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This article provides researchers with the background and guidance necessary to practically incorporate skeletal maturity estimation into any study of adolescents with imaging of the shoulder, elbow, hand, hip, knee, or foot. It also provides clinicians with a comprehensive, concise synopsis of systems that can be used to estimate skeletal maturity in clinical practice. In the article, we provide a relatively brief overview of each currently available skeletal maturity system that has been validated on a longitudinal dataset. The supplementary files include 2 PowerPoint files for each skeletal maturity system. The first PowerPoint file offers examples and instructions for using each radiographic system. The second PowerPoint file includes 20 graded radiographs that can be used for reliability analyses in the research setting. We have also developed a free mobile application available on the iOS and Android platforms named “What’s the Skeletal Maturity?” that allows clinicians to rapidly estimate skeletal maturity on any patient using any commonly obtained orthopaedic radiograph.

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Purpose: We have previously demonstrated that proximal humeral ossification patterns are reliable for assessing peak height velocity in growing patients. Here, we sought to modify the system by including medial physeal closure and evaluate whether this system combined with the Cobb angle correlates with progression to surgery in patients with adolescent idiopathic scoliosis. Methods: We reviewed 616 radiographs from 79 children in a historical collection to integrate closure of the medial physis into novel stages 3A and 3B. We then analyzed radiographs from the initial presentation of 202 patients with adolescent idiopathic scoliosis who had either undergone surgery or completed monitoring at skeletal maturity. Summary statistics for the percentage of patients who progressed to the surgical range were calculated for each category of humerus and Cobb angle. Results: The intra-observer and inter-observer ICC for assessment of the medial physis was 0.6 and 0.8, respectively. Only 3.4% of radiographs were unable to be assessed for medial humerus closure. The medial humerus physis begins to close about 1 year prior to the lateral physis and patients with a closing medial physis, but an open lateral physis were found to be the closest to PHV (0.7 years). Stratifying patients by Cobb angle and modified humerus stage yield categories with low and high risks of progression to the surgical range. Conclusion: The medial humerus can be accurately evaluated and integrated into a new modified proximal humerus ossification system. Patients with humerus stage 3A or below have a higher rate of progression to the surgical range than those with humerus stage 3B or above.

Study Design: Anatomical study.Objectives: This study was conducted to determine the prevalence of abnormal lumbar vertebrae (4 and 6) and note any differences in pelvic incidence (PI) between spines with 4, 5, and 6 lumbar vertebrae.Methods: We screened 2980 dry cadaveric specimens from an osteological collection. Pelvises were reconstructed by articulating the sacra and innominate bones. PI was measured in all specimens via lateral photographs. L6-pelvic incidence (L6PI) was also measured, by articulating L6 to the sacrum and measuring PI from the superior aspect of the L6 vertebral body.Results: Of the specimens screened, 969 specimens were evaluated. Average age of death for all specimens was 50.4 ± 15.4 years. The prevalence of 6 lumbar vertebrae was 0.8% (n = 23), and the prevalence of 4 lumbar vertebrae was 1.8% (n = 54). PI measured 38.5° in specimens with 4 lumbar vertebrae, and 46.7° and 47.1° in specimens with 5 and 6 lumbar vertebrae, respectively. PI was significantly different between specimens with 4 and 5 lumbar vertebrae (P< .001) but not between specimens with 5 and 6 lumbar vertebrae (P= .38). For specimens with 6 lumbar vertebrae, when L6 was added to the sacrum, mean L6PI was 27.4°.Conclusions: In our large cadaveric study of full spines, we reported a lower prevalence of spines with 4 and 6 lumbar vertebrae compared to previous studies. PI was significantly decreased in subjects with 4 lumbar vertebrae compared with those with normal spines, and special caution should be taken when managing sagittal balance in these patients.

