Progressive slip after removal of screw fixation in slipped capital femoral epiphysis: two case reports

<p>Abstract</p> <p>Introduction</p> <p>In slipped capital femoral epiphysis the femoral neck displaces relative to the head due to weakening of the epiphysis. Early recognition and adequate surgical fixation is essential for a good functional outcome. The fixation should be secured until the closure of the epiphysis to prevent further slippage. A slipped capital femoral epiphysis should not be confused with a femoral neck fracture.</p> <p>Case presentation</p> <p>Case 1 concerns a 15-year-old boy with an adequate initial screw fixation of his slipped capital femoral epiphysis. Unfortunately, it was thought that the epiphysis had healed and the screw was removed after 11 weeks. This caused new instability with a progressive slip of the femoral epiphysis and subsequently re-fixation and a subtrochanteric correction osteotomy was obligatory. Case 2 concerns a 13-year-old girl with persistent hip pain after screw fixation for slipped capital femoral epiphysis. The screw was removed as lysis was seen around the screw on the hip X-ray. This operation created a new unstable situation and the slip progressed resulting in poor hip function. A correction osteotomy with re-screw fixation was performed with a good functional result.</p> <p>Conclusion</p> <p>A slipped epiphysis of the hip is not considered ‘healed’ after a few months. Given the risk of progression of the slip the fixation material cannot be removed before closure of the growth plate.</p

Automatic determination of Greulich and Pyle bone age in healthy Dutch children

Background: Bone age (BA) assessment is a routine procedure in paediatric radiology, for which the Greulich and Pyle (GP) atlas is mostly used. There is rater variability, but the advent of automatic BA determination eliminates this. Objective: To validate the BoneXpert method for automatic determination of skeletal maturity of healthy children against manual GP BA ratings. Materials and methods: Two observers determined GP BA with knowledge of the chronological age (CA). A total of 226 boys with a BA of 3-17 years and 179 girls with a BA of 3-15 years were included in the study. BoneXpert's estimate of GP BA was calibrated to agree on average with the manual ratings based on several studies, including the present study. Results: Seven subjects showed a deviation between manual and automatic BA in excess of 1.9 years. They were re-rated blindly by two raters. After correcting these seven ratings, the root mean square error between manual and automatic rating in the 405 subjects was 0.71 years (range 0.66-0.76 years, 95% CI). BoneXpert's GP BA is on average 0.28 and 0.20 years behind the CA for boys and girls, respectively. Conclusion: BoneXpert is a robust method for automatic determination of BA

Case report: Rare skeletal manifestations in a child with primary hyperparathyroidism

Background: Primary hyperparathyroidism (PHPT) is uncommon among children with an incidence of 1:300,000. This diagnosis is often missed in children in contrast to adults where it is detected at a pre symptomatic stage due to routine blood investigations. Etiology of PHPT can be due to adenoma, hyperplasia or rarely carcinoma. Case presentation: A 12year old Sri Lankan girl presented with progressive difficulty in walking since 1year. On examination she had bilateral genu valgum. Skeletal survey revealed valgus deformity of knee joints, bilateral subluxation of upper femoral epiphysis(SUFE), epiphyseal displacement of bilateral humeri, rugger jersey spine and subperiosteal bone resorptions in lateral aspects of 2nd and 3rd middle phalanges. There were no radiological manifestations of rickets. Metabolic profile revealed hypercalcemia with hypophosphatemia. Intact parathyroid hormone levels were elevated at 790pg/ml. Vitamin D levels were deficient. She had low bone mineral density with Z score of -3.4. Vitamin D supplementation resulted in worsening of hypercalcemia without reduction in PTH levels. Tc 99 Sestamibi uptake scan showed abnormal tracer retention in left inferior pole of thyroid. A large parathyroid gland was removed with histology favoring parathyroid adenoma. Post operatively she developed hypocalcemia. Bilateral osteotomy was done for SUFE and further surgeries for correction of limb deformities planned. Conclusion: PHPT in children is usually diagnosed late when irreversible organ damage has occurred. Children can present with non specific symptoms involving gastrointestinal, musculoskeletal, renal and neurological systems. PHPT can cause disarray in bone and epiphysis in children during pubertal growth spurt. Genu valgum and SUFE are rare skeletal manifestations in PHPT and only 10 cases of genu valgum and 9 cases of SUFE have been reported up to now. So far no cases have been reported on epiphyseal displacement of humeri. Awareness regarding the occurrence of these rare skeletal manifestations especially during puberty is important for early diagnosis to prevent irreversible outcomes

