Mihai Luchian Azoitei, PhD

• Assistant Professor in Medicine
• Member of the Duke Human Vaccine Institute

https://medicine.duke.edu/faculty/mihai-luchian-azoitei-phd

Femoral anteversion and any coxa valga associated with the untreated condition have an excellent chance to resolve during this time medicine omeprazole generic remeron 15mg otc. In this age group treatment coordinator purchase remeron discount, the treating surgeon must also consider whether to perform concomitant femoral shortening in conjunction with the open reduction symptoms of strep order remeron 30 mg otc. Schoenecker and Strecker reported a 54% incidence of aseptic necrosis with a 32% incidence of redislocation medicine wheel native american discount remeron 15 mg on-line, when skeletal traction was used in patients older than 3 years (288) medications online order 30mg remeron visa. A theoretical advantage of open reduction accompanied by femoral shortening is that it can be used for correcting any anatomic abnormality medicine 657 discount 15 mg remeron overnight delivery, such as excessive femoral anteversion. The disadvantages of femoral shortening include the need for a second incision and internal fixation for the osteotomy, and a further operation for hardware removal. The age range of 18 months to 3 years is considered a "gray zone"; some surgeons advocate preliminary traction before open reduction, but an increasing number of surgeons prefer to perform concomitant femoral shortening (354ͳ56). In this age range, because the potential for acetabular development is markedly diminished, many surgeons recommend a concomitant acetabular procedure, either in conjunction with the open reduction or 6 to 8 weeks after it (357). The decision about whether to perform a secondary acetabular procedure is subjective. If good stability is evident, the author prefers to observe acetabular development for the next few years, and if acetabular development is not improving by radiographic criteria. Most surgeons have been adopting earlier rather than later intervention for residual dysplasia, as the results are more predictable with fewer complications (347). The most common accompanying acetabular procedure performed in this age group in conjunction with open reduction is innominate osteotomy as described by Salter (41, 361ͳ64) and by Pemberton (40, 365ͳ69). Anatomic deficiency of the acetabulum in this age group is usually anterior, and the Salter innominate osteotomy gives anterior coverage, although at the expense of posterior coverage. The Pemberton osteotomy provides anterior coverage, and also various degrees of lateral coverage, depending on the direction of the osteotomy cuts. In this age group, the standard anterolateral approach described by Smith-Petersen with the Salter modification is the ideal approach, because it enables capsular plication, immobilization of the hip joint in a more functional position, and innominate osteotomy, all at the same time and through the same incision. After 3 years of age, open reduction of the hip should be accompanied by femoral shortening, and probably by a concomitant acetabular procedure, depending on hip stability at the time of surgery (347, 353, 356, 370ͳ73). A: Preoperative anteroposterior radiograph of a 4-year-old girl with developmental dislocation of the left hip. B: Eighteen months after reduction and femoral shortening, accessory centers of ossification are appearing in the lateral portion of the acetabular cartilage. The evidence demonstrates that residual acetabular dysplasia, even in the absence of subluxation, eventually leads to degenerative joint disease, so this also should be corrected (374, 375). When evaluating the patient with persistent dysplasia, the relation between the acetabulum and the femur should be assessed. If there has been a disturbance of proximal femoral growth secondary to previous treatment, the femoral side may be more dysplastic. Deformities of the femoral neck assume significance only if they lead to subluxation of the joint: lateral subluxation with extreme coxa valga or anterior subluxation with excessive anteversion (185). They may have persistent anteversion that gives the radiologic appearance of subluxation (disrupted Shenton line). When the Shenton line is disrupted, the proper relation of the proximal femur can usually be restored by derotation osteotomy, with or without various degrees of varus. The varus derotation osteotomy is used alone in such cases by surgeons who think that redirection of the femoral head toward the center of the acetabulum stimulates normal acetabular development (156, 184, 208, 393ʹ02). If the proximal femoral varus derotation osteotomy is to be used for "stimulating" more normal acetabular development in patients with persistent femoral anteversion, it must be performed in children younger than 4 years (393). After 8 years of age, no improvement in acetabular dysplasia can result from this procedure alone. However, recent reports show that varus derotation osteotomy in conjunction with open reduction was not as effective in resolving dysplasia as was open reduction combined with innominate osteotomy (227). A 34-year-old woman with residual dysplasia, who had undergone closed reduction for right developmental dysplasia of the hip at 16 months