Angular Malalignment Research Articles

Childhood femoral fracture can lead to premature knee-joint arthritis

Background and purpose During the past decades, treatment of pediatric femoral fractures in Finland has changed from mostly non-operative to more operative. In this retrospective study, we analyzed the long-term results of treatment.Patients and methods 74 patients (mean age 7 (0–14) years) with a femoral fracture were treated in Aurora City Hospital in Helsinki during the period 1980–89. 52 of 74 patients participated in this clinical study with a mean follow-up of 21 (16–28) years. Fracture location, treatment mode, time of hospitalization, and fracture alignment at union were assessed. Subjective assessment and range of motion of the hip and knee were evaluated. Leg-length discrepancy and alignment of the lower extremities were measured both clinically and radiographically.Results Of the 52 children, 28 had sustained a shaft fracture, 13 a proximal fracture, and 11 a distal fracture. 44 children were treated with traction, 5 by internal fixation, and 3 with cast-immobilization. Length of the hospital treatment averaged 58 (3–156) days and the median traction time was 39 (3–77) days. 21 of the 52 patients had angular malalignment of more than 10 degrees at union. 20 patients experienced back pain. Limping was seen in 10 patients and leg-length discrepancy of more than 15 mm was in 8 of the 52 patients. There was a positive correlation between angular deformity and knee-joint arthritis in radiographs at follow-up in 6 of 15 patients who were over 10 years of age at the time of injury.Interpretation Angular malalignment after treatment of femoral fracture may lead to premature knee-joint arthritis. Tibial traction is not an acceptable treatment method for femoral fractures in children over 10 years of age.

A study of management of fracture shaft femur in children in a rural population

Background: Femoral shaft fractures account for 1.6% of all bony injuries in children, and the mode of treatment for children between 6 and 16 years of age is still debatable. Objectives: To compare the merits and demerits of operative and conservative managements of fracture shaft femur in children in a rural population in a developing country. Materials and Methods: Forty patients in the age group of 6-14 years with transverse fractures of shaft of the femur and two different treatment protocols were selected. The patients treated in skeletal traction or fixed traction in Thomas' splint were included in one group and patients who were treated operatively with titanium elastic nails comprised the other group. Data was analyzed using Chi-square test. Results: The commonest cause of injury was motor vehicle accident, accounting for 70% of the cases, with left femur (60%) more commonly injured. All fractures in the operative group united clinically by 8 weeks and radiologically by 10 weeks, and, in the conservative group, by 9 weeks clinically and 12 weeks radiologically. The difference was statistically significant. Shortening and angular mal alignments were found more commonly in the conservative group, and the difference was significant. The follow-up for 1 year of all cases were uneventful. Conclusion: Internal fixation with titanium elastic nails provides better results than conservative treatment in traction.

Radius Crossover Sign

Radius shaft greenstick fractures in children can be a challenging injury to treat because angulation and rotational alignment are difficult to assess. In this report, we describe a simple method for analyzing the deformity and identifying rotational and angular malalignment. This technique involves analyzing the forearm radiographs as 2 segments, proximal and distal, and assuring that the rotational position of each matches the other. We present 3 cases of proximal radius greenstick fractures in malalignment to demonstrate the radius crossover sign. Identifying the radius crossover sign, and proceeding with further closed reduction may prevent deformity that could otherwise result in a significant loss of forearm motion. Level V.

Clinical Implications In Pyle`s Disease, (Familial Metapyseal Dysplasia), Report Of Five Cases with Review Of The Literature.

Background: Pyle`s disease is a distinct skeletal dysplasia with defective metaphyseal modeling and Erlenmeyer-flask deformity of tubular bones.Objectives: Clinical implications in five reported cases with mechanical bone properties different from normal bones were presented. One patient with Genu-valgum deformity had corrective osteotomy done with internal fixation showing osteotomy healing and sustained deformity correction with more than twelve years of follow up. Two patients presented with fractures and angular malalignment with abundant callus .The other two had insufficiency fractures due to repetitive low energy activities.Results: Patients with Pyle`s disease have less than normal mechanical bone properties, insufficiency fracture or gross fractures may develop after low energy or repetitive trauma. Internal fixation can be used and healing may progress with abundant callus.Conclusions: Pyle`s disease stands as a distinct type of metapyseal dysplasia with characteristic clinicalradiological criteria.Genu valgum deformity may warrant osteotomy correction, Internal Fixation can be used and osteotomy may be rapid to heal with the widened bone surfaces. Protection against potential angular malalignment is important until there is sound healing of the fractured bone. Because of increased fragility of bone, a word of caution may be appropriate in the young patient indulged with sports activity.

