Developmental Coxa Vara
Dr. Emad,There are three main types of coxa vara.Congenital includes PFFD/congenital short femur, and congenital bowed femurDevelopmental is not present at birth, but develops shortly thereafter. This includes isolated cases (but not PFFD) and those associated with skeletal dysplasias such as cleidocranial dysostosis, Jansen's metaphyseal chondrodysplasia, and SMD Kozlowski type.Acquired includes rickets, fibrous dysplasia, and early traumatic proximal femoral epiphyseal plate closureFor a technique paper with great figures, see Heimkes et al.[Subtrochanteric end-to-side valgus osteotomy for severe infantile coxa vara].Heimkes B, Komm M, Melcher COper Orthop Traumatol. 2009 Mar. doi: 10.1007/s00064-009-1609-7. 21. (1). :97-111PMID: 19326071 (Link to Abstract)
Slipped Capital Femoral Epiphysis
Another article commonly referenced for the modified Dunn is from Slongo et al who reported the results of 23 patients treated with this procedure. However, this series included 3 patients pre-operatively classified as unstable using the Loder criteria, compared to all 27 hips in the series reported by Sankar et al.Treatment of slipped capital femoral epiphysis with a modified Dunn procedure.Slongo T, Kakaty D, Krause F, Ziebarth KJ Bone Joint Surg Am. 2010 Dec 15. pii: 92/18/2898. doi: 10.2106/JBJS.I.01385. 92. (18). :2898-908PMID: 21159990 (Link to Abstract)
For the modified Dunn procedure for unstable slips, see Sankar et al. Five surgeons from different institutions treated 27 unstable hips with the modified Dunn procedure. Four patients (15%) had broken implants at three to eighteen weeks after surgery and required revision fixation. Seven patients (26%) developed osteonecrosis at a mean of 21.4 weeks, with each surgeon having at least one case of osteonecrosis.The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multicenter perspective.Sankar WN, Vanderhave KL, Matheney T, Herrera-Soto JA, Karlen JWJ Bone Joint Surg Am. 2013 Apr 3. pii: 1668920. doi: 10.2106/JBJS.L.00203. 95. (7). :585-91PMID: 23553292 (Link to Abstract)
Pediatr Radiol. 1998 Aug;28(8):612-6.
Dr. Waibel,I think the most effective imaging study for tarsal coalition depends on a number of factors including type of coalition as well the definition of effective (most sensitive, most specific, most cost effective, etc...).For tarsal coalitions, an oblique radiograph is needed for calcaneonavicular coalitions and an axial view for talocalcaneal coalitions. A standing AP x-ray of the ankle is recommended to identify a ball and socket ankle which may be present with non-idiopathic coalitions. Radiographs may miss the coalition, especially talocalcaneal, thus requiring advanced imaging. CT vs MRI is interesting. Emery et al compared the two by obtaining both studies on 40 feet in 20 consecutive patients referred for possible tarsal coalition. Both tests identified 15 coalitions and each missed 1 calcaneonavicular coalition. However, an atypical incomplete talocalcaneal coalition seen on CT was not identified prospectively on MRI. While MRI is likely not the first line study, it can be helpful to identify fibrous coalition not seen on CT.Tarsal coalition: a blinded comparison of MRI and CT.Emery KH, Bisset GS 3rd, Johnson ND, Nunan PJPediatr Radiol. 1998 Aug. doi: 10.1007/s002470050430. 28. (8). :612-6PMID: 9716636 (Link to Abstract)
I wonder if a standard radiograph (anteroposterior view, standing lateral foot view, 45-degree internal oblique view) or CT scan would be most effective in diagnosing a TC.
Tibial Tubercle Fracture (C2414)
11 / M - Acute knee pain after an injury during a soccer match.
How would you treat this injury?
I believe that the choice of treatment was adequate to initiate an early rehabilitation
excellent case, and great result ¡¡¡
what is the differences between congenital vs developmental vs adolescent coxa vara?
Subtrochanteric fracture extended to the neck in female child (C2348)
4 / F - S/p car accident 5/4/2015
How would you classify this fracture on initial injury?
