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Of seven young children with epiphyseal separation in the distal end of the humerus and medial displacement of the distal fragment, five had significant cubitus varus (10 to 15 degrees) at follow-up. This rare injury therefore is one that is likely to produce that residual deformity.
Fractures about the elbow are common in children. In addition to the more frequent humeral supracondylar type, fractures of the lateral humeral condyle, the medial humeral epicondyle and the proximal radius often occur. Fortunately, these latter types are rarely associated with neurovascular compromise, as seen with the supracondylar type. However, accurate anatomic reduction is required to permit appropriate growth at these epiphyseal sites and to prevent complications.
The problems related to internal fixation for the treatment of slipped femoral capital epiphyses were reviewed in 164 cases and by a questionnaire of 59 orthopedic surgeons. Significant problems were reported with all fixation devices. With Trifin nails, the main difficulty was getting them to stay in in place. With threaded pins, there was difficulty removing them. The best fixation was obtained with the cast Vitallium Knowles pin, but it requires additional modification and improvement.
Chronic recurrent osteomyelitis is a recognized clinicopathological entity with typical radiographic findings in the metaphyses of the long bones. Epiphyseal lesions usually are small and may easily be overlooked. Bone scintigraphy is helpful in identifying multiple lesions whether symptomatic or not. The diagnosis is one of exclusion without pathognomonic findings. Recognition of the condition is important to avoid treatment with antibiotics and repeated operations.
INTRODUCTION: Obstetrical separation of the proximal femoral epiphysis at birth is rare. Most of these fractures are associated with complicated deliveries. MATERIAL AND METHODS: Our patient was admitted on the first day after birth. He was born by caesarean section due to a breech presentation. The clinical examination revealed << pseudoparalysis >> of the left lower extremity. Laboratory studies were within normal limits. RESULTS: Roetgenograms showed a superolateral displacement of the proximal femur with normal acetabular development. An ultrasound examination revealed a normal position for the left femoral head within the acetabulum and no joint effusion. This excluded the possible diagnosis of septic or congenital dislocation of the hip and confirmed the diagnosis of traumatic epiphyseal separation. CONCLUSION: Recognition of this rare injury by using ultrasound may allow early diagnosis and treatment, thus preventing permanent deformities.
INTRODUCTION: The goal of this study was to evaluate the mid-term follow-up of fractures of the proximal tibial epiphysis. MATERIAL AND METHODS: From January 1981 to May 1987, 12 male teenagers sustaining 13 fractures of the proximal tibial epiphysis were treated in our institution. 9 patients totalizing 10 fractures were reviewed with a minimal 5 years follow-up. RESULTS: All knees were painless with a symmetric range of motion except in one case with a 15 degree flexion lag. One case of PCL deficiency was observed. Differences in femoro-tibial angles between both limbs was under 5 degrees in 7 of the 9 patients. In 2 cases, an evolving deformity was noted. Differences in posterior epiphyseal tibial tilt between both knees was over 5 degrees in 2 of the 8 unilateral cases. In 1 surgically treated patient an evolving deformity was noted. Mean tibial length discrepancy (T.L.D.) was over 10 millimeters in 1 case with evolving discrepancy. 3 cases of asymptomatic minimal post traumatic arthritis were noticed. DISCUSSION: In our series, as opposed to most others, Salter-Harris type IV fracture was the most often encountered due to the advanced age of our patients. Unusual cases, such as 2 triplane fractures and Salter-Harris type II avulsion fracture, were present. Lateral ligament insufficiency was noted in case of varus malalignement of the fractured limb. Due to the advanced age of our patients, no major T.L.D. was noted, but frontal or sagittal malalignement occurred in half of the unilateral cases, 50 per cent of which were proved to be evolutive. Arthritic remodeling was noticed only in cases of Salter-Harris type IV when aggravated by limb malalignement. CONCLUSION: Fractures of the proximal tibial epiphysis are mainly encountered in late adolescence with an unusual proportion of Salter-Harris type III and IV fractures. In spite of their advanced age, these patients are at high risk for limb malalignement which can increase. We have noted the incidence of arthritic remodeling in Salter-Harris type IV fracture. A longer follow-up is needed to determine if these changes will have clinical relevance.
Epiphyseal fracture-retrosternal dislocation of the medeial end of the clavicle is an unusual injury. It may occur as a result of a blow either indirectly on the posterolateral aspect of the shoulder girdle or directly over the sternal end of the clavicle. It is clinically impossible to differentiate from the true posterior dislocation even with the computed tomography, but the treatment for either lesion is the same. Recently we uneventually treated a 15-year-old boy with conservative treatment and got a satisfactory result. The purpose of this paper is to draw the attention of the readers to the rarity and serious nature of such injury and the potential difficulties in establishing diagnosis and achieving reduction.
A father and son with unusual congenital skeletal symptoms, mainly characterized by short stature and epiphyseal dysplasia limited to the femoral heads are described. The comparative analysis with other spondyloepiphyseal dysplasias supports the notion that the syndrome reported here is a distinct autosomal dominant connective tissue disorder.