CORRECTIVE OSTEOTOMY AND LOCAL BONE GRAFTING FOR EXTRA-ARTICULAR MALUNION OF THE PROXIMAL PHALANX

Corrective osteotomies are often utilised to treat finger deformities that may occur due to a phalangeal malunion. Rotational or angular malalignment, in addition to shortening of the digit may negatively affect hand function and be aesthetically displeasing. Thorough preoperative examination of the malunion and its associated deformities is crucial in determining the type of osteotomy technique to be used. Osteotomies can create bony defects that need to be filled with bone graft or some type of graft substitute. We describe an opening wedge osteotomy with local cancellous bone graft combined with dual plating to treat a dorsal angular deformity in a proximal phalangeal malunion.

Randomized, Prospective Comparison of Plate versus Intramedullary Nail Fixation for Distal Tibia Shaft Fractures

Malalignment has been frequently reported after intramedullary stabilization of distal tibia fractures. Nails have also been associated with knee pain in several studies. Historically, plate fixation has resulted in increased risks of infection and nonunion. Our purposes were to compare plate and nail stabilization for distal tibia shaft fractures by assessing complications and secondary procedures. We hypothesized that nails would be associated with more malalignment and nonunion. Randomized, prospective study. Level I trauma center. One hundred four skeletally mature patients with extra-articular distal tibia shaft fractures with a mean age of 38 years (range, 18-95 years) and mean Injury Severity Score of 13.5 (range, 9-50). The majority had high-energy injuries. Patients were randomized to a reamed intramedullary nail (n = 56) or a large fragment medial plate (n = 48). Forty fractures (39%) were open. Twenty-eight (27%) had concomitant fibula fractures that were stabilized. Malunion, nonunion, infection, and secondary operations. The two treatment groups were evenly matched with respect to age, gender, Injury Severity Score, fracture pattern, and presence of open fracture. Six patients (5.8%) developed deep infection with equal numbers in the two groups. Eighty-three percent of infections occurred after open fracture (P < 0.001). Four patients (7.1%) developed nonunion after nailing versus two (4.2%) after plating (P = 0.25) with a trend for nonunion in patients who had distal fibula fixation (12% versus 4.1%, P = 0.09). All nonunions occurred after open fracture (P = 0.0007); the primary union rate for closed fractures was 100%. Primary angular malalignment of 5° or greater occurred in 13 patients with nails (23% of all nails) and four with plates (8.3% of all plates; P = 0.02 for plates versus nails). Six additional patients experienced malalignment after immediate weightbearing against medical advice. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (55%, P = 0.04). Eighty-five percent of patients with malalignment after nailing did not have fibula fixation. Eleven patients underwent 15 secondary procedures after plating, five of which were for prominent implant removal. This was not significantly different from patients treated with nailing: 10 patients had 14 procedures and five for prominent implant removal. High primary union rates were noted after surgical treatment of distal tibia shaft fractures with both nonlocked plates and reamed intramedullary nails. Rates of infection, nonunion, and secondary procedures were similar. Open fractures had higher rates of infection, nonunion, and malunion. Intramedullary nailing was associated with more malalignment versus plating. Fibula fixation may facilitate reduction of the tibia at the time of surgery. The effect of fibula fixation on tibia healing deserves further study. Economic assessment and functional outcomes data for this population will help to enhance our treatment decision-making.