Introduction: The distance between the pubic symphysis and sacrococcygeal joint has been noted as an important parameter in evaluating pelvic tilt in an anteroposterior (AP) radiograph. Similarly, pelvic incidence measures the sagittal balance of the pelvis and is influenced by pelvic rotation. The relationship between these 2 parameters is unknown and could affect interpretation of pelvic AP radiographs.Methods: We reconstructed 248 cadaveric pelvises. Pelvic incidence was measured using a previously validated method. Pubic symphysis-sacrococcygeal joint (PSS) height was measured from the superior pubic tubercle to the sacrococcygeal joint. The pelvises were positioned so that the anterior pelvis lay flush with the surface. A ruler was zeroed on the pubic tubercles and a transverse projecting laser was used to measure the height to the sacrococcygeal joint.Results: A total of 248 pelvises were reconstructed. Average age of death of the specimens was 33±6.0 years. 80% of the pelvises were male, 56% were Caucasian, and 44% African American. The mean PSS height was 2.2 ± 1.4 cm and mean PI was 44.3° ± 10.6°. Multiple regression analysis found PI and PSS height were not correlated (p= 0.144). Females had a larger PSS height than males (beta = 1.17, p< 0.001) and African Americans a larger PSS height than Caucasians (beta = 0.63, p< 0.001).Conclusions: This study provides useful information for clinicians in evaluating AP radiographs of the pelvis in that it supports the use of PSS height to judge the adequacy of a radiograph even in the context of abnormal pelvic incidence.

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Coxa magna, the asymmetrical circumferential enlargement of the femoral head, is an important sequela of pediatric disorders such as Legg-Calvé-Perthes disease. Definitions vary because of lack of controls and a scarcity of research on the distribution of the femoral head asymmetry. This study aims at defining the normal distribution of asymmetry between the left and the right femoral head and neck in the population and how demographics affect these properties. The study also looked at the distribution of side dominance (left or right).

Study Design Adult human osteologic specimens were assessed for spondylolytic defects and characterized.Objectives To characterize and determine the prevalence of spondylolytic defects in an osteological collection.Methods Lumbar vertebrae from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History were examined. Digital images of specimens with L5 isthmic spondylolytic defects were analyzed, examining the distance of the pars defect in the sagittal plane in relation to the caudal aspect of the pedicle.Results There were 95 bilateral complete (BC), 16 unilateral incomplete (UI), 5 unilateral complete (UC), and 4 unilateral complete defects with an incomplete defect on the contralateral side. The mean distance of BC defects from the pedicle and inferior vertebral end plate was 4.03?mm and 4.88?mm, respectively. The mean distance of the defect from the inferior end plate on the left and right sides were 5.31?mm and 4.44?mm, respectively (p?=?0.001, correlation coefficient?=?0.56). The mean distance of UI and UC defects from the inferior end plate was 6.38?mm and 2.6?mm, respectively.Conclusion L5 spondylolytic defects were found in 3.87% of the sample. This large-scale description of isthmic spondylolytic defects reveals that significant variability exists in the location of the defect. The anatomic location of the pars defect likely plays a role in the development of L5 nerve root compression and radiculopathy in this clinical scenario. Classifying these defects might allow surgeons to better identify those patients who might benefit from fusion alone without posterior decompression.

The anatomy of the undulating distal femoral physis may be relevant to growth disturbance after physeal fractures and screw fixation about the physis. The surface anatomy of this physis has not been well described.

Spinal osteoarthritis is greater in patients with known hip pathology secondary to alterations in spinopelvic geometry. To our knowledge, no study has investigated the long-term impact of slipped capital femoral epiphysis (SCFE) on the spine.

