encouraging results at two years. The concern with such an operation is that it might interfere with the growth of the outer aspect of the acetabulum and so prejudice the long-term outcome. We describe a review at maturity of 26 children presenting with early disease after the age of eight years who were treated by lateral shelf acetabuloplasty. The results suggest that the outcome is improved; 22 of 27 hips were rated as Stulberg groups 1 to 3. Poor results occurred in children, particularly girls, presenting with Group-4 disease over the age of 11 years

Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes premature physeal closure. The use of a modified, standard, single, cannulated screw designed to maintain epiphyseal fixation without causing premature closure of the physis was reviewed in ten patients. The nine boys and one girl aged between 10.6 and 12.6 years with unilateral slipped capital femoral epiphysis (SCFE), were markedly skeletally immature (Tanner stage I, bone age 10 to 12.6 years). Clinical and radiological review at a mean follow-up of 44.3 months (36 to 76) showed no difference in the time to physeal closure between the involved and uninvolved side. Measurement of epiphyseal and physeal development showed continued growth and remodelling in all patients. Use of this device provided epiphyseal stability and maintained the capacity for physeal recovery and growth following treatment for both unstable and stable slipped capital femoral epiphysis

We made a prospective longitudinal clinical and radiological study of 18 children diagnosed as having dysplasia epiphysealis capitis femoris. Half the cases were bilateral. Boys were affected five times more often than girls. There were no symptoms or clinical signs in most but some of the bilateral cases had an inconsistent waddling gait. The imaging studies suggest that the cartilaginous proximal femoral epiphysis is hypoplastic, with delayed appearance of single or multiple ossification centres. Progressive improvement occurred and at an average age of five years and six months, there was complete fusion of all the ossific nuclei and normal density and texture of the epiphyseal bone. The end result was a round epiphysis with a slightly diminished height. The dysplasia is attributed to focal hypoplasia of the proximal femoral epiphysis

Hereditary multiple exostoses is an autosomal dominant disorder characterised by multiple osteochondromata, most commonly affecting the forearm, knee and ankle. Osteochondromata of the proximal femur have been reported to occur in 30% to 90% of affected patients with coxa valga in 25%. Acetabular dysplasia is rare but has been described. This is the first report of a patient requiring surgical intervention. A girl was seen at the age of nine with hereditary multiple exostoses and when 12 developed bilateral pain in the groin. Radiographs showed severely dysplastic acetabula with less than 50% coverage of the femoral heads and widening of the medial joint space. Large sessile osteochondromata were present along the medial side of the femoral neck proximal to the lesser trochanter, with associated coxa valga. The case illustrates the importance of obtaining initial skeletal surveys in children with hereditary multiple exostoses to identify potential problems such as acetabular dysplasia and subluxation of the hip

A 14-year-old girl with a congenitally deformed and shortened right leg and foot is described. The patient could not bear weight on the deformed limb and had to hop on the left leg. The deformed foot faced backwards and had nine toes. The right leg was shorter than the left by 26 centimetres. Radiologically, the lower end of the right femur was ill-developed and there was no knee joint. There were two fibulae and the tibia and the patella were absent. A through-knee disarticulation was done and a prosthesis fitted later. The amputated leg and foot were dissected. Many of the muscles in the leg and foot were duplicated. There were two calcanei, one talus, one navicular, two cuboids and four cuneiforms. Ther were nine metatarsals, and all the toes had three phalanges except for one which had two

The different methods described in the literature for the reduction of severe spondylolisthesis are reviewed. The case histories of two girls with neurological deficits in their legs due to Grade IV spondylolisthesis are described. Reduction and fusion by the posterior route in a one-stage operation were performed on these patients. For this purpose special instruments have been designed to exert a controlled force on the displaced vertebra in two perpendicular directions. Technical details of the procedure are reported. In both patients intervertebral and posterolateral fusion were carried out. Fusion was successful and redisplacement did not occur. There have been only few descriptions in the literature of a technique that reduces and stabilises spondylolisthesis in one stage. However, only patients with Grade III and IV spondylolisthesis require reduction and in less severe cases fusion without reduction is sufficient

A randomly selected sample of 3494 children evenly representing a total population of 37 391 schoolchildren aged between eleven and twelve was screened for idiopathic scoliosis by the bending test. Ten per cent of the children showed clinical evidence of scoliosis and 6.4 per cent had positive radiological findings. Small curves were equally distributed between the two sexes, while large ones were more common in girls. Children with fair hair and blue eyes showed a higher percentage of positive findings than children with a dark complexion. A group of 112 children with curves between 7 and 16 degrees were followed up for an average of nineteen months. The pattern and evolution of these curves showed their close relationship to established scoliosis. Potential factors of instability and deterioration of the curves were evaluated

