Distal Epiphysis Research Articles

Dimensions of the anterior cruciate ligament and thickness of the distal femoral growth plate in children: a MRI-based study.

When determining the dimensions of an anterior cruciate ligament (ACL) graft in children, bone age should be considered in addition to the patient's age, gender, and body height. We aimed to determine the relationship between age, gender, and ACL dimensions as well as thickness of growth plate cartilage of the distal femur during puberty. We retrospectively analyzed MRI scans of the knee in 131 children (82 girls, 49 boys) aged 6-18years (mean age: 14.9 ± 2.6years). ACL length and width as well as thickness of the growth plate cartilage at the distal femoral epiphysis were measured. Mean ACL length increased linearly up to the age of 12years in females and 14years in males; thereafter, mean ACL length remained constant. Mean ACL length was largest at the age of 12 to < 13years (38.18mm) in females and at 15 to < 16years (39.38mm) in males. Mean ACL width increased up to the age of 12years in girls and 13years in boys. After the age of 12years, both the ACL length and width were significantly larger in boys than girls (p = 0.002 and p = 0.045, respectively). Mean thickness of the growth plate cartilage of the distal femur remained stable up to the age of 12years in girls and 14years in boys. Thickness of the growth plate cartilage changed most markedly between the age intervals of 11 to < 12years and 12 to < 13years in girls and between the age intervals of 13 to < 14years and 14 to < 15years in boys. ACL dimensions depended on both age and gender during the growth period. Measurement of cartilage thickness of the femoral distal growth plate proved to be an objective parameter to assess the maturation stage of local bone. This may be useful for the planning and timing of orthopedic ACL procedures. III-retrospective cohort study.

Method of radioulnar superposition in the treatment of patients with congenital radial club hand

New technique for the treatment of congenital club foot in patients with great malformation of the radius in the distal forearm is presented. Surgical intervention consists of 2 stages. First the distraction device is applied to correct the radius deviation and simultaneously to descent the hand distally together with hypoplastic radius. On the second stage the distraction device is taken off, partial resection of the distal ulnar epiphysis and resection of the proximal end of the hypoplastic radius is performed with following reposition of the ends. This method radioulnar superposition enables to eliminate the club hand, to preserve the wrist joint and to restore its physiologic functions.

A Novel, Low-Cost Telescopic Nail Design for Prevention and Treatment of Osteogenesis Imperfecta Associated Long-Bone Pathological Fractures in Children.

Telescopic nailing and intermittent doses of bisphosphonates are now considered the standard treatment for preventing long bone pathological fractures in osteogenesis imperfecta (OI) children. Even though the telescopic nail designs have evolved over time, we are yet to get an affordable, worldwide uniformly and easily available, surgeon-friendly telescopic nail with good rotational stability. We designed a telescopic nail with modifications in Küntscher nail (outer, hollow component) and square nail (inner, solid component). The distal end of the square nail has a slot to allow locking in the distal epiphysis using a threaded K wire. The interlocking geometry between the two nails allows reasonable rotational control while allowing only longitudinal movements. This novel, low-cost, rotationally stable telescopic nail design is a good alternative to existing telescopic nails in the market, especially for children from low and middle-income countries (LMIC) where affordability and uniform availability are a concern.

Age estimation of epiphyseal union around wrist joint and its correlation with chronological age: A radiological study in Qassim population, Saudi Arabia

ABSTRACT In forensic anthropology, age estimation is one of the most important aspects of analysis. The use of radiographic data for age estimation based on the epiphyseal union is a scientifically approved and widely accepted method. X-ray images of the right wrist joint of 281 patients (143 males and 138 females) aged 12–22 years were retrospectively examined and the stages of union at the distal epiphyses of radius and ulna were assessed, to estimate age in a Qassim population, Saudi Arabia. The distal epiphyses of radius and ulna fused completely at 18–19 years in females and 19–20 years in males. Mean age gradually increased and varied with each stage of union, with a statistically significant difference of the females’ and males’ comparable means. Females experienced epiphyseal union one year earlier than males. The ROC curve showed 90.9% accuracy in males and 90.6% in females. The findings of this study indicate that radiographic analysis of the union at distal epiphyses of radius and ulna is a helpful technique for estimation of chronological age. When compared to other studies, the results showed limited variance among different population groups.