of age. B: False profile lateral view demonstrating anterior deficiency of the acetabulum. B: the radiograph shows the leg abducted approximately 30 degrees and maximally internally rotated. The femoral head is seated well within the acetabulum, and the Shenton line is restored. D: Anteroposterior view of the left hip 18 months after varus derotation osteotomy, with hardware removed. The Shenton line has been restored; persistent acetabular dysplasia remains, but development of the teardrop figure improved, and accessory centers of ossification have appeared in the periphery of the acetabular cartilage. If concentric reduction is not documented, this procedure should be accompanied by open reduction. In hip dysplasia, intertrochanteric osteotomy may be simply a derotation osteotomy or a derotation osteotomy combined with femoral shortening or a combination of the above adding varization to the procedure. As preoperative planning is essential, a more detailed description of this particular procedure follows. As mentioned above, an intertrochanteric osteotomy can have one or several components. Among these are varus, valgus, extension, flexion, rotation, shortening, medialization, lateralization, and transfer of the trochanter. The indications for each of these components are found in a careful analysis of the physical examination and the preoperative radiographs. Altering the varus inclination of the femoral neck will have profound effects on the abductor lever arm as well as on the forces across the knee joint. Thus, in a particular circumstance, a varus osteotomy may require both greater trochanter transfer, to restore the articulotrochanteric distance, and medialization of the femoral shaft, to maintain an equal weight distribution through the medial and lateral compartments of the knee. For most of the intertrochanteric osteotomies in children in which the remainder of the limb is in normal alignment, it is usually sufficient to account for the following relations in planning: Varus osteotomy results in genu varum and requires medial displacement of the femoral shaft to restore normal alignment to the leg. Valgus osteotomy results in genu valgum and requires lateral displacement of the femoral shaft to restore normal alignment to the leg. A varus intertrochanteric osteotomy in the normal hip of >25 degrees may need trochanteric transfer to maintain normal abductor muscle function. If a varus intertrochanteric osteotomy is performed in a hip with an already decreased articulotrochanteric distance, with a proximal physeal growth arrest as frequently seen in Perthes disease, or in conjunction with a medial displacement pelvic osteotomy. A valgus intertrochanteric osteotomy lengthens the leg and increases the pressure on the femoral head (just as a varus osteotomy shortens the leg). Preoperative planning in the detail described here is not usually necessary for an intertrochanteric varus osteotomy in a 2-year-old child undergoing reduction of a congenitally dislocated hip. It is essential for intertrochanteric osteotomies in the older child, however, because the mechanical effects are greater, the potential for remodeling is less, and derangements are more complex. After reviewing the clinical aspects of the condition, planning begins with a preoperative anteroposterior view of the pelvis and both hips. The normal hip radiograph should be taken in internal rotation to see the normal neck shaft angle. If there are other mechanical alterations in the alignment of the limb, a full-length radiograph from the hips to the ankles with the patient standing should be obtained on a 36-inch cassette. This permits the surgeon to examine the effect of the intertrochanteric osteotomy on the alignment of the limb and the need for additional osteotomies. Depending on the circumstances, additional radiographs with the limb in various positions can be obtained to determine the range of motion of the femoral head in the acetabulum and the best position for congruity. In our opinion, the degree of anteversion is best determined functionally by the rotation of the hip in extension rather than by radiographic means because the surgeon may be misled into correcting the radiographically determined amount of rotation only to find that the hip will not have sufficient internal rotation postoperatively. The actual process of planning the osteotomy has been well described by Muller (1975). This first drawing traces the exact outline of the femoral head and the proximal shaft and the acetabulum. A dotted line (A) is drawn down the axis of the femoral shaft and a second solid line (B) is drawn perpendicular to the dotted line just above the lesser trochanter. The second drawing, on a separate sheet of paper, traces the outline of the acetabulum. The drawings are turned until the femoral head on the first drawing is in the desired relationship to the acetabulum of the second one. Because the femoral axis remained superimposed, the correct amount of medial displacement is accounted for, and there is no change in the alignment of the leg. If blade plates are used as a means of internal fixation, the insertion point of the chisel can be determined. For the adult-sized plate, this is about 12 to 15 mm proximal to the osteotomy site. For the juvenile and adolescent