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We evaluated the prevalence of slipped capital femoral epiphysis in the contralateral hip of 169 children who had been managed with pinning in situ and thirty who had been managed with immobilization in a spica cast. Only children who had initially been seen with a unilateral slip and had been followed for a minimum of two years or until skeletal maturity were included in the study. The average duration of follow-up was 3.6 years (range, 0.5 to 9.5 years) for the group that had been managed with a cast and 2.8 years (range, 1.0 to 8.3 years) for the group that had been managed operatively. In sixty-one (36 per cent) of the 169 patients who had had operative treatment and two (7 per cent) of the thirty who had been managed with a spica cast, a slip subsequently developed in the contralateral hip; this difference was significant (p = 0.001). On the basis of these findings, we recommend that closer attention be paid to the potential development of a slip in the contralateral hip after pinning.

We reviewed our experience with a modified triple innominate osteotomy for hip instability and limb shortening due to poliomyelitis in 62 adolescent and adult patients, treated from 1973 to 1990. Their ages at surgery ranged from 12 years to 35 years (average 22.3). At a mean follow-up of 4 years (2 to 18) 59 of the patients (95.2%) had substantial improvement in hip stability, and all but one had radiological improvement as determined by the acetabular angle, centre-edge angle and acetabulum-head quotient. In 59 cases in which transiliac limb lengthening was attempted, the mean gain was 1.7 cm (0.6 to 3.0). When the abductor muscles had been partially paralysed, the operation produced an appreciable increase in power in 12 of the 39 hips examined.

Treatment of both-bone forearm fractures remains a difficult dilemma for the orthopedist. We assessed the results of 33 children treated with closed reduction and a long-arm cast using traction with finger traps in neutral rotation. Patients were grouped according to age and analyzed for residual angulation and range of motion (ROM). Despite some residual angulation and loss of rotation, all patients were fully active with no functional restriction at follow up. For patients 10 years old or younger with less than 30 degrees of post-casting angulation, full ROM and minimal residual angulation on radiograph can be expected. For patients ages 11 to 15 years (the oldest patient in this series was 15), residual angulation is likely and approximately 60% of patients will have residual loss of less than or equal to 30 degrees of rotation. In spite of this, we found no evidence of functional loss at follow up. Our series supports the continued use of closed manipulation as an effective treatment in children with both-bone forearm fractures.

Sensation, strength, dexterity, length, and range of motion were evaluated after index finger pollicization in 10 patients (14 hands). Diagnoses included congenital absence of the thumb (10 hands) and hypoplasia (4 hands). Average age at operation was 7 years, and follow-up averaged 9 years. Patients with unilateral pollicization averaged 67% grip strength, 60% lateral pinch, 56% palmar pinch, and 39% three-point pinch as compared with the normal contralateral hand. Manual dexterity averaged 70% efficiency as compared with normal standards defined according to age and sex. However, 55% of the patients, when stressed, used side-to-side pinch. It was noted that in those patients who used side-to-side pinch performance averaged 54% of normal standards, compared with 93% in patients who used tip-to-tip pinch for prehension.

One hundred thirty children who sustained spinal cord injuries between birth and age 21 years were reviewed to determine the progression rate of paralytic scoliosis and the effects of bracing and surgery. Patients were divided into two groups: those injured before and those injured after the adolescent growth spurt. Scoliosis developed in 97 and 52%, respectively. Bracing was effective in delaying progression in the preadolescent group. The progressive paralytic spinal deformity did not appear to be related to the level of injury. The older patient is at much less risk for paralytic scoliosis, but still requires routine examination.

Congenital inferior tibiofibular diastasis is a rare condition of unknown etiology, possibly a form of tibial hypoplasia, marked by a clinical triad of talipes equinovarus, ankle diastasis, and limb length inequality. An analysis of 10 cases reported previously is given with two additional examples. Ankle mortise reconstitution and clubfoot correction by surgery have been the basis of treatment. We present two cases in which no ankle reconstruction was done with good results. Syme amputation is considered for cases with severe tibial shortening. Prognosis for a plantigrade foot is encouraging if limb length inequality is corrected operatively or non-operatively as indicated.