Forensic age prediction and age classification for critical age thresholds via 3.0T magnetic resonance imaging of the knee in the Chinese Han population.

To assess the performance of knee MRI for forensic age prediction and classification for 12-, 14-, 16-, and 18-year thresholds. The ossification stages of distal femoral epiphyses and proximal tibial epiphyses were assessed using an integrated staging system by Schmeling et al. and Kellinghaus et al. for knee 3.0T MRI with T1-weighted turbo spin-echo (T1-TSE) in sagittal orientation among 852 Chinese Han individuals (483 males and 369 females) aged 7-30 years. Regression models for age prediction were constructed and their performances were evaluated based on mean absolute deviation (MAD) values. In addition, the performances of age classification were assessed using receiver operating characteristic (ROC) analyses. The intra- and inter-observer agreement levels were very good (κ > 0.80). The complete fusion of those two types of epiphyses took place before 18.0 years in our study participants. The minimum MAD values were 2.51 years (distal femur) and 2.69 years (proximal tibia) in males, and 2.75 years (distal femur) and 2.87 years (proximal tibia) in females. The specificity values of constructed prediction models were all above 90% for the 12-, 14-, and 16-year thresholds, compared to the 74.8-84.6% for the 18-year threshold. Better performances of age prediction and classification were observed in males by distal femoral epiphyses. Ossification stages via 3.0T MRI of the knee with T1-TSE sequence using an integrated staging system could be a reliable noninvasive method for age prediction or for age classification for 12-, 14-, and 16-year thresholds, especially in males by distal femoral epiphyses. However, assessments based on the full bony fusion of the distal femoral epiphysis and proximal tibial epiphysis seemed not reliable for age classification for the 18-year threshold in the Chinese Han population.

Lower Tibial Shaft Spiral Fracture Concurrent with Distal Tibial Triplane Fracture

Background: The clinical and imaging features of lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture are not clear. Introduction: This study was conducted to investigate these features for correct diagnosis, treatment and prevention of possible premature physeal arrest or angular deformation. Method: Patients with lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture were enrolled, and the clinical, imaging, treatment and follow-up data were analyzed. Result: Five patients with lower tibial shaft spiral fracture concurrent with distal tibial triplane fracture were found including four men and one woman with an age range of 12-15 years (mean 13.6). Injury to the distal tibial epiphysis was missed in the diagnosis in plain radiography reports, but careful reevaluation confirmed distal tibial epiphysis fracture in four cases including Salter-Harris type II in three cases and type III in one case. The remaining case had no apparent distal tibial epiphysis injury in the plain radiograph. CT scan revealed that all five patients had distal tibial triplane fracture of the lateral type including two fragments in three cases and three fragments in two cases. The fracture was divided into type I(within the articular weight-bearing line) in three cases, type II (outside the articular weight-bearing line) in two cases based on the involvement of the articular surface by the fracture line. For the lower tibial fracture, one patient was treated with closed reduction and fixation with an elastic nail, three patients had internal plate fixation, and the remaining patient had cast immobilization. Followed up for 3-11 months (mean 7), all the distal tibial fractures and the triplane fractures were healed without varus or valgus deformity in the ankle. Conclusion : Distal tibial triplane fracture can be readily missed in plain radiography and should be suspected in patients with distal tibial spiral fracture which should be evaluated with a computed tomographic scan.

GENDER FEATURES OF THE AREAS OF ATTACHMENT OF THE ANTERIOR CRUCIATE LIGAMENT TO THE LATERAL FEMORAL CONDYLE FROM THE POSITION OF SURGICAL ANATOMY

Injury of the anterior cruciate ligament (ACL) remains the most common cause leading to limited knee function and earlier development of gonarthrosis. The results of ACL repair in male and female patients remain heterogeneous. Women have worse results of surgical treatment, as well as higher risks of ACL injuries (from 1,5 to 10 times) when playing sports. It is assumed that the features of the anatomical structure of the knee play the key role in this joint. We have studied 40 unpaired anatomical preparations of the human knee joint obtained from women and men.The morphometry of the distal femoral epiphysis was performed using a digital sliding caliper according to 16 parameters. When examining the areas of femoral ACL attachment, their shape, size, area, and center distance from individual bone structures were assessed. The data obtained were correlated with the type of structure of the knee joint. Were studied the anatomical features characteristic of the "female" type of structure of the knee joint. It was found that the type of structure of the knee joint affects the topography of the femoral attachment area of the ACL, which must be taken into account in anatomical ligament reconstruction.