Radiographic Analysis of Wedge Allograft Correction of Angular Malalignment in Ankle Fusion

Patients undergoing ankle arthrodesis often have coronal or sagittal plane malalignment. Correction of this deformity can be technically challenging. This retrospective review examines the use of an augmented interposition wedge allograft for deformity correction in ankle arthrodesis. Nineteen patients underwent open ankle arthrodesis with interposition allograft at our institution since 2003. Sixteen patients had isolated ankle fusions and three patients had ankle fusions as part of a tibiotalocalcaneal fusion. A wedge of frozen tricortical iliac crest or femoral head allograft was cut to appropriate size and shape to correct angular deformity with an average maximum graft width of 9.5 mm. Fixation of the arthrodesis was with either a cannulated screw and plate construct or a lateral blade plate. Radiographs were reviewed to assess preoperative, initial postoperative and final alignment at the time of solid fusion. Fusion was assessed on plain radiographs by visualization of bridging bony trabeculae. Seventeen of 19 patients (89%) obtained fusion at an average of 14.9 wks. Eleven ankles had preoperative tibiotalar valgus deformity with an average coronal alignment of 98.8 degrees and sagittal alignment of 110.5 degrees. Final coronal alignment was 90.9 degrees and sagittal alignment was 107.7 degrees. Eight ankles had varus deformity with an average coronal alignment of 77.4 degrees and sagittal alignment of 101.9 degrees. Final coronal alignment was 89.4 degrees and sagittal alignment was 107.4 degrees. The tibiotalar joint fusion rate in this series compares favorably to historically published data for standard ankle fusion. Interposition allograft was an effective method for deformity correction in difficult ankle arthrodeses.

Radiographic and Clinical Comparisons of Distal Tibia Shaft Fractures (4 to 11 cm Proximal to the Plafond): Plating Versus Intramedullary Nailing

The purposes of this study were to review distal tibia shaft fractures treated with a plate or a nail and to assess the clinical and radiographic results, complication rates, and the need for secondary procedures. Retrospective review. Two Level I trauma centers. We retrospectively reviewed 111 patients with 113 extra-articular distal tibia fractures between 4 and 11 cm proximal to the plafond. Seventy-six were treated with an intramedullary nail and 37 were treated with a medial plate. Twenty-nine (27%) of the concomitant fibula fractures were fixed. Complications and secondary procedures were evaluated in 111 patients after a mean of 24 months (range, 12-84 months). A total of 111 patients with 113 fractures of the distal tibia were reviewed. Their mean age was 39.1 years, 69% were men, and 30% had open fractures. Four patients underwent additional procedures for soft tissue coverage. None of these had infection. Five patients (4.4%) developed osteomyelitis: four after intramedullary nailing (5.3%) and one after plating (2.7%). Nine patients (12%) had delayed union or nonunion after nailing. One patient (2.7%) had a nonunion after plating (P = 0.10). Nonunion was more common after concurrent fixation of the fibula (14% versus 2.6%, P = 0.04). Angular malalignment of > or =5 degrees occurred in 22 patients with nails (29%) and 2 with plates (5.4%, P = 0.003). Eight patients had malunions of > or =10 degrees. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (38%, P = 0.006) but was not related to fibula fixation. Painful hardware was removed in six patients (7.9%) with nails and in two patients (5.4%) with plates. Distal tibia fractures may be treated successfully with plates or nails. Delayed union, malunion, and secondary procedures were more frequent after nailing. Randomized prospective assessment may further clarify these issues and provide information about costs associated with these fractures.

Retrograde Nailing for Distal Third Femoral Shaft Fractures: A Prospective Study

To evaluate the postoperative knee function and results of unreamed retrograde nailing for distal third femoral shaft fractures. Between January 2002 and 2003 inclusive, a consecutive series of 27 patients (with 28 fractures) who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified Knee Society Knee Score. Correlations between union time and other variables were also studied. In these patients 26 (93%) of the 28 fractures achieved union, of which 5 underwent dynamisation; the mean union time for the other 21 fractures was 4.4 months. Angular malalignment was present in 4 patients and shortening in 4 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 26 patients. 19 patients had anterior knee pain and 10 had instability. By the end of one year, excellent or good scores for pain and function were recorded in 77% and 73% respectively, of the 26 patients. In view of such favourable union rates but significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.

Retrograde femoral nailing in elderly patients with supracondylar fracture femur; is it the answer for a clinical problem?