plates, this distance is less and can be determined from transparent templates or measurement from the desired size of plate. On this same drawing, the correct amount of displacement can also be measured and the correct plate selected. Finally, the desired length of the blade can be measured and the blade plate drawn in. The amount of shortening that the osteotomy produces can be determined directly from the drawings. The femoral axis (A) of both drawings is aligned and the acetabular joint line of each is superimposed. The degree of immobilization or bed rest during this period depends on many factors: the size of the child and hence the strength of the plate used, the strength of the bone, the stability of the osteotomy, and the ability of the patient to cooperate with partial weight bearing. Cooperative children between 8 and 12 years of age can usually be left out of the cast during bed rest or given the use of a wheelchair. In the adolescent group, the fixation is usually strong enough to permit a partial weight-bearing crutch gait if the patient is cooperative. Full weight bearing is permitted in all age groups when there is radiographic evidence of bony union. In young children under 5 years of age, many physicians may choose to do the osteotomy using an Altdorf clamp for fixation. Although this plate is designed for varus osteotomies, the fact that it can be easily bent makes it ideal for the treatment (by valgus osteotomy) of developmental coxa vara in small children. In small children, any leg-length discrepancy resulting from varus osteotomy should resolve by growth stimulation and restoration of the normal neck-shaft angle (405). In teenagers, however, more than a 15-degree lessening of the neck-shaft angle may result in limb shortening. If the varus osteotomy is excessive, it can cause lateralization of the shaft, shifting the mechanical axis medial to the knee joint and leading to mechanical abnormalities at the knee (406). Proximal femoral osteotomy may, in some cases, be indicated in order to correct residual deformity from a partial physeal arrest resulting from aseptic necrosis; however, minimal literature exists on this procedure. If the osteotomy is transfixed with smooth wires, they can be removed after 6 to 8 weeks. Internal fixation devices are usually removed 12 to 18 months postoperatively; if they are not removed in young children, they become encased within the proximal femur, and this could pose problems if future operations become necessary. In the adolescent or adult patient with residual acetabular dysplasia and a disrupted Shenton line in whom there is no potential for acetabular growth and remodeling, changing the orientation of the proximal femur does not increase the weight-bearing area, but only shifts the weight-bearing area to another portion of the femoral head (407ʹ09). Indications for the treatment of residual radiographic acetabular dysplasia after closed or open reduction (or discovered incidentally) depend on the age of the child and whether the patient has symptoms (410). The goal of treatment is to restore the anatomy to as near normal as possible by the time skeletal maturity is attained. The surgeon without an assistant may find it easier to place the larger adolescent patient on a fracture table to control the leg more easily. Many fracture tables do not accommodate small children or permit bilateral hip surgery, making the choice obvious. To position children without a fracture table, it is useful to roll or fold a sheet with tape wrapped around it with the sticky side out. The patient should be positioned so that anteroposterior and lateral views of the hip can be obtained on an image intensifier. This is necessary to confirm the correct placement of the osteotomy and blade of the fixation device. For the patient who is not on a fracture table, the hip may be placed in the "frog-leg" position. The incision should extend from the tip of the greater trochanter as far distally as necessary. The distal extent of the incision depends on the fixation device used and the type of osteotomy; a shortening osteotomy requires a longer incision. After the incision is deepened through the subcutaneous fat and fascia lata, two self-retaining retractors are placed beneath the fascia lata. The vastus ridge, where the vastus lateralis muscle inserts, is identified, and the cautery current is used to cut through this muscle. This cut in the vastus lateralis muscle should extend from the anterior femoral shaft posteriorly to the point where the insertion ends. A sharp rake is used to pull up the belly of the vastus lateralis muscle, exposing its posterior attachment into the femur at the linea aspera. This muscle should be divided as close to this attachment as possible because all the muscle posterior to the division will be denervated. It is not wise to cut the muscle at its attachment because two to three large vessels will be encountered coming around the posterior aspect of the femur to enter the muscle. This can be done carefully, with the cautery current, or bluntly, by pulling a periosteal elevator from cephalad to caudad, tearing the muscle, and dividing the periosteum. With care and a bit of luck, these perforating vessels can be identified and cauterized before they are divided.