Surgical treatment of patients with peroneal hemimelia

Forty two cases of surgical crus lengthening in children with congenital fibular hemimelia were analysed. It was determined that relapse of foot and segment axis deformity, abnormal development of tibia distal epiphysis were frequently noted in case of preservation of fibular-cartilagi- nous band. Transcutaneous tenotomy of fibular band provided the best conditions for crus development during the process of growth. However the tenotomy prevented the recurrence of segment axis deformity only in one third of all cases, the correct position of foot was most often instable. Distraction osteosynthesis should be combined with open reposition of fibular fibrous- cartilaginous bend that improved the conditions for ankle formation and prevented the recurrence of crus and tibial deformity during the growth process. Ultrasonography is the compulsory method for the determination of surgical intervention tactics.

Differences in pathways contributing to thyroid hormone effects on postnatal cartilage calcification versus secondary ossification center development.

The proximal and distal femur epiphyses of mice are both weight-bearing structures derived from chondrocytes but differ in development. Mineralization at the distal epiphysis occurs in an osteoblast-rich secondary ossification center (SOC), while the chondrocytes of the proximal femur head (FH), in particular, are directly mineralized. Thyroid hormone (TH) plays important roles in distal knee SOC formation, but whether TH also affects proximal FH development remains unexplored. Here, we found that TH controls chondrocyte maturation and mineralization at the FH in vivo through studies in thyroid stimulating hormone receptor (Tshr-/-) hypothyroid mice by X-ray, histology, transcriptional profiling, and immunofluorescence staining. Both in vivo and in vitro studies conducted in ATDC5 chondrocyte progenitors concur that TH regulates expression of genes that modulate mineralization (Ibsp, Bglap2, Dmp1, Spp1, and Alpl). Our work also delineates differences in prominent transcription factor regulation of genes involved in the different mechanisms leading to proximal FH cartilage calcification and endochondral ossification at the distal femur. The information on the molecular pathways contributing to postnatal cartilage calcification can provide insights on therapeutic strategies to treat pathological calcification that occurs in soft tissues such as aorta, kidney, and articular cartilage.

Технологія репозиції переломів дистального метаепіфіза променевої кістки

Незадовільні результати лікування у пацієнтів старше 60 років з переломами дистального метаепіфіза променевої кістки зустрічаються в 44 % випадків (не вдається отримати задовільного зіставлення відламків після первинної репозиції або настає вторинне зміщення). Переважна більшість пацієнтів лікується консервативно за рядом об’єктивних причин. Великий відсоток поганих результатів обумовлює пошук оптимальної методики ведення таких пацієнтів. Мета: оптимізувати тактику надання амбулаторно-поліклінічної допомоги постраждалим із переломами дистального метаепіфіза променевої кістки шляхом мультимодального знеболення, малотравматичної репозиції за допомогою запропонованого пристрою і фіксації фрагментів адекватними засобами іммобілізації з використанням нових технологій, що дозволить поліпшити результати лікування. Матеріали та методи. При надходженні пацієнтам із переломом дистального метаепіфіза променевої кістки проводили щадну репозицію з застосуванням запропонованого пристрою пластирного витягнення, фіксації сучасними пластиковими фіксуючими пов’язками скотчкаст. У всіх 12 пацієнтів визначали компоненти болю. Проведення профілактичних заходів (психогенна підготовка постраждалих, мультимодальне знеболювання, медикаментозна профілактика та лікування, раннє фізіолікування і лікувальна фізкультура) призвело до зниження вираженості больового синдрому. Вже до 4-ї доби після травми постраждалі відзначали зниження інтенсивності болю з 7,42 ± 0,31 бала до 2,40 ± 0,12 бала на 7-му і 14-ту добу за даними візуально-аналогової шкали (задовільна переносимість болю — 2,1 ± 0,1 бала і 2,2 ± 0,3 бала, що є свідченням доброї переносимості болю). Такі ж показники збереглися і до кінця іммобілізаційного періоду. Результати лікування оцінювали через 90 днів після травми. Після відновного лікування 11 пацієнтів оцінювали біль як незначну і терпиму. У 1 постраждалого мала місце хронізація больового синдрому (5,2 ± 0,6 бала). Були контрактури пальців і променезап’ясткового суглоба. Зберігався нейропатичний виражений больовий синдром. У 2 пацієнтів мали місце виражені нейротрофічні та функціональні порушення, які в подальшому потребували тривалого консервативного лікування. При опитуванні хворих за шкалою DASH функцію пошкодженої руки визначили як задовільну (33,2 ± 0,4 бала). Отримані нами результати свідчать про ефективність запропонованого підходу до лікування пацієнтів із переломами дистального метаепіфіза променевої кістки.