Seventy children who had suffered from Perthes' disease were reviewed clinically and radiologically three to eight years from the onset of the condition in order to determine retrospectively the most satisfactory method of assessing the prognosis and the correlation between the clinical and radiological result. In younger children the femoral head was more likely to be spherical at the conclusion of the pathological process but not necessarily of normal proportions nor normally covered by the acetabulum. The prognosis was significantly poorer for girls than for boys. Clinical factors were not an aid to prognosis in the individual cases, but overall there was a close correlation between the clinical and the radiological end-results. The most reliable radiological factors indicating the prognosis were the extent of uncovering of the femoral head, the Catterall grouping, the presence of calcification lateral to the outer limit of the acetabulum and lateral displacement of the femoral head, as measured by comparing the head to tear-drop distances on each side

The bone-marrow oedema syndrome is associated with local vascular disturbances and may be treated either conservatively or by core decompression after which recovery may take several weeks. We describe a 15-year-old girl with bone-marrow oedema of the left acetabulum which was confirmed by MRI. She presented with a four-week history of severe constant pain. Routine blood tests and plain radiographs were normal. She was treated with intravenous infusions of iloprost on five consecutive days (20 μg administered in 500 ml of sodium chloride). Iloprost causes vasodilatation with reduction of capillary permeability and it inhibits platelet aggregation. She had relief from pain at rest after three days of treatment and was completely free from symptoms after two weeks. MRI after six weeks showed almost complete resolution of the marrow oedema and was normal after four months. This is the first report of the pharmacological treatment of the bone-marrow oedema syndrome in children

We have examined the effect of arthrodiastasis on the preservation of the femoral head in older children with Perthes’ disease. We carried out a prospective trial in boys over the age of eight years and girls over seven years at the time of the onset of symptoms. The patients had minimal epiphyseal collapse and were compared with a conventionally treated, consecutive, historical control group. Arthrodiastasis was applied for approximately four months. The primary outcome measure was the extent of epiphyseal collapse at the end of the fragmentation phase. One of the 15 treated hips and nine of the 30 control hips showed a loss of height of 50% or more of the lateral epiphyseal column on the anteroposterior radiographs (Herring grade-C classification). On a Lauenstein view, one of the treated hips and 19 of the control hips showed at least a loss of height of 50% of the anterior epiphyseal column. The complications of arthrodiastasis included pin-site infection in most hips, transient joint stiffness in two, and breakage of a pin in two. The final outcome will be known when all the patients and the control group reach skeletal maturity

Forty-nine patients treated by epiphysial stapling for idiopathic genu valgum are reviewed. The children were aged from eleven to fourteen and a half years. The severity of the condition and subsequent correction were assessed by measuring the inter-malleolar distance. Results show that femoral stapling is the treatment of choice for most patients with inter-malleolar separation of up to 12-5 centimetres. The optimum age for stapling for both boys and girls is eleven and a half years. Stapling of both epiphyses is advised for those patients presenting late, for example, between thirteen and fourteen and a half years, or where the deformity is greater than 12-5 centimetres of separation. Correction rarely takes more than one year, and was cosmetically satisfactory in all cases. The operation is virtually free from complication except for a tendency for the scars to be broad and conspicuous. Stapling has proved to be a safe, effective and predicatable operation for idiopathic genu valgum

It has been noted that bony union of a pars defect can be achieved in children if they wear a trunk brace. Our aim was to evaluate how the stage of the defect on CT and the presence or absence of high signal change in the adjacent pedicle on T2-weighted MRI were related to bony healing. We treated 23 children conservatively for at least three months. There were 19 boys and four girls with a mean age of 13.5 years (7 to 17). They were asked to refrain from sporting activity and to wear a Damen soft thoracolumbosacral type brace. There were 41 pars defects in 23 patients. These were classified as an early, progressive or terminal stage on CT. The early-stage lesions had a hairline crack in the pars interarticularis, which became a gap in the progressive stage. A terminal-stage defect was equivalent to a pseudarthrosis. On the T2-weighted MR scan the presence or absence of high signal change in the adjacent pedicle was assessed and on this basis the defects were divided into high signal change-positive or -negative. Healing of the defect was assessed by CT. In all, 13 (87%) of the 15 early defects healed. Of 19 progressive defects, only six (32%) healed. None of the seven terminal defects healed. Of the 26 high signal change-positive defects 20 (77%) healed after conservative treatment whereas none of the high signal change-negative defects did so. We concluded that an early-stage defect on CT and high signal change in the adjacent pedicle on a T2-weighted MR scan are useful predictors of bony healing of a pars defect in children after conservative treatment