Supracondylar fractures of femur constitute 7% of all femoral fractures. In elderly patients, they are invariably low-energy fractures predisposed to by osteoporosis. Treatment of these fractures in the elderly is a challenging task for most orthopaedic surgeons. There is no consensus on what would be the ideal treatment for such cases. This study looks at the results of retrograde femoral nailing as a treatment option for this vulnerable group of patients. This retrospective study looks at 23 elderly patients with supracondylar fractures of the femur treated by retrograde femoral nailing. Patients had an average age of 75 years (range between 65 years and 97 years). All patients were assessed with regard to operative time, blood loss, hospital stay, and postoperative complications. All patients were assessed clinically and radiologically every 6 weeks for average period of 14 months (range 12 to 18 months). two patients died a few weeks postoperatively. Average operative time 70 minutes, average blood loss 350ml. Radiologically all cases united, 39.2% had angular malalignment. There were no cases of implant or fixation failure. Retrograde femoral nailing is a surgically limited and reliable procedure for elderly patients with supracondylar fractures of the femur without intra-articular extension. Although it has a high incidence of angular malalignment, the overall functional demands of this age group are perhaps not affected much by that particular complication.

Intraoperative skeletal traction in the dog

A standard skeletal traction technique was applied to each major segment of the appendicular skeleton of ten fresh dog cadavers. Opposition points and anchorage points for the application of traction were determined for each skeletal segment. Traction was exerted by means of a micrometric traction stand, connected to the limb by bands or a stirrup. Traction was applied to the antebrachium and the tibia through nylon traction bands anchored to the metacarpus and metatarsus, respectively. A traction stirrup applied to the condylar region was used as the anchorage point to load the humerus and femur. Once a peak force of 25 kg weight was achieved, the load was monitored for half an hour to check for any variation. After that, each skeletal segment was osteotomized in the mid-diaphyseal region, and evaluated for any angular malalignment due to a mismatch between the axis of the bone and the applied loading. Any ensuing angular malalignment was successfully corrected by manoeuvres using the traction stand. The technique used in this study to perform intraoperative skeletal traction proved to be reliable and consistent for each segment of the appendicular skeleton.

Focal dome osteotomy for the correction of tibial deformity in children

Tibial deformity in childhood often combines torsional and angular malalignment. A focal dome osteotomy was performed, proximally or distally, in 39 tibiae in 31 patients. In 33 limbs, the primary deformity was varus (with internal torsion). The osteotomy was held with K-wires and a plaster cast. The mean age at surgery was 10.25 years and the minimum follow-up 24 months. All osteotomies united and no compartment syndrome occurred. Postoperatively, two patients (5%) had temporary neurological deficits. Thirty of 31 patients had good clinical and radiological correction of alignment. Recurrent deformity was seen in one patient with hypophosphataemic rickets.

The Usefulness of Blocking Screw in Intramedullary Nail on Proximal Tibial Fracture

Purpose: To evaluate the effectiveness of a blocking screw in intramedullary nailing at the tibia proximal shaft fracture. Materials and Methods: 63 tibia proximal shaft fractures from January 2000 to December 2002 treated with only intramedullary nailing were referred to as group I, and 8 fractures from January 2003 to December 2003 treated with both intramedullary nailing and the blocking screw were referred to as group II. Retrospective studies were done for group I and II. The incidence of nonunion and the postoperative angular alignments were compared. Malalignment was defined as an angle of 5 degrees anteroposteriorly or mediolaterally. Results: There were 7 nonunion (11%) in group I in compare with none in group II. There were 21 angular malalignments (33%) in group I and 1 in group II (12%) and most of them had valgus deformity or anterior anglulation. No complications were directly due to the use of the Blocking screw. Conclusion: The technique of the blocking screw used to be one of the option for proximal tibial nailing at tibial proximal shaft fracture helps to overcome angular malalignments of bones.

Antegrade nailing of femoral shaft fractures combined with neck or distal femur fractures. A retrospective review of 25 cases, with a follow-up of 36-150 months.