Distal femoral physeal fractures account for approximately 1% of all epiphyseal injuries. Complications include growth arrest and leg length discrepancy, malunion and deformity, and stiffness and knee instability. However, nonunion of such a fracture is exceedingly rare and has only been reported in patients with spinal dysraphism. We report a case of distal femoral physeal nonunion in a neurologically intact adolescent athlete. Initially, there was a delay in the diagnosis of this nondisplaced fracture, as the patient had normal roentgenograms. Additional imaging modalities (magnetic resonance imaging, stress radiographs) should be performed if there is a high index of suspicion of physeal injury when roentgenograms are normal.
Forty-eight patients with severely displaced proximal humeral epiphyseal fractures were reviewed. Twenty-one patients were followed up for an average of 9 years after injury with a personal interview, examination, and radiographs. Average age was 14.1 years, half of whom were age 15 years or older. Initial head-shaft displacement averaged 80%, and 31 fractures were displaced by > or = 80%. All underwent attempted closed reduction. Radiographs for all except three were sufficient to judge the adequacy of reduction. Twenty-six of 45 attempted closed-reductions failed to improve displacement significantly. Nine patients underwent operative treatment, and the remainder had a closed reduction. In the operative group, complications occurred in three of nine patients. No complications occurred in the nonoperative group. No patients seen at late follow-up identified any activity or employment restrictions as a result of their injuries. Several patients incurred humeral shortening or imperfect radiographic remodeling, but this did not correlate with clinical outcome. Comparing the operative complications with the excellent late results after nonoperative treatment in this series supports previous recommendations to avoid operative intervention with few exceptions. The magnitude of displacement alone does not appear to justify operative treatment.
A large solitary bone cyst involving the epiphysis produced 5.0 cm shortening of the proximal humerus in a 15-year-old girl. Biopsy revealed the cyst was filled with thin yellow fluid under pressure and lined by a fibrous membrane. X-rays 9 months after biopsy demonstrated progressive cyst obliteration. A review of literature revealed no similar case. It is postulated that solitary cysts rarely may involve the physeal and epiphyseal structures and thereby retard longitudinal bone growth.
We describe a 5-4/12-year-old girl with the unique combination of bilateral radial ray hypoplasia and multiple epiphyseal dysplasia (MED). Radial ray hypoplasia was diagnosed at birth. MED was documented at age 4-3/12 years when she presented with leg pain and short stature and was found to have femoral anteversion and tibial torsion giving rise to severe genu valgum deformity and intoeing. She has no facial anomalies and is developmentally normal. Family history is unremarkable and chromosomal analysis was normal. Investigation of mineral metabolism showed idiopathic hypercalciuria. Surgical lengthening of her severely hypoplastic left radius at age 19 months was successful. Bilateral femoral and tibial osteotomies at age 5-4/12 years corrected her lower limb deformities. This combination of two distinctive but rare skeletal abnormalities may represent a new syndrome.
We reviewed 20 patients in the early stage of Legg-Calvé-Perthes disease who showed a subchondral fracture line in radiographs. All 20 patients underwent magnetic resonance imaging (MRI) within 2 months after the first symptoms. Follow-up MRI after treatment was performed in 10 patients. The subchondral fracture line in radiographs and serial T1-weighted image was used to measure the extent of the epiphyseal necrosis volumetrically. These extents in the early stage were compared with those in the late stage for determination of prognostic significance. The intensities of coronal MRIs under the subchondral fracture were not homogeneous. The uninvolved epiphysis also showed nonhomogeneous intensities because the posterior column revealed higher intensity compared with the anterior column. The extent of the subchondral fracture line is more accurate in predicting the amount of eventual necrosis than is the extent of necrosis in MRI, which does not have a consistent correlation.
Basic fibroblast growth factor (bFGF) is a permissive mitogen for cultured chondrocytes and has been localized in the specific zones of the epiphyseal growth plate. In this study, we demonstrate that bFGF present in cartilage originates from within the cellular constituents of this tissue. Utilizing reverse transcription coupled to the polymerase chain reaction (PCR), bFGF mRNA was found in extracts of cartilage tissue. Immunocytochemical studies revealed that bFGF was present intracellularly in freshly isolated proliferative chondrocytes and in the extracellular matrix (ECM) after 24 h of culture. Western blot analysis of protein extracts from isolated proliferative chondrocytes identified a bFGF immunoreactive species with a molecular weight of approximately 18 kDa. In situ hybridization confirmed the presence of bFGF mRNA in freshly isolated proliferative chondrocytes. The bFGF in the ECM seemed to be sequestered and not available for biological activity, since these cells still required exogenous bFGF for cell proliferation. This sequestered bFGF could be released to stimulate cell proliferation when cultures were treated with plasmin, a proteolytic enzyme. These data support the hypothesis that bFGF is synthesized by chondrocytes and functions as an autocrine/paracrine mitogen via its deposition into the ECM with subsequent release from the ECM of cartilage being a critical step in biological activity. In addition, the study provides further evidence that locally produced bFGF plays an important role in normal growth and development of cartilage tissue.