Реабілітація хворих з переломами дистального метаепіфіза променевої кістки

Переломи дистального метаепіфіза променевої кістки (ПДМЕПК, переломи променя в типовому місці) зустрічаються досить часто, особливо у людей похилого віку. Незадовільні результати лікування у пацієнтів віком понад 70 років відмічаються у 44 % випадків. Робота присвячена поліпшенню результатів лікування хворих із переломами дистального метаепіфіза променевої кістки. Реабілітаційне лікування включало мультимодальне знеболювання, диференційовано і обґрунтовано застосовану медикаментозну терапію, щадну репозицію із застосуванням запропонованого пристрою, ранню кінезитерапію, масаж і фізіотерапію. Функціональні результати реабілітації хворих із переломами ДМЕПК за шкалою DASH свідчили про її високу ефективність.

Knee Trauma.

Knee Trauma.

SIS therapy in the treatment of distal radius epiphyseal fracture (Case report)

Introduction. Fractures of the distal radius epiphysis are the most common fractures of the upper limb, present both in the general population active following major trauma and in the elderly population in minimal trauma due to osteoporosis. Among the adjuvant therapies for orthopedic treatment of distal radius epiphyseal fracture we can list Super Inductive System (SIS), a therapy based on the interaction between the electric field and the human body with the improvement of the healing process by acting on the pathophysiological stages of bone callus. Material and method. A clinical case study was performed on a 28-year-old patient, hospitalized and treated in the neurosurgery department of the Constanta County and Emergency Hospital for a polytrauma by road accident (passenger) with amyelotic cervical vertebral trauma, thoracic trauma and trauma to the right upper limb, subsequently performing 12 SIS therapy sessions at the Balneal and Rehabilitation Sanatorium of Techirghiol. CT examination of the cervical spine reveals fractures of C4 vertebra (the blade and pedicle) and C5 vertebra (vertebral body, lamina and pedicle). Right forearm radiography reveals fracture of the right radial styloid. After conservative treatment of the cervical injury and orthopedic treatment of the upper limb injury, the clinical evolution is favorable, allowing the patient to be discharged and allowed to do 12 sessions of SIS therapy, 3 times a week, within 4 weeks. The subsequent clinical and paraclinical evolution was favorable for the outpatient orthopedic ambulatory reevaluation performed at 5 weeks. Results and discussions. Due to the type of fracture of the radial distal epiphysis (linear fracture without displacement), absence of comorbidities and young age, led to the indication of orthopedic treatment with immobilization in the antebrachio-palmarcast, which allowed subsequent physiotherapy. Keywords: radial fracture, callus, polytrauma, cervical spine, lamina, Super Inductive System,

Tibial cortical and trabecular variables together can pinpoint the timing of impact loading relative to menarche in premenopausal females.

Though relationships between limb bone structure and mechanical loading have provided fantastic opportunities for understanding the lives of prehistoric adults, the lives of children remain poorly understood. Our aim was to determine whether or not adult tibial skeletal variables retain information about childhood/adolescent loading, through assessing relationships between cortical and trabecular bone variables and the timing of impact loading relative to menarche in premenopausal adult females. Peripheral quantitative computed tomography was used to quantify geometric and densitometric variables from the proximal tibial diaphysis (66% location) and distal epiphysis (4% location) among 81 nulliparous young adult female controls and athletes aged 19-33 years grouped according to intensity of impact loading both pre- and post-menarche: (1) Low:Low (Controls); (2) High:Low; (3) High:High; (4) Moderate:Moderate; (5) Low:Moderate. ANCOVA was used to compare properties among the groups adjusted for age, stature, and body mass. Significant increases in diaphyseal total cross-sectional area and strength-strain index were documented among groups with any pre-menarcheal impact loading relative to groups with none, regardless of post-menarcheal loading history (p < .01). In contrast, significantly elevated distal trabecular volumetric bone mineral density was only documented among groups with recent post-menarcheal loading relative to groups with none, regardless of pre-menarcheal impact loading history (p < .01). The consideration of diaphyseal cortical bone geometric and epiphyseal trabecular bone densitometric variables together within the tibia can identify variation in pre-menarcheal and post-menarcheal impact loading histories among premenopausal adult females.