The epiphyseal tubercle in adolescent hips

Background It has already been shown in animals and using anatomical human specimens that chronic slippage of the adolescent upper (capital) femoral epiphysis is unlikely to take place by shearing due to the presence of an epiphyseal tubercle projecting down into the metaphysis

Indications for implant removal after fracture healing: a review of the literature

Introduction: The aim of this review was to collect and summarize published data on the indications for implant removal after fracture healing, since these are not well defined and guidelines hardly exist. Methods: A literature search was performed. Results: Though there are several presumed benefits of implant removal, such as functional improvement and pain relief, the surgical procedure can be very challenging and may lead to complications or even worsening of the complaints. Research has focused on the safety of metal implants (e.g., risk of corrosion, allergy, and carcinogenesis). For these reasons, implants have been removed routinely for decades. Along with the introduction of titanium alloy implants, the need for implant removal became a subject of debate in view of potential (dis)advantages since, in general, implants made of titanium alloys are more difficult to remove. Currently, the main indications for removal from both the upper and lower extremity are mostly 'relative' and patient-driven, such as pain, prominent material, or simply the request for removal. True medical indications like infection or intra-articular material are minor reasons. Conclusion: This review illustrates the great variety of view points in the literature, with large differences in opinions and practices about the indications for implant removal after fracture healing. Since some studies have described asymptomatic patients developing complaints after removal, the general advice nowadays is to remove implants after fracture healing only in symptomatic patients and after a proper informed consent. Well-designed prospective studies on this subject are urgently needed in order to form guidelines based on scientific evidence

A Dutch guideline for the treatment of scoliosis in neuromuscular disorders

<p>Abstract</p> <p>Background</p> <p>Children with neuromuscular disorders with a progressive muscle weakness such as Duchenne Muscular Dystrophy and Spinal Muscular Atrophy frequently develop a progressive scoliosis. A severe scoliosis compromises respiratory function and makes sitting more difficult. Spinal surgery is considered the primary treatment option for correcting severe scoliosis in neuromuscular disorders. Surgery in this population requires a multidisciplinary approach, careful planning, dedicated surgical procedures, and specialized after care.</p> <p>Methods</p> <p>The guideline is based on scientific evidence and expert opinions. A multidisciplinary working group representing experts from all relevant specialties performed the research. A literature search was conducted to collect scientific evidence in answer to specific questions posed by the working group. Literature was classified according to the level of evidence.</p> <p>Results</p> <p>For most aspects of the treatment scientific evidence is scarce and only low level cohort studies were found. Nevertheless, a high degree of consensus was reached about the management of patients with scoliosis in neuromuscular disorders. This was translated into a set of recommendations, which are now officially accepted as a general guideline in the Netherlands.</p> <p>Conclusion</p> <p>In order to optimize the treatment for scoliosis in neuromuscular disorders a Dutch guideline has been composed. This evidence-based, multidisciplinary guideline addresses conservative treatment, the preoperative, perioperative, and postoperative care of scoliosis in neuromuscular disorders.</p

Review for the generalist: evaluation of pediatric hip pain

Hip pathology may cause groin pain, referred thigh or knee pain, refusal to bear weight or altered gait in the absence of pain. A young child with an irritable hip poses a diagnostic challenge. Transient synovitis, one of the most common causes of hip pain in children, must be differentiated from septic arthritis. Hip pain may be caused by conditions unique to the growing pediatric skeleton including Perthes disease, slipped capital femoral epiphysis and apophyseal avulsion fractures of the pelvis. Hip pain may also be referred from low back or pelvic pathology. Evaluation and management requires a thorough history and physical exam, and understanding of the pediatric skeleton. This article will review common causes of hip and pelvic musculoskeletal pain in the pediatric population

Implant removal associated complications in children with limb fractures due to trauma

Surger