If the problem is identified treatment for 6mm kidney stone cheap remeron 30 mg with visa, greater trochanteric physeal plate arrest may be carried out symptoms high blood sugar 15 mg remeron with amex, and this may maintain articular trochanteric distance if performed in children younger than 8 years (22 treatment 3rd stage breast cancer remeron 30 mg mastercard, 527 medications journal generic remeron 15 mg, 528 4 medications list remeron 30mg fast delivery, 568 medications jejunostomy tube 15 mg remeron for sale, 569); otherwise, distal transfer of the greater trochanter may be necessary (465, 529͵31, 570͵72). It is the initial treating physician who has the greatest chance of successfully achieving a normal hip. Orthopaedic surgeons must educate primary care colleagues in making the diagnosis early and initiating prompt referral (573). B: Ten months after operative open reduction, femoral shortening, and Pemberton osteotomy. A: Anteroposterior view of a 5-year-old girl, 3 months after varus derotation osteotomy, an innominate osteotomy for residual dysplasia. A physeal growth arrest pattern may not be evident until a patient is 9 years of age or older. The patient is placed in the lateral decubitus position and the hip exposed through a Kocher-Langenbeck incision. With the leg internally rotated, the posterior border of the gluteus medius is identified. An incision from the posterior superior edge of the greater trochanter extending distally along the posterior border of the trochanter to the vastus lateralis ridge is made. The osteotomy should exit just anterior to the most posterior insertion of the gluteus medius which will allow preservation and protection of the medical femoral circumflex artery, which becomes intracapsular at the level of the superior gemellus muscle. The trochanteric fragment is mobilized anteriorly with the vastus lateralis after releasing it along its posterior border to the middle of the tendon of the gluteus maximus. The vastus lateralis and intermedius are elevated from the lateral and anterior aspects of the femur. The inferior border of the gluteus minimus is separated from the piriformis and the underlying hip joint capsule. The sciatic nerve that passes in most cases inferior to the piriformis muscle must be protected to avoid injury. The first capsular incision extends along the long axis of the femoral neck anterolaterally. This incision must remain anterior to the lesser trochanter in order to avoid damage to the main branch of the medial femoral circumflex artery. The capsular incision is then extended toward the acetabular rim where it is then sharply turned posteriorly parallel to the labrum reaching the retracted tendon of the piriformis. It is critically important to avoid injury to the labrum during this capsular incision. D: the hip joint can now be dislocated with the leg in flexion and external rotation off the front of the operating table. It is important during the surgical procedure to continue to irrigate the exposed cartilage of the femoral head and acetabulum with Ringer lactate solution. Viability of the femoral head can be assessed by a 2-mm drill home in the dislocated femoral head. After surgical intervention, the femoral head is easily relocated into the acetabulum and the hip joint capsule can be repaired loosely. Some patients with this deformity have an abductor lurch, necessitating distal transfer of the greater trochanter. Controlled trial of immediate splinting versus ultrasonographic surveillance in congenitally dislocatable hips. The fetal acetabulum: a histomorphometric study of acetabular anteversion and femoral head coverage. Morphology of the acetabulum in congenital dislocation of the hip: gross, histological and roentgenographic studies. The influence of the femoral head on pelvic growth and acetabular form in the rat. Growth and development of the acetabulum in the normal child: anatomical, histological and roentgenographic studies. Histological study of the fetal development of the human acetabulum and labrum: significance in congenital hip disease. The effects of trochanteric epiphysiodesis on growth of the proximal end of the femur following necrosis of the capital femoral epiphysis. The development of the upper end of the femur with special reference to its internal architecture. Trochanteric growth disturbance after upper femoral osteotomy for congenital dislocation of the hip. Relative trochanteric overgrowth after ischemic necrosis in congenital dislocation of the hip. Sequelae of experimental dislocation of a weight-bearing ball-and-socket joint in a young growing animal. Genetic and environmental factors in the etiology of congenital dislocation of the hip. Acetabular dysplasia and familial joint laxity: two etiological factors in congenital dislocations of the hip. Correlation between arthrograms and operative findings in congenital dislocation of the hip. Pitfalls in the