Complex femoral fractures pose considerable therapeutic challenges to orthopedic surgeons. We present a retrospective review of 25 patients with complex femoral fractures treated with intramedullary locked nailing and supplemental screw fixation. Fifteen patients with ipsilateral femoral neck and shaft fractures (group 1) and 10 patients with ipsilateral femoral shaft and distal femur fractures (group 2) were treated from 1990 to 1998. High-energy injuries occurred in all patients. There were 4 open fractures. Antegrade, locked nailing of diaphyseal fractures was performed in all cases. Supplemental screws for the neck were used in all patients in group 1 and in 3 patients in group 2. All of the fractures united during the follow-up. Five patients in group 1 underwent reoperation (33.3%): one due to a delayed union, the second due to an implant failure, the third due to a nonunion of a neck fracture, and the last two because of an initially missed femoral neck fracture. None of the patients in group 2 underwent reoperation. Angular malalignment of the shaft was found in 6 fractures in group 1 (average 4.8 degree, range 3 degree-11 degree) and in 4 fractures in group 2 (average 6 degree, range 3 degree-12 degree). Shortening of the limb occurred in 3 patients in group 1 (average 1.4 cm, range 1-1.8) and in 1 patient in group 2 (2 cm). Loss of fixation was seen in 1 patient in each group. Avascular necrosis and infection were not seen in any case in both groups. Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. New nail designs, usually more expensive than the conventional nails, have been introduced into the market for this purpose. One has to keep in mind that antegrade, locked nailing of femoral shaft fractures combined with neck or distal femur fractures is a technically demanding but efficacious procedure. The success rate is high when the technique is meticulously implemented.

Unreamed Nailing of Diaphyseal and Metaphyseal Fractures of the Femur

Background: Femoral intramedullary nails with antegrade or retrograde options for insertion and different locking possibilities have extended the indications to include both diaphyseal and metaphyseal fractures. Patients and Methods: A prospective series of 63 patients were treated with three different unreamed nailing and interlocking techniques selected according to the predominant fracture location. Median age of the 30 women and 33 men was 39 (17–97) years. High-energy injuries had occurred in 37 patients. Antegrade nailing and interlocking with standard technique was used in 29 diaphyseal fractures, antegrade nailing and placement of the proximal locking device to the femoral head was performed in eleven proximal fractures with involvement of the intertrochanteric region, and retrograde nailing and standard interlocking was done in 23 mainly distal fractures. Results: We encountered two types of major mechanical complications: angular malalignment and protrusion of the nail into the knee joint following compression in the fracture. Angular malalignment was found in four fractures. One midshaft fracture was fixed in a valgus reduction. Varus malalignment and loss of fixation occurred in two high subtrochanteric fractures after proximal locking with a spiral blade. In another midshaft fracture redisplacement in varus occurred. Compression in the fracture with protrusion of the nail by 2–10 mm into the knee joint following retrograde nailing was observed in six osteoporotic patients. Only two of these patients had significant knee problems. The median time to union – 4 months – did not differ significantly between the fixation groups. Conclusions: Thus, there are still problems after nailing very proximal and distal fractures. Most postoperative complications were seen after retrograde nailing of distal fractures, but the consequences of fixation failure in very proximal fractures were worse. Nevertheless, a protocol that takes advantage of the different options for nail introduction and locking depending on the fracture location seems promising.

The use of trans-articular and extra-articular external fixation for management of distal tibial intra-articular fractures

Twenty-nine consecutive cases of distal tibial intra-articular fractures treated by trans-articular or extra-articular external fixation techniques have been reviewed. Eleven cases were treated initially with a trans-articular dynamic axial fixator. Of these seven were converted to an extra-articular SHF, for a combination of poor ankle motion and delayed healing of the metaphyseo-diaphyseal dissociation (MDD). Three of these cases (two patients) required bone grafting for delayed healing of the diaphyseal component of the fracture. Apart from one refracture through the MDD, no major complications were seen. No deep infections and no angular malalignments were noted. There were 11 pin track infections. Subjective assessment using short form-36 (SF-36) questionnaires, however, revealed significant differences compared to a normal population particularly in physical function and pain at a mean follow-up of 21 months. Using Bone’s criteria for assessment of range of motion there were 62% excellent and good results, which dropped to 53% when fractures with a metaphyseo-diaphyseal extension were included. The use of minimally invasive techniques of internal fixation and stabilisation with a Sheffield hybrid frame in the management of distal tibial intra-articular fractures has minimal complications. Trans-articular external fixation is a good primary treatment for badly comminuted articular fractures with poor soft tissue condition. Conversion to extra-articular external fixation is recommended for slower healing fractures allowing ankle movement and early weight-bearing. The presence of a MDD dissociation lengthens the treatment time significantly, adds to the morbidity and affects final outcome.

Angular malalignment after intramedullary nailing of femoral shaft fractures.