Phenotypic expression of chondrocytes can be modulated in vitro by changing the culture technique and by agents such vitamins and growth factors. We studied the effects of ascorbic acid, retinoic acid (0.5 and 10 microM), and dihydrocytochalasin B (3, 10, 20 microM DHCB), separately or in combination (ascorbic acid + retinoic acid or ascorbic acid + DHCB), on the induction of maturation of fetal bovine epiphyseal chondrocytes grown for up to 4 weeks at high density in medium containing 10% fetal calf serum and the various agents. In the absence of any agent or with retinoic acid or DHCB alone, the metabolic activity of the cells remained very low after day 6, with no induction of type I or X collagen synthesis nor increase in alkaline phosphatase activity. Chondrocytes treated with fresh ascorbic acid showed active protein synthesis associated with expression of types I and X after 6 and 13 days, respectively. This maturation was not accompanied by obvious hypertrophy of the cells or high alkaline phosphatase activity. Addition of retinoic acid to the ascorbic acid-treated cultures decreased the level of type II collagen synthesis and delayed the induction of types I and X collagen, which were present only after 30 days. A striking increase in alkaline phosphatase activity (15-20-fold) was observed in the presence of both ascorbic acid and the highest dose of retinoic acid (10 microM). DHCB was also a potent inhibitor of the maturation induced by treatment with ascorbic acid, as the chondrocytes maintained their rounded shape and synthesized type II collagen without induction of type I or X collagen. The pattern of protein secretion was compared under all culture conditions by two-dimensional gel electrophoresis. The different regulations of chondrocyte differentiation by ascorbic acid, retinoic acid, and DHCB were confirmed by the important qualitative and quantitative changes in the pattern of secreted proteins observed by two-dimensional gel electrophoresis along the study.
Epiphyseal chondrocytes end their life cycle through apoptosis. While this event provides a mechanism for the removal of terminally differentiated cells from cartilage, agents that promote this physiological process have not been defined. To address this issue, using a cell culture technique that models events that take place in the growth plate, we asked the following questions: Can agents that promote chondrocyte maturation and cartilage mineralization serve as specific triggers for cell death? Are chondrocytes susceptible to apoptogens at a singular developmental stage? Treatment of embryonic tibial chondrocytes with inorganic phosphate (Pi) induced death in a dose- and time-dependent manner. Within 48 hr, 3 mM Pi increased chondrocyte death by 30%; lower concentrations of Pi induced death after 48 hr. To ascertain if death was due to apoptosis, we evaluated Pi-induced death by a number of different methods and compared the results to those induced by the apoptogen, staurosporine. Analysis of the death process indicated that cartilage cells shared many of the common biological features of the apoptotic process. Thus, there was DNA fragmentation, terminal deoxynucleotidyl transferase (TUNEL) labeling, an increase in cells in the sub-G1 fraction of the cell cycle, and morphological evidence of apoptosis. To explore the specificity of the Pi effect, the experiment was repeated using embryonic sternal cephalic and caudal chondrocytes, cells that are at an earlier developmental stage than the terminally differentiated tibial cells. We noted that these cells remained vital despite a major increase in the medium Pi content. Results of this study suggest that Pi is a stage-specific inducer of apoptosis in maturing chondrocytes and that this role may be linked to chondrocyte maturation and mineralization of the extracellular matrix.
Multiple anomalies of vertebral and long bone growth were observed in the incomplete skeleton of an adult male from a collection of 693 medieval skeletons excavated at Abingdon, Oxfordshire. The skeleton consists of a fragmented skull, right scapula and humerus, left humerus, radius, ulna and partial hand, vertebrae from C1 to T11, and fragments of the ribs and sternum. The bones were examined, measured, and radiographed. The humeri are abnormally short and thick, with exaggerated muscle attachments. Both shoulder joints show extensive osteoarthritic destruction. Some vertebrae show slight flattening of the bodies, and there is possible evidence of both kyphosis and scoliosis. Skull, forearm, and hand bones are of normal size and morphology. Lack of lower limb bones and abnormal proportions in the upper limbs prevent meaningful estimation of stature. However, the other features of the skeleton are consistent with a diagnosis of spondylo-epiphyseal dysplasia. No other skeletons displaying similar anomalies were observed.
We report on an 11-year-old boy with thoracolumbar fusion, carpal synostosis, short stature, scoliosis, lordosis, defective dentition, and recurrent otitis media consistent with the diagnosis of spondylocarpotarsal synostosis syndrome. Unlike other documented cases, radiographs of our patient at 5(1/2) years of age show delay in ossification of many of the epiphyses in addition to delay in carpal ossification. Such delay may have contributed to the distinctly short stature of this boy. This report both confirms and extends the phenotype of this recently delineated syndrome.