use of the pavlik harness for treatment of congenital dysplasia, subluxation and dislocation of the hip. Acetabular development in congenital dislocation of the hip with special reference to the indications for acetabuloplasty and pelvic or femoral realignment osteotomy. Acetabular growth potential in congenital dislocation of the hip and some factors upon which it may depend. Pericapsular osteotomy of the ilium for treatment of congenital subluxation and dislocation of the hip. Acetabular development after reduction of congenital dislocation of the hip: a follow-up study of fifty hips. Congenital dislocation of the hip in Finland: an epidemiologic analysis of 1035 cases. Osteoarthrosis and congenital dysplasia of the hip in family members of children who have congenital dysplasia of the hip. Untreated congenital hip disease: a study of the epidemiology, natural history and social aspects of the disease in a Navajo population. Radiologic pelvic asymmetry in unilateral late diagnosed developmental dysplasia of the hip. Is there a difference between the epidemiologic characteristics of hip dislocation diagnosed early and late? Morphological variants in the human fetal hip joint: their significance in congenital hip disease. Morphometric study of the fetal development of the human hip joint: significance for congenital hip disease. Prevention of congenital dislocation of the hip: the Swedish experience of neonatal treatment of hip joint instability. Recent advances in the prevention, early diagnosis, and treatment of congenital dislocation of the hip in Japan. The relationship between neonatal developmental dysplasia of the hip and maternal hyperthyroidism. Orthopedic screening: especially congenital dislocation of the hip and spinal deformity. Screening for congenital dislocation of the hip, scoliosis, and other abnormalities affecting the musculoskeletal system. Etiology, pathogenesis, and possible prevention of congenital dislocation of the hip. Mehad: the Saudi tradition of infant wrapping as a possible aetiological factor in congenital dislocation of the hip. Preluxation of the hip joint: diagnosis and treatment in the newborn and the diagnosis of congenital dislocation of the hip joint in Sweden during the years 1948ͱ960. Neonatal screening for congenital dislocation of the hip: a prospective 21-year survey. Screening of children with congenital dislocation of the hip joint on the maternity wards in Sweden. Problems encountered in the early diagnosis and management of congenital dislocation of the hip. Late diagnosis of congenital dislocation of the hip and presence of a screening programme: South Australia population-based study. Significance of inguinal folds for diagnosis of congenital dislocation of the hip in infants aged three to four months. Closed versus open reduction of congenital hip dislocation in patients under 2 years of age. Congenital hip dislocation: long-range problems, residual signs, and symptoms after successful treatment. Soft tissue interposition after closed reduction in developmental dysplasia of the hip: the long term effect on acetabular development and aseptic necrosis. Treatment of congenital dislocation of the hip in infancy using the medial approach. Congenital dislocation of the hip: acetabular deficiency in adolescence (absence of the lateral acetabular epiphysis) after limbectomy in infancy. The pelvic osteotomy of Chiari: an anatomical study of the hazards and misleading radiographic appearance. Ultrasonography in developmental displacement of the hip: a critical analysis of our results. Assessment of variations in the measurement of hip ultrasonography by the Graf method in developmental dysplasia of the hip. Routine ultrasound screening for neonatal hip instability: can it abolish late-presenting congenital dislocation of the hip? Effective use of ultrasound in the management of congenital dislocation and/or dysplasia of the hip. Comparison of audible sound transmission with ultrasound in screening for congenital dislocation of the hip. Sonographic hip screening and early management of developmental dysplasia of the hip. The diagnosis of congenital hip-joint dislocation by the ultrasonic compound treatment. The role of ultrasound in the diagnosis and management of congenital dislocation and dysplasia of the hip. The role of ultrasound in diagnosis and management of developmental dysplasia of the hip. Real-time ultrasound in the diagnosis of congenital dislocation and dysplasia of the hip. Ultrasound and congenital dislocation of the hip: the importance of dynamic assessment. Congenital dislocation of the hip: a prospective study comparing ultrasound and clinical examination. Cost effectiveness of alternative screening strategies for developmental dysplasia of the hip. Ultrasound as the primary imaging method in the diagnosis of hip dysplasia in children aged < 2 years. Economic evaluation of ultrasonography in the