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Skeletally immature athletes do get major knee injuries. Hemarthrosis is associated with peripheral meniscal tears, anterior cruciate ligament ruptures, tibial tubercle avulsion injuries, and patellar/femoral osteochondral fractures and cannot be ignored. The primary diagnostic tool for patients with a knee injury is a clinical examination by a physician well trained in knee evaluation. MR imaging has significant limitations in this age group. The algorithm for anterior cruciate ligament injury treatment must take into account the patient's physiologic maturity, not chronological age.

Ehlers-Danlos syndrome is the most prevalent heritable disorder of connective tissue. Musculoskeletal problems include joint pain, swelling and instability, and spinal deformity. This study was undertaken to assess functional orthopaedic problems of patients with Ehlers-Danlos syndrome. Sixty patients with genetically verified Ehlers-Danlos syndrome (range, 8-60 years; mean, 34 years) who attended a National Ehlers-Danlos Syndrome Foundation learning conference were evaluated by questionnaire, clinical examination, and when indicated, radiographs. A database of 250 items per patient was constructed and statistically assessed using analysis of variance. Because of rarity of Types VII and VIII, these two patients were dropped from the analysis. Fifty-eight patients had Ehlers-Danlos syndrome Types I, II, III, or IV and form the study cohort. Among these four types, there were no significant differences in history of joint dislocation, swelling, or types of orthopaedic surgical procedures experienced. Thirty patients with Type III Ehlers-Danlos syndrome reported joint pain more frequently than did patients with Types I, II, or IV. Ambulation was impaired significantly in patients with Type III disorder as a whole, as was functional hand strength and upper extremity function. Back or neck pain was a common (67.2%) report among patients with all types of disease but did not correlate with the presence or absence of spinal deformity. Contrary to most previous reports, the patients in this study showed that Type III Ehlers-Danlos syndrome was the most debilitating form with respect to musculoskeletal function.

Clinical and radiographic records of 210 consecutive children treated for Type III extension humeral supracondylar fractures during a 66-month period were reviewed retrospectively to determine (1) the incidence of neural and vascular injuries associated with this fracture; (2) the frequency of the type of nerve injured; and (3) the relationship of fracture displacement to neural and vascular compromise. Forty patients (19.1%) had neural compromise, vascular compromise, or both. Nerve injuries occurred in 13.3% of patients, combined nerve and vascular compromise occurred in 2.9%, and vascular compromise occurred in 2.9% of patients. Median nerve injuries accounted for 58.9% of nerve injuries followed by radial (26.4%) and ulnar (14.7%) lesions. Eighty percent of the median nerve injuries involved the anterior interosseous nerve. Posterolateral fracture displacement was correlated with median nerve and vascular compromise. Posteromedial fracture displacement strongly correlated with radial nerve injury. Recognition of fracture displacement pattern provides a guide to clinical examination to assess associated neural injury, in particular, the anterior interosseous nerve, which may be difficult to evaluate in a child who is uncooperative.

Objectives: a) To determine if antidiuretic hormone (ADH) is elevated in patients undergoing spinal fusion, especially in those who have clinical evidence of syndrome of inappropriate antidiuretic hormone (SIADH); b) to evaluate the relationship between ADH secretion and the secretion of atrial natriuretic peptide (ANP)., Setting: Tertiary care pediatric intensive care unit (ICU) in a university hospital., Design: A prospective cross-sectional, observational study with factorial design., Patients: Thirty patients > or = 10 yrs of age undergoing spinal fusion admitted to the ICU for postoperative care., Interventions: Patients underwent anterior, posterior, or both anterior/posterior spinal fusion. Blood was collected for serial measurements of ADH, ANP and serum electrolyte levels. Heart rate, blood pressure and central venous pressure were measured., Measurements and Main Results: Thirty children were studied. Nineteen had idiopathic scoliosis, nine had neuromuscular scoliosis, one had Marfan's disease, and one had congenital scoliosis. Ten (33%) children met clinical criteria of SIADH. There was no difference in duration of surgery, blood loss, volume of iv fluid administration pre- and intraoperatively, or type of scoliosis between those who developed SIADH and those who did not. Hemodynamic variables were similar in both groups. ADH levels increased in both groups immediately postoperatively and at 6 hrs after surgery, but were much more elevated in those patients with SIADH. Patients with SIADH also had significantly higher ADH levels preoperatively. In relation to serum osmolality, ADH was considerably higher in those with SIADH compared with those who did not. Although ANP values tended to be higher in the group with SIADH, this did not reach statistical significance., Conclusion: SIADH occurs in a subset of children who undergo spinal fusion. The diagnosis of SIADH can be made easily using clinical parameters which are well-defined. In the face of SIADH, continued volume expansion may be harmful, and should therefore be avoided.

Sequelae of congenital, developmental, infectious, degenerative, and neoplastic processes present themselves throughout adolescence, a time of rapid growth and spinal development. The author outlines the elements of an accurate diagnostic physical examination, the signs and symptoms of various spinal deformities, and their diagnosis and treatment. The potential causes of back pain in children and adolescents are explored. The author cautions against dismissing complaints of back pain in the skeletally immature population as mere "growing pains."

Thirty-six patients, 9 males and 27 females, average age 13.2 years, undergoing posterior fusion and segmental instrumentation surgery for idiopathic adolescent scoliosis were studied for abnormalities of platelet count (PC), prothrombin time (PT) and partial thromboplastin time (PTT). Intraoperative and immediate postoperative values were obtained at 2, 4, 6, 12, 24, and 48 hours. All patients showed diminution of platelet counts during the study period, but mean values were reduced below normals only at 4 hours after operation. The PT was significantly elevated in all patients intraoperatively and for the first 24 hours postoperatively, with return to normal by 48 hours. The PTT levels were essentially unaffected at any time.