The term “acetabular dysplasia” suggests a smaller than normal acetabulum or one that is abnormally vertical. Acetabular dysplasia has been linked to the development of hip osteoarthritis over the last 90 years in 3 ways. First, it has been linked through the concept that biomechanical forces can cause osteoarthritis. A smaller than normal acetabulum will result in a smaller than normal contact surface between the femoral head and the acetabulum. This will generate increased pressure per unit of area, which will precipitate articular cartilage failure when the pressure reaches a critical point. Osteoarthritis will ensue in response to this cartilage failure. A more vertical than normal acetabulum will be associated with increased shear. When that shear reaches a critical level, articular cartilage will fail, leading that to osteoarthritis. This critical level, for a small or a steep acetabulum, may differ between individuals, based on their biology and their life styles. Second, it has been linked by multiple empirical studies. One of these is Wiberg’s 1939 thesis entitled “Studies on Dysplastic Acetabula and Congenital Subluxation of the Hip Joint with Special reference to the Complication of Osteoarthritis.” It is among the most quoted and most powerful works in the Orthopaedic literature connecting a disease entity with an antecedent. Third, the linkage is reenforced by an absence of glaring exceptions to the hypothesis that acetabular dysplasia causes osteoarthritis. Orthopaedic surgeons just do not report on dysplastic hips in the arthritis-free elderly. The inability of the Orthopaedic community to identify even 1 elderly, arthritis-free individual with significant hip dysplasia should not carry weight in establishing the concept that acetabular dysplasia causes osteoarthritis. However, the longer this case report goes unpublished, the more certain orthopaedic surgeons will be that the 2 are linked.

Although seldom described, varus and valgus osteotomies of the proximal femur can affect femoral version. The magnitude of the effect can be predicted with an understanding of the distinction between femoral version and femoral neck inclination. The purpose of this study was to elucidate this relationship.

Correlating peak height velocity (PHV) with assessments of skeletal maturity has important implications in the treatment of scoliosis and other pediatric orthopaedic disorders. This study aims to compare the appearance of the elbow to the PHV in both boys and girls.

Anterior cruciate ligament reconstructions in skeletally immature patients are becoming more commonplace. Complications of growth disturbance remain a major concern, especially at the distal femoral physis, and are often attributed to technical errors. A review of the literature revealed limited anatomical data of the skeletally immature intercondylar notch to guide surgical technique.

The purpose of this study was to identify the percentage of individuals with distinct anterior and middle calcaneal facets. Calcaneal lengthening osteotomy, as popularized by Mosca, is extra-articular, with its site being the interval between the anterior and middle calcaneal facets. For individuals without a distinct anterior and middle facet, the subtalar joint must be violated to perform this operation. The authors studied 1,056 calcanei in 528 human cadavers from the Hamann-Todd Osteology Collection at the Cleveland Museum of Natural History. Findings were categorized using the Bunning and Barnett classification of subtalar facet configuration. Type A was found in 389 calcanei (37), type B in 480 calcanei (46), and type C in only two calcanei. Transitional type was found in 122 calcanei (12). There was no anterior facet in 61 calcanei (6). Asymmetry was found in 51 cadavers (10). Most calcaneal lengthening osteotomies will occur intra-articularly, which may affect clinical results.

Assess the characteristics associated with the risk of complications and mortality in children sustaining pelvic fractures.

The authors evaluated, clinically and radiographically, 13 of 28 patients with bladder exstrophy treated at their institution between 1964 and 1982. All had been treated with bilateral iliac osteotomies and pelvic rami reapproximation to assist in urologic repair. At skeletal maturity, the diastasis had partially recurred and the patients had short stature and were living normal lives. Mild acetabular dysplasia and other pelvic abnormalities were common, as were abnormal radiographic findings in the lumbosacral spine. Despite these findings, most did not affect function. These results support the need for pelvic reconstruction for urologic repair, as well as the need for periodic radiographic evaluation of the pelvis and lumbosacral spine. If present, these have the potential to adversely affect function as an adult.