diagnosis and management of developmental hip dysplasia in the United Kingdom and Ireland. Monitoring treatment of developmental dysplasia of the hip with the pavlik harness: the role of ultrasound. Computed tomography measurements of the acetabulum in adult dysplastic hips: which level is appropriate? Radiographic screening at four months of infants at risk for congenital hip dislocation. Normal values of the hip joint for the evaluation of x-rays in children and adults. Acetabular floor thickening and femoral head enlargement in congenital dislocation of the hip: lateral displacement of femoral head. Activity-dependence of the "safe zone" for impingement versus dislocation avoidance. The pelvic tear-figure: a three-dimensional analysis of the anatomy and effects of rotation. The predictive value of the development of the acetabular teardrop figure in developmental dysplasia of the hip. The teardrop in congenital dislocation of the hip diagnosed late: a quantitative study. The predictive value of the development of acetabular teardrop figure in developmental dysplasia of the hip. Signs by which to diagnose congenital dislocation of the hip, 1928 (Classical article). Prediction of reduction in developmental dysplasia of the hip by magnetic resonance imaging. Magnetic resonance imaging study of acetabular morphology in developmental dysplasia of the hip. Morphology of untreated bilateral congenital dislocation of the hips in a seventy-four-year-old man. Long term results of late non operative reduction of developmental dysplasia of the hip.

The results of fasciotomy in the management of chronic exertional compartment syndrome medications nurses purchase remeron once a day. Chronic exercise-induced compartment pressure elevation measured with a miniaturized fluid pressure monitor medications hypertension purchase remeron amex. Women athletes with menstrual irregularity have increased musculoskeletal injuries medications in mothers milk cheap remeron 30 mg without a prescription. Contributing factors to medial tibial stress syndrome: a prospective investigation medicine engineering purchase 30mg remeron overnight delivery. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system medicine naproxen 500mg order remeron line. The natural history and treatment of delayed union stress fractures of the anterior cortex of the tibia treatment uveitis purchase remeron cheap. Prevention and management of calcaneal apophysitis in children: an overuse syndrome. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. The effect of pitching biomechanics on the upper extremity in youth and adolescent baseball pitchers. A biomechanical comparison of youth baseball pitches: is the curveball potentially harmful? A peculiar affection of the capitulum humeri resembling Calv鮐erthes disease of the hip. Overuse injuries to the physes in young athletes: a clinical and basic science review. Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes. Sequential alterations in magnetic resonance imaging findings after autologous osteochondral mosaicplasty for young athletes with osteochondritis dissecans of the humeral capitellum. Donor site evaluation after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint. Dual direct lateral portals for treatment of osteochondritis dissecans of the capitellum: an anatomic study. Osteochondritis dissecans of the capitellum: arthroscopicassisted treatment of large, full-thickness defects in young patients. A biomechanical comparison of the fastball and curveball in adolescent baseball pitchers. Nearly one of three children will have at least one fracture during childhood (3). Orthopaedic surgeons, pediatricians, emergency room, personnel and primary care physicians will all be commonly exposed to fractures and other musculoskeletal trauma in children and, therefore, must have an understanding of the basic diagnostic and treatment principles. The general assumption is that fractures in children heal with little intervention and any deformity will remodel. Although this may be true much of the time, it is critical to be able to determine which injuries require greater attention and need intervention. For example, lateral condyle fractures may be more likely to go on to a nonunion, while physeal fractures are more likely to cause a growth arrest. It is also important to challenge the diagnosis and recognize that other disorders may first present as an acute injury, such as bone tumors diagnosed after a sports-related injury (1) or osteomyelitis seen within several days of a bone contusion from a fall (2). The purpose of this chapter is to provide a practice-based overview of fracture care in children. The specific management of each of the various pediatric fracture types is beyond the scope of this chapter. The emphasis here is on the general principles of fracture management in the pediatric age group. The specific management of the individual fracture