The authors reviewed 43 patients with the onset of idiopathic scoliosis between 4 and 9 years who were followed to skeletal maturity to document the natural history, effects of bracing, and factors associated with progression. Average age at onset was 7.1 years for female and 6.7 for male patients. Twelve were treated with observation only; six improved, five progressed, and one refused an orthosis and required surgery. Thirty-one patients wore an orthosis; five patients improved or were unchanged, and 26 progressed, including 13 who subsequently required surgery. All patients treated with observation had a rib vertebral angle difference (RVAD) of less than 10 degrees; whereas patients progressing despite orthosis and all but one patient requiring operation had an RVAD greater than 10 degrees. Thoracic hypokyphosis (less than 20 degrees) was present in 20% of observed patients, 64% of those treated with an orthosis, and 78% of those requiring operation.

In order to determine the indications and usefulness of MRI scanning in evaluating spinal cord trauma, MRIs on 43 subacute and chronic spinal cord injured children were compared with CT myelograms and other diagnostic tests. MRI scans were superior to CT myelograms in evaluating post-traumatic syrinx, disc pathology and the physiological status of the cord. CT myelogram remains an essential study before considering spinal cord decompression. The presence of internal fixation is not a contraindication to MRI scanning.

Twenty-three patients who were treated by posterior spinal fusion with neurofibromatous scoliosis were reviewed to study the adequacy of spinal fusion, rate of pseudarthrosis, and incidence of complications. Twenty patients achieved a solid fusion with posterior surgery alone. Thirteen patients required one or more posterior augmentation procedures because of progressive deformity. Three patients with dystrophic kyphoscoliosis required an anterior spinal fusion in addition to the posterior fusion to achieve a solid fusion mass. The type of graft material, Harrington instrumentation, and degree of kyphosis or scoliosis had no effect on the rate of pseudarthrosis. Preoperative neuroradiographic evaluation was found to be warranted for all patients with neurofibromatous scoliosis.

The triple osteotomy of the innominate bone is a total redirectional reconstruction and is obtained by circum-acetabular osteotomies through the ilium, ischium and pubis. The method achieves coverage of a dislocated or subluxated femoral head where other iliac osteotomies are ineffective or incomplete. Triple osteotomy was performed on 175 hips including 121 congenital dislocation-subluxations. The patients' ages ranged from 6 to 35, with 70 per cent falling between 9 and 12. Eighty-six per cent had a satisfactory result. Most of the unsatisfactory results were in cerebral palsy, myelodysplasia and peroneal muscular atrophy and associated with uncontrolled muscle contractures or progressive disease.

This is a report of 5 cases of congenital pseudarthrosis of the clavicle, a rare disorder of the shoulder girdle. Little more than 100 cases have been reported in the literature; 3 of our 5 cases represent a very rare form of left side involvement with dextrocardia. The pseudarthrosis mass generally protrudes under the skin and may need surgical correction. When unilateral, there is marked and unexplained predominance for the right side. Three cases required no treatment; 2 were successfully treated by excision of the bone ends, bone grafting and internal fixation.

Review of the literature reveals how difficult it is to assess the results of treatment of pseudarthrosis of the tibia. There is disagreement as to when the result can be considered final. This study reviewed the long-term results of treatment to determine if skeletal maturity could be considered the definitive end point of treatment or if the results deteriorate past skeletal maturity. In addition, the effect of neurofibromatosis on pseudarthrosis of the tibia is analyzed. Forty-one patients were reviewed. Only 25 had sufficient follow-up data to be included in this study. Eighteen of the 25 had neurofibromatosis. The results were classified according to criteria developed by Morrissy et al. At skeletal maturity, there were ten good results, three fair results, and three poor results, with nine patients having had amputation. At long-term follow-up evaluation (average 36 years; range five to 62 years), one patient with a fair result had elected amputation. About one half of the patients with neurofibromatosis required amputation. This study suggests that the results at skeletal maturity are reliable indicators of long-term results.