The authors studied 37 presumed calcaneonavicular tarsal coalitions from the Hamann-Todd Osteological Collection at the Cleveland Museum of Natural History. The anatomy of the coalitions and the associated subtalar and transverse tarsal joints was quite variable. The coalitions in 8 specimens completely spared the anterior facet of the calcaneus and in 7 specimens it was partially replaced by the navicular portion of the coalition, whereas in 22 specimens the anterior calcaneal facet was completely replaced by the navicular portion of the coalition. The authors suggest that the pathoanatomy of calcaneonavicular coalitions is not uniform and may involve the subtalar and transverse tarsal joints. This may have clinical relevance and contribute to the unsatisfactory results in feet undergoing coalition resection and soft tissue interposition.

Tarsal coalitions are the major cause of painful rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalitions are the most common sites. They are often bilateral and may be asymptomatic. They represent a failure of fetal mesenchymal differentiation, and onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilaginous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerized tomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and interposition of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, with arthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions.

Tarsal coalitions are the major cause of painful rigid flatfoot deformity in children and adolescents. Talocalcaneal and calcaneonavicular coalitions are the most common sites. They are often bilateral and may be asymptomatic. They represent a failure of fetal mesenchymal differentiation, and onset of symptoms in children often corresponds to the time of ossification of the fibrous or cartilaginous coalition. The most common presenting symptom is pain, and diagnosis is aided by plain radiographs and computerized tomography. Some patients respond to conservative measures, but surgical treatment is often required. Resection and interposition of fat or tendon (talocalcaneal) or muscle (calcaneonavicular) are the most common operative treatments, with arthrodesis reserved for symptomatic recurrences, patients with degenerative changes, and those with multiple coalitions.

We report a multicenter long-term follow-up study of patients with septic arthritis of the hip during infancy or childhood. Group I (“infantile”) consisted of patients with onset before age 3 months, and Group II (“childhood”) consisted of patients in whom onset occurred after age 3 months. Patients were specifically examined for this review. Generally, patients at follow-up had poor anatomic appearance radiographically and scored poorly on the Harris rating system. However, pain and activity restriction were minimal. Patients who were not treated operatively tended to function better than patients who underwent operative reconstruction.

This article discusses factors that relate to the prognosis for development of hip joint arthritis following juvenile rheumatoid arthritis (JRA), Perthes disease, and postreduction avascular necrosis in congenital hip dislocation (CDH). In JRA, the integrity of the articular cartilage determines prognosis. In Perthes disease, prognosis is strictly related to the shape of the hip. In postreduction avascular necrosis in CDH, half the patients have a prognosis primarily related to hip joint shape, and half have a prognosis apparently more related to the integrity of the articular cartilage.

We evaluated 38 noninstitutionalized patients with spastic quadriplegic cerebral palsy with 51 dislocated hips. Nine hips had been reduced. The mean follow-up was 18 years, with an average age of 26 years. At follow-up, four were ambulatory with aids. Patients who could walk had normal intelligence and a level pelvis. In patients with 18 unreduced unilateral hip dislocations, pelvic obliquity and scoliosis were present in 12. In seven patients with reduced unilateral hip dislocations, similar findings were present in only two patients. Half of the dislocated hips were painful. Based on these findings, we recommend reduction of unilateral dislocations. Bilateral dislocations may benefit from reduction if treatment is undertaken before significant adaptive deformity of the femoral head occurs.

Cast room procedures, such as cast application and removal, pin removal, and suture removal can cause significant anxiety in young children. The use of music therapy in the cast room to decrease anxiety has not been previously reported.

We had the opportunity to examine a naturally occurring Salter-Harris Type I fracture in the distal tibia of a 9-year-old boy. The injury was simultaneous with traumatic amputation of the extremity a few centimeters distal to the knee. The epiphyseal plate was examined microscopically, and the plane of cleavage was found not to be uniform, but to involve the zones of resting, proliferating, hypertrophying, and provisionally calcified cartilage cells. We hope by demonstrating the inconsistency of the cleavage plane in this case to assist in understanding the complexity of physeal fractures and the unpredictable results that occasionally occur.