Micro-CT Study of Mongolian Gerbil Humeral Bone After Prolonged Spaceflight Based on a New Algorithm for Delimitation of Long-Bone Regions.

The Mongolian gerbil displays unique physiological and anatomical features that make this species an attractive object for biological experiments in space. However, until recently, the Mongolian gerbil has remained a novel, mostly unstudied animal model in investigating bone loss in weightlessness (G0). After 12 days of orbital Foton-M3 mission, the humerus of Mongolian gerbils has been studied here via micro-computed tomography (micro-CT) to quantify bone morphometric parameters. The samples from the flight group, delayed synchronous ground-control group, and basal control group were investigated, and main morphometric parameters were reported in the article. The accurate selection of a region of interest is an essential step for a correct assessment of bone parameters. We proposed a new, easy and efficient method for delimiting the bone’s basic regions in the humerus. It is based on quantitative estimation of X-ray attenuation in the cortical bone as a function of humerus bone length. The micro-CT analysis of the basic bone regions revealed a difference in bone morphometric parameters between the flight and control gerbils. The most significant bone loss was observed in the cortical part of the proximal humeral zone in the flight group. No statistically significant changes of volume fraction in the cancellous tissue of proximal and distal epiphyses and metaphyses were observed. A statistically significant increase in both cancellous bone volume and bone X-ray attenuation in the flight group was detected in the proximal part of the diaphyses. We assume that enhanced calcium deposition in the diaphyseal cancellous tissue occurred due to a bone response to G0 conditions.

Prediction of Distal Femur and Proximal Tibia Bone Mineral Density From Total Body Dual Energy X-Ray Absorptiometry Scans in Persons with Spinal Cord Injury

Bone density decreases rapidly after spinal cord injury (SCI), increasing fracture risk. The most common fracture sites are at the knee (i.e., distal femur or proximal tibia). Despite this high fracture incidence, knee-specific scans for bone density using dual x-ray absorptiometry (DXA) were not available until 2014 and are still not routinely used in clinical practice today. This has made it difficult to determine the rehabilitation efficacy and hindered understanding of the long-term changes in knee areal bone density. The purpose of this investigation was to compare areal bone mineral density values for the knee from both total-body and knee-specific DXA scans in persons with SCI. A total of 20 participants (16 males) >1 yr-post spinal cord injury received two DXA scans; a total-body scan and a knee-specific scan. Standardized methods were used to create regions of interest to determine bone density of four regions – the epiphysis and metaphysis of the distal femur and proximal tibia – from the total-body scan. Linear regressions and Bland-Altman analyses were conducted to determine the correlation (r2) and agreement (mean bias ± 95% level of agreement) respectively between the two scan types for each region. Linear regression analyses showed strong significant (p < 0.001) relationships between the two scan types for the distal femur epiphysis (r2 = 0.88) and metaphysis (r2 = 0.98) and the proximal tibia epiphysis (r2 = 0.88) and metaphysis (r2 = 0.99). The mean bias ± 95% level of agreement were distal femur epiphysis (0.05 ± 0.1 g/cm2) and metaphysis (0.02 ± 0.04 g/cm2); proximal tibia epiphysis (-0.02 ± 0.1 g/cm2) and metaphysis (0.02 ± 0.03 g/cm2). Results suggest knee-specific bone density can be assessed using a total-body DXA scan. This may allow for more comprehensive use of DXA scans which would reduce the burden of multiple site-specific scans for persons with SCI and enable more widespread adoption of knee bone density assessment in this population.