Acute patellar dislocation and relocation produces major forces at the articular surfaces. Articular injury was assessed in 48 patients, 24 boys and 24 girls (mean age, 14 years), with acute, initial, noncontact patellar dislocations. Correlation of the findings of radiographic and arthroscopic examinations was done. Eleven of the 48 patients (23%) had radiologic diagnoses of articular injuries. Thirty-four of the 48 patients (71%) had arthroscopic evidence of articular damage, 32 osteochondral and 2 chondral injuries. Eight of the 28 (29%) arthroscopically identified osteochondral loose bodies (4 to 20 mm) were identified radiologically. Overall, only 11 of the 34 (32%) arthroscopically documented articular injuries were defined by preoperative radiographs. These standard radiographs provided limited information for management decisions. Poor results after patellar dislocation treatment may involve nonrecognition of articular compromise.

This study evaluated the correlation among clinical diagnosis, magnetic resonance imaging reports, and arthroscopic findings in 28 patients aged 8 to 17 years (average, 14.4) with knee injuries. Meniscal, anterior cruciate ligament, and articular surface injuries were evaluated. A highly positive correlation (78.5%) was found between clinical and arthroscopic findings. A highly negative correlation was found between arthroscopic and magnetic resonance imaging findings (78.5%) and between clinical and magnetic resonance imaging findings (75%). In this series, accuracy, positive predictive value, negative predictive value, sensitivity, and specificity data were much more favorable from clinical examination than from magnetic resonance imaging. Overall, magnetic resonance imaging diagnoses added little guidance to patient management and at times provided spurious information.

We reviewed the records of 12 patients ages 9 to 16 years with knee osteochondritis dissecans. All patients had clinical histories and examinations, four radiographic views of the knee, and technetium-99m diphosphonate quantitative bone scans. Scan results (symmetric, increased, or decreased activity), clinical course, healing time, and final outcome were correlated to determine the prognostic value of the scan. We divided the patients into those with open physes (distal femoral and proximal tibial) and those with closed physes. Four of the six patients with open physes had increased activity on the bone scan. All four of these knees healed with nonsurgical treatment. The other two patients had decreased activity on bone scan, and both required surgical treatment after nonsurgical treatment failed. Of the six patients with closed physes, all had increased activity on the bone scan, but only two patients had healing of the osteochondral lesion without surgery. Quantitative bone scanning had a 100% predictive value for the prognosis in osteochondritis dissecans patients with open physes, but for those with closed physes the predictive value was less. Because the natural history in the adolescent group is less predictable, it is in this group that the quantitative scan would be most helpful. In this small group of patients, quantitative bone scanning had limited prognostic value.

Scholastic-age sports are generally safe, and major musculoskeletal injuries are uncommon. Injuries are proportional to the athlete's age, size, and type of sport. Significant knee injuries do occur, especially during adolescence, and they require prompt, accurate diagnosis and specific treatment. The team physician plays a major role in injury prevention and management.

To determine if acetabular orientation is abnormal in patients with slipped capital femoral epiphysis (SCFE), we measured acetabular version in 60 patients with stable and unstable SCFE by computed tomography (CT) scan. Comparison of the involved sides of the two groups with the standard values for age, with the opposite uninvolved hip, or between stable and unstable hips showed no significant differences.

Seven patients with seven acute slipped capital femoral epiphyses (SCFE) had computed tomography (CT) scan determination of femoral version. Version value differences were compared between the involved and uninvolved sides, and each was compared with a standard value for age. Comparison was also made with chronic slipped femoral version values. As compared to the standard of 20 degrees, the acute, involved side femoral version was 9.3 degrees (p = 0.057). Comparisons of involved and uninvolved sides showed no significant difference (p = 0.25). Analysis of differences of bilateral femoral version of patients with acute SCFE with that of patients with chronic SCFE version showed a significant difference (p = 0.009). Version in patients with acute SCFE more closely resembles the normal value than does that of patients with chronic SCFE, further emphasizing the uniqueness of the acute type of SCFE.

Thirty adolescents with acute, primary patellar dislocation were assessed for a relationship between articular hypermobility and chondral injury. The 15 patients without articular hypermobility had a 2.5 times increased frequency of articular lesions when compared with 15 patients with hypermobility. Assessment of articular hypermobility should be part of the examination in patients with patellar dislocation.

We report the results of 36 femoral lengthenings in 30 consecutive patients using the Ilizarov technique. Patient age at surgery in 19 boys and 11 girls averaged 13.4 years (range, 5-18). Minimum follow-up was 2 years. The etiology of femoral shortening was congenital in 21 femora and acquired in 15. Twelve femora underwent concomitant correction of associated angular deformities during treatment. The average lengthening was 8.3 cm (range, 3.5-12 cm) with a treatment time of 6.4 months (range, 2.5-12). The mean number of surgeries per patient was 2.3, including apparatus application and removal. Lengthening index (months of treatment/centimeter lengthening) was 0.74. Complications included premature consolidation in four patients, malunion of > 10 degrees in two patients, and residual limb length inequality (< 2 cm) in two. There were two instances of knee subluxation [corrected]. No osteomyelitis, ring sequestra, neurologic or vascular compromise, compartment syndrome, hypertension, or hip or knee dislocations occurred. Psychological problems necessitated cessation of lengthening in two patients. These results show a significant improvement over previous reports of earlier techniques of femoral lengthening in terms of greater lengthening, simultaneous deformity correction, and fewer major complications.