Dr Jeff,how you will fix subtroch fx in 3 years old?
Great short term outcome. The greatest risk of course, is re-fracture. Avoidance of this complication lends itself to justification of an external fixation approach.My experience with subtrochanteric fractures and flexible nailing has been positive in the right patient. Minimally invasive, low risk of infection or re-fracture, and easy to care for have been my suggestions.The definition and treatment of pediatric subtrochanteric femur fractures with titanium elastic nails.Pombo MW, Shilt JSJ Pediatr Orthop. 2006 May-Jun. doi: 10.1097/01.bpo.0000203005.50906.41. pii: 01241398-200605000-00016. 26. (3). :364-70PMID: 16670550 (Link to Abstract) A paper by Li et al reporting a higher complication rate failed to used advanced techniques in flexible nailing (evidenced by technique demonstrated in Figure 1 of paper) and therefore is a poor comparison of outcomes. Furthermore, the authors conclusions that earlier weight bearing is possible from plating was not supported by their own data, in which patients undergoing flexible nailing began walking earlier.Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures.Li Y, Heyworth BE, Glotzbecker M, Seeley M, Suppan CA, Gagnier J, VanderHave KL, Caird MS, Farley FA, Hedequist DJ Pediatr Orthop. 2013 Apr-May. doi: 10.1097/BPO.0b013e318288b496. pii: 01241398-201304000-00003. 33. (3). :232-8PMID: 23482257 (Link to Abstract)
J Hand Surg Am. 2008 Dec;33(10):1911-23.
Distal Radius Fractures - Pediatric
Dr. Ulstrup,Bae suggests that surgical indications for distal radius physeal fractures include irreducible fractures and those with soft-tissue compromise or neurovascular injury that precludes cast immobilization. Tolerances for translation in this injury are mentioned less often. The textbook Skeletal Trauma in Children (3rd edition) suggests using 50% of apposition with correction of angular and rotational malalignment will be sufficient for tolerances, especially if there is more than 2 years of growth remaining.Pediatric distal radius and forearm fractures.Bae DSJ Hand Surg Am. 2008 Dec. pii: S0363-5023(08)00894-0. doi: 10.1016/j.jhsa.2008.10.013. 33. (10). :1911-23PMID: 19084202 (Link to Abstract)
Proximal Humerus Fracture - Pediatric
Dr. Lescheid:If you achieve acceptable reduction with a closed method, crpp is certainly acceptable in both the pediatric and adult literature. The link is to the adult section: http://www.orthobullets.com/trauma/1015/proximal-humerus-fracturesThanks for the comment.
If length, rotation and angulation are acceptable, how much ad latus dislocation can be accepted with no need for further intervention for a paediatric distal radius SH2-fracture?
Instr Course Lect. 1999;48:543-50.
This is a good article.
Legg-Calve-Perthes Disease (Coxa plana)
Dr. Shafik,Yes, most studies support observation alone for Perthes with age of onset < 6 years. Herring described four lateral pillar groups: A, B, B/C, and C. A D group was not described.The natural history of Perthes' disease.Terjesen T, Wiig O, Svenningsen SActa Orthop. 2010 Dec. doi: 10.3109/17453674.2010.533935. 81. (6). :708-14PMID: 21067434 (Link to Abstract)Legg-Calve-Perthes disease. Part I: Classification of radiographs with use of the modified lateral pillar and Stulberg classifications.Herring JA, Kim HT, Browne RJ Bone Joint Surg Am. 2004 Oct. pii: 86/10/2103. 86-A. (10). :2103-20PMID: 15466719 (Link to Abstract)
Patients with myelomeningocele have an allergic response (type 1 hypersensitivity) to latex by what cellular mechanism?
Overactive complement system
Hyperactive killer-T cells
illustration says PCN allergy is Type 2 hypersensitivity, purple Miller's page 87 says PCN allergy is Type 1 hypersensitivity.. not sure which to go with.. would assume anaphylactic PCN allergy is really a Type 1?