Cultural influences on the castration age of cattle in the northern Baltic Sea region during the medieval and post-medieval periods

Oxen – castrated male cattle (Bos taurus) – were used as draught animals in Finland, Estonia and Sweden for centuries. From the medieval period onwards, the wider phenomenon of oxen culture is evidenced by zooarchaeological material and historical documents, which reflect, among other things, the castration age. When males were castrated at a young age – a method used in Sweden, according to the ethnological sources – it affected the growth of the metacarpal bones; thus, the metacarpals of these oxen should be distinct from those of cows and bulls. However, when males were castrated as adults – a method used in Estonia – it had less effect on the bones, so the metacarpals of these oxen are more likely to resemble those of bulls. Documents from the early modern period indicate that in Finland, cattle were castrated as calves (as they were in Sweden), but some medieval bone finds indicate that they were castrated in adulthood (as they were in Estonia). To resolve this apparent contradiction between the zooarchaeological data and the written evidence, and to understand the cultural transitions in farming practices relating to draught oxen in the northern Baltic Sea region, we studied morphometric changes in 621 metacarpals in Finland and Estonia dating from the medieval and post-medieval periods (13th to 20th century) and compared them with previously published contemporaneous data from Sweden. To investigate the size and shape of the individuals and to distinguish oxen from bulls and cows, we applied widely used osteometric criteria, including the maximum breadth of the distal epiphysis and Mennerich indices. For a set of uncertain samples from medieval Turku, Finland, we identified the sex by amplifying the TSPY gene and X and Y chromosome-specific variations in the ancient DNA. Our results confirm that throughout the medieval and post-medieval periods, late castration was practised in Estonia and early castration was practised in Sweden. In Finland, however, we detected a temporal change in the castration age: cattle were castrated as adults in the medieval period and at a young age in the post-medieval period.

Tibial Sliding Elastic Nailing Technique in Moderate-to-Severe Osteogenesis Imperfecta: Long-term Outcomes.

Osteosynthesis of leg fractures and deformities in children with osteogenesis imperfecta should align the skeleton and overcome its fragility during growth with a telescopic effect. A high rate of mechanical complications is associated with various surgical techniques described in the literature. The objective of this work was to assess the long-term clinical and radiologic outcomes of tibial sliding elastic nailing technique. A total of 22 children with an average age of 4.7 years were operated using the technique between 2004 and 2018 unilaterally (6) or bilaterally (16), that is, 38 operations. They were listed according to the Sillence classification into type I (3), III (17), or V (2). The nails were introduced percutaneously at the distal tibial epiphysis through the medial malleolus, and in the prespinal area for the proximal tibial epiphysis. The stainless-steel rods diameter was 1.5 to 2.5 mm, adapted to the size and weight of the patient. Realignment osteotomies were performed if necessary. Radiographic data including the correction of the deformation in the frontal and sagittal planes, as well as the width at mid-shaft of the tibia in the frontal and sagittal planes, were reviewed. Gillette Functional Score, assessment of pain, mechanical and infectious complications were collected. The average follow-up was 8.6 years. In the frontal plane, preoperative average varus was 8 degrees (maximum, 40 degrees), 5 degrees (maximum, 13 degrees) postoperatively, and 6 degrees (maximum, 12 degrees) at last follow-up. Preoperative valgus was 11 degrees (maximum, 22 degrees), 9 degrees (maximum, 15 degrees) postoperatively, and 9 degrees (maximum, 14 degrees) at the last follow-up. In the sagittal plane, the mean sagittal bowling of the tibia was 32 degrees (4 to 75 degrees) preoperatively, 9 degree (1 to 26 degrees) postoperatively, and 9 degrees (1 to 24 degrees) at last follow-up. The width at mid-shaft of the tibia in the frontal plane was 1.1 cm (0.6 to 1.8 cm) preoperatively and 1.3 cm at the last follow-up (0.7 to 2.0 cm). In the sagittal plane, it was 1.25 cm (0.7 to 2.7 cm) preoperatively and 1.27 cm (0.8 to 2.8 cm) at the last follow-up. Ten patients did not require revision surgery during their follow-up. Sixteen mechanical complications occurred in 12 patients (12 fractures or deformities following a lack of overlap of the 2 rods at an average time of 4.9 years after the initial surgery, 3 prominence of the nail, 1 pseudarthrosis). No infectious complication was reported. Gillette Functional Score was 20.54/65. Fifteen patients were able to walk at last follow-up, and 18 had no painful discomfort. The tibial sliding elastic nailing technique provides satisfactory clinical and radiologic results over time. Performed in case of fracture or as a preventive treatment, it allows a good correction of angular deformations. It is particularly suitable for young patients with a narrow medullary shaft. Level IV-therapeutic study.