To determine factors associated with angular malalignment of femoral shaft fractures treated with intramedullary nails and to determine differences in the incidence of angular malalignment based on fracture location, fracture comminution, and method of treatment (i.e., antegrade or retrograde). Retrospective. Level I trauma center. Three hundred sixty patients with 374 femoral shaft fractures were identified from a prospectively obtained orthopaedic trauma database. Complete sets of immediate postoperative anteroposterior and lateral radiographs were available for 355 (95 percent) of the 374 fractures. Patients were treated with antegrade (183 cases) or retrograde (174 cases) intramedullary femoral nailing. Goniometric measurements were made on all immediate postoperative radiographs to determine the coronal plane and sagittal plane angular alignments. A multiple linear regression statistical analysis was used to determine factors associated with increasing angular malalignment. The incidence of malalignment was determined using more than 5 degrees of deformity in any plane as the definition of malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern were associated with increasing fracture angulation (p < 0.001). Fracture location in the middle third, stable fracture pattern, method of treatment (i.e., antegrade or retrograde), and nail diameter were not associated with increasing fracture angulation (p > 0.05). The incidence of malalignment was 9 percent for the entire group of patients, 30 percent when the fracture was of the proximal third of the femoral shaft, 2 percent when the fracture was of the middle third, and 10 percent when the fracture was of the distal third. The incidence of malreduction was 7 percent for patients with stable fracture patterns and 12 percent for those with unstable fracture patterns. Patients with fractures of the proximal third of the femoral shaft treated with intramedullary nails are at highest risk for malalignment. Proximal fracture location, distal fracture location, and unstable fracture pattern are associated with increasing fracture angulation.

Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty

Over a period of 20 years, 34 patients with a total hip arthroplasty were treated conservatively for a femoral shaft fracture. Thirty-five fractures were treated by traction followed by cast-brace or by cast-brace alone. Sound healing was obtained in 33 fractures. Problems were angular malalignment jeopardizing revision surgery in cases of loosening, long hospitalization, and a considerable complication rate. As a consequence, the authors no longer recommend conservative treatment as the first choice for these difficult fractures.

Supracondylar Fractures of the Femur Treated by External Fixation

To determine the results and complications of treating supracondylar fractures of the femur with external fixation. Retrospective follow-up from the time of injury (inception cohort) to an average of thirty-one (range thirteen to seventy-two) months after injury. Tertiary care university hospital. All thirteen adult patients with supracondylar femur fractures treated with the method described were included. There were seven closed and five open fractures and five vascular injuries that required repair. Fractures were chosen for this technique on an individual basis by the treating surgeon. The femoral condyles were reduced percutaneously or via a medial arthrotomy and stabilized with 6.5-millimeter cannulated screws. Fixator pins were placed from lateral to medial in the condyles and in the shaft above the fracture. The monolateral fixator was applied laterally and stabilized the reduced condyles to the shaft. Initial grafts of bone were used in five fractures. External fixation time averaged 127 days. During treatment we determined the occurrence of complications at the pin sites and the fracture site, the time of healing, and the angular alignment at healing. At the latest follow-up we determined the range of motion of the knee, knee stability, a standardized knee score, and on radiographs the occurrence of arthrosis. Twelve fractures healed primarily. One patient had a fracture site infection and required further treatment before healing. Knee flexion was restricted while in the fixator but rapidly recovered after frame removal. At follow-up (average thirty-one months), the range of knee flexion averaged 111 degrees (range sixty-five to 140). The Iowa Knee Score averaged 87 points (range 75-93 points). Four femurs healed with angular malalignments, shortening, or both. Twelve knees had no detectable arthrosis. We concluded that in select supracondylar femur fractures, monolateral external fixation is a satisfactory treatment alternative.

TORSIONAL AND ANGULAR DEFORMITIES

A general understanding of the cause and natural history of rotational and angular malalignment of the lower extremity allows accurate differentiation between pathologic and physiologic conditions. One can then educate the involved and often concerned family and proceed with observational management of physiologic conditions as spontaneous improvement of alignment can be expected. Aside from treatment for resistant metatarsus adductus, other forms of treatment, such as special shoes, casts, or braces, are rarely beneficial and have no proven efficacy. Persistent deformity beyond skeletal maturity is unusual and rarely causes significant functional disability. In rare cases of severe residual deformity, operative correction is the only effective treatment.