The hips of 1000 newborn babies were examined clinically and by ultrasonography. The ultrasound assessment was based on measurements of the coverage of the femoral head by the bony acetabular roof, and this parameter was called the Bony Rim Percentage (BRP). The mean BRP was 55.3% in girls and 57.2% in boys, a significant difference. Clinical instability occurred in 0.7% of the newborn babies, and all of the unstable hips had a BRP below the lower limit of normal. All infants with normal clinical findings and suspected abnormal hips based on ultrasound were followed up; in all but two the hips became normal spontaneously. We conclude that ultrasonography, using the measurements of femoral head coverage, is appropriate for screening the newborn, is reliable in differentiating between a true and a false positive Ortolani sign, and that hip dysplasia which is not clinically demonstrable at birth can be detected by ultrasound. Ultrasound should replace radiography as the routine method of following up high-risk infants and those with suspicious signs

Recent clinical studies have suggested that a neurological lesion may be a cause of adolescent idiopathic scoliosis and animal experiments have implicated the posterior column pathway. We have tried to determine if differences in neurological response could be detected and measured clinically, and have compared the threshold of detection of vibratory sensation in 20 girls with adolescent idiopathic scoliosis with that in 20 clinically normal age-matched controls. A highly significant reduction of the threshold of detection of vibration was seen in the scoliotic group compared to the controls (p less than 0.001). Curve magnitude did not correlate with this threshold for either the upper (r = 0.172) or lower extremity (r = 0.126). Significant asymmetry between right- and left-sided thresholds to vibration was demonstrated in the scoliotic group. Our study supports the concept that an aberration in the function of the posterior column pathway of the cord may be of primary importance in the aetiology of idiopathic scoliosis. A clinically practical test to measure this function is presented

Aims

Perthes’ disease is a condition leading to necrosis of the femoral head. It is most common in children aged four to nine years, affecting around one per 1,200 children in the UK. Management typically includes non-surgical treatment options, such as physiotherapy with/without surgical intervention. However, there is significant variation in care with no consensus on the most effective treatment option.

Seat-belt fractures of the lumbar spine in adolescents and adults are well recognised but there are few reports of these injuries in young children. We reviewed all seat-belt injuries in skeletally immature patients (Risser 0), seen at a tertiary referral centre between 1974 and 1991. There were ten cases, eight girls and two boys, with an average age of 7.5 years (3 to 13). Four distinct patterns of injury were observed, most commonly at the L2 to L4 level. Paraplegia, which is thought to be uncommon, occurred in three of our ten cases. Four children had intra-abdominal injuries requiring laparotomy. There was a delay in diagnosis either of the spinal or of the intra-abdominal injury in five cases, although all had contusion of the abdominal wall, the 'seat-belt sign'. Treatment of the fractures was conservative, by bed rest and then hyperextension casts. The incidence of this potentially devastating injury can be reduced by the optimal use of restraints, but there is often a delay in diagnosis. Our classification system may aid in the early detection and evaluation of this injury

At The Hospital for Sick Children in Toronto, 21 undescended scapulae were corrected by the Woodward procedure in 20 patients over the past 18 years. The average age at operation was six years six months. The average follow-up period after operation was 8 years 9 months. Fifteen patients were girls and five were boys. All the patients had other associated abnormalities. Only one patient had a concomitant clavicular osteotomy. The average increase in glenohumeral abduction was 37 degrees. The average scapular lowering was two centimetres. Excellent or good cosmetic results were obtained in 80 per cent of patients. Ninety-three per cent of patients expressed satisfaction with the operative results. Complications were few. The Woodward procedure is a safe and relatively straightforward surgical means to effect a good cosmetic and functional improvement in a patient with a congenital undescended scapula. We do not recommend clavicular osteotomy as a routine, but it may be added to gain more correction with less risk of neurovascular compression

A girl aged ten, of Cape Coloured stock, with typical features of parastremmatic dwarfism has been investigated. The clinical manifestations included disproportionate dwarfism, limb deformity, a short stiff neck, and marked thoracic kyphosis. The radiographic changes were dramatic, the skeleton having a "flocky" appearance due to patches of radiolucency in an irregular lattice of sclerosis. The metaphyses and epiphyses of the long bones were grossly expanded, and the vertebrae were flattened and distorted. The clinical and radiographic features of five other previously reported individuals with parastremmatic dwarfism were very similar to those of our patient. The differential diagnosis of this condition includes metatrophic dwarfism, diatrophic dwarfism and the spondylo-epiphysial dysplasias. However, the unique "flocky" radiographic appearance of the bones permits diagnostic precision. There is some evidence to indicate that parastremmatic dwarfism might be transmitted as an autosomal dominant, although this is by no means certain. The fact that our patient had seven normal siblings and unaffected parents would be compatible woth autosomal recessive inheritance