Quantitative analysis of distal femoral epiphysis blood supply in healthy infants with superb microvascular imaging: a pilot study

This study aimed to determine the blood supply of the distal femoral epiphysis (DFE) using superb microvascular imaging in newborns and infants, and to investigate the correlation with ossification center (OC) length, sex, and age. A total of 140 cases were evaluated in this study. The cases were divided into 2 groups of less than 90 days and over 90 days. Cartilage blood supply was measured with vascularity index (%) (VI). The mean OC length and median VI values were measured as 10.20 ± 3.72 mm and 0.80% (0.58–1.50) for boys and 10.03 ± 3.36 mm and 0.70% (0.30–1.40) for girls, respectively. There was no significant difference in OC length and VI between sexes. The mean OC length in Group II was significantly higher than in Group I (12.14 ± 3.14 vs 8.09 ± 2.64) (p < 0.001). The median VI in Group I was higher than in Group II (1.40% vs 0.40%) (p < 0.001). There were positive correlations between age and OC length (r = 0 .716), negative correlations between age and VI (r = –0.822), and between VI and OC length (r = –0.657). Quantitative reference values for DFE blood supply and OC length can guide the diagnosis and follow-up of many skeletal diseases.

Open Reduction and Internal Screw Fixation of Transitional Ankle Fractures in Adolescents.

Surgical treatment of a triplane fracture is indicated if there is >2 mm articular displacement of the distal aspect of the tibia or if the fracture pattern is deemed unstable following closed reduction and casting. Preoperative planning (Step 1) involves the use of radiographs and computed tomography scans to determine accurate fracture classification, the intended reduction maneuver, possible blocks to reduction, and screw trajectory and length. Room setup and patient positioning (Step 2) include placing the patient in the supine position with a bump under the hip, as well as the placement of a ramp or stack of blankets under the affected limb and adequate general anesthesia with muscle relaxation to facilitate reduction. Incision and surgical exposure (Step 3) is performed with use of an anterior ankle incision at the anatomic plane between the extensor hallucis longus and extensor digitorum longus, protecting the neurovascular bundle (i.e., the anterior tibial artery and deep peroneal nerve). Open reduction and assessment of reduction (Step 4) begins by removing any soft tissue, such as the periosteum, that may be interposed in the fracture site precluding a reduction. The ankle is then put through internal rotation and dorsiflexion in order to reduce the fracture, utilizing direct visualization through the incision and fluoroscopy to verify reduction with <2 mm articular step-off. Screw placement (Step 5) typically involves a 2-screw construct, with 1 screw starting at the anterolateral distal tibial epiphysis aiming medially (and staying within the epiphysis) and a metaphyseal screw aiming from the anterior metaphysis to the posterior Thurston-Holland fragment. Closure and immobilization (Step 6) usually involve a layered skin closure, as no deep closure is necessary in most cases. A below-the-knee cast is applied with the ankle in neutral dorsiflexion. Nonoperative treatment typically involves closed reduction and long-leg cast immobilization. Surgical treatment with reduction and screw fixation of triplane fractures is indicated for patients with >2 mm articular displacement or >3 mm physeal displacement of the distal aspect of the tibia. Achieving and maintaining reduction with screw fixation within these tolerances helps decrease the chance of arthritis development by 5 to 13 years postoperatively5,7. Following treatment of a triplane fracture with reduction and screw fixation, full ankle range of motion and normal growth are anticipated. Postoperative follow-up continues until skeletal maturity or until 1 year postoperatively with evidence of continued growth by Park-Harris lines on sequential radiographs. Short-term recovery is expected to be excellent, and long-term results are expected to be good as long as <2 mm articular reduction is achieved and maintained5,7. General anesthesia with muscle relaxation helps with closed or open reduction.Computed tomography is valuable for determining the maximum articular displacement and for 3D surgical planning for screw trajectories.Be aware of the periosteum and perichondrial ring as possible soft-tissue blocks to reduction, and do not hesitate to visualize the periosteum with an open technique to achieve anatomic reduction. AITFL = anterior inferior tibiofibular ligamentAP = anteroposteriorCT = computed tomography.