types is very adequately covered in the two major textbooks devoted specifically to Fractures in Children. Girls have a similar pattern of incidence of fractures when young, but fracture occurrence decreases prior to the teenage years (3, 5). These injury patterns differ from the incidence of other types of childhood injures, such as head and soft-tissue injuries, which peak by age 2 (6). Child abuse as an etiology of fractures is less common as children age but must always be considered when fractures occur in young children, especially prior to walking age. Upper extremity fractures account for two-thirds of childhood fractures, with the forearm being the most common location. Open fractures are uncommon in children, occurring in only 2% of fractures, and multiple fractures occur in 4% of injuries (5). Worldwide, over 830,000 children die each year from accidental injuries such as motor vehicle accidents, drowning, falls, and firearm injuries. Although not all fractures and childhood injuries can be prevented, there are many ways in which the rate and severity of injuries can be decreased. An understanding of the causes and prevention strategies of childhood injuries is important for the health care providers, so they can share this with their patients and their caregivers. Injuries and fractures most commonly occur at home, especially in the younger child. The patterns and incidence depend on a number of variables including age, sex, climate, time of year, and environmental and cultural differences. In children from birth to 16 years of age, 42% of boys and 27% of girls suffer a fracture and about 2% of children sustain at least one fracture per year (3). Falls from windows can be much more serious, especially in an urban environment with high-rise buildings and concrete sidewalks. Serious injury or mortality occurs most frequently in falls from heights greater than three stories (8). Considering the amount of time that children spend at school, proportionally few injuries occur there. Most of these injuries are minor sprains and contusions and are associated with athletic activities; fractures infrequently occur at school (9). Motorized recreational sports, such as motocross and use of all-terrain vehicles, are also associated with serious musculoskeletal injuries when safety guidelines are disregarded. Vehicles that are too heavy or powerful to be handled properly and poor driver judgment are important factors in injury occurrence. About 1% of children who use playgrounds sustain injuries, mostly from activities on playground equipment, according to one study. While most injuries are fractures (39%) and soft-tissue injuries, such as contusions and sprains (48%), traumatic brain injuries are not uncommon (8. Most children, however, do not require hospital admission for playground injuries (10). Changing playground surfaces from concrete to more impact-absorbing surfaces, such as bark or sand, can reduce the incidence and severity of head injury and potentially other injuries. Fracture risk, however, may be more related to the height of the fall than to the playground surface (11). The four sports activities associated with the most injuries to bones and muscles are bicycle riding, basketball, football, and roller sports (12). More significantly, bicycle accidents are the most common causes of serious head injury in children (13). Recently, however, evidence suggests that the use of helmets is increasing over the last several years (14). Roller sport injuries include those from skateboarding, roller skating, and inline skates. Skateboarding tends to result in the most severe injuries (15), with a high incidence of fractures. In one report, as many as 60% of inline skaters sustained a traumatic injury, mostly contusions but occasionally fractures (16). Ice skating has a higher incidence of head injury than roller skating, making use of head protection for these athletes particularly important (18). Appropriate instruction, supervision, and protective equipment, including helmets, wrist guards, and elbow and knee pads, should be mandated (18). Trampoline-related injuries are becoming much more common and, like skateboard injuries, are frequently high-energy injuries. These injuries typically occur in the home setting often under the supervision and with the knowledge of the parents, most of whom know of the potential dangers of trampoline use (21, 22). Jumping with more than one person on the trampoline increases the risk of injury significantly. It is unclear if trampolines at home or on playgrounds can ever be used safely, and some advise that trampolines be Motor Vehicle Accidents. Motor vehicle accidents are the most common cause of death for children and adolescents in the United States. Vehicle-versus-pedestrian accidents are about twice as common as injuries sustained by children who are occupants in a car involved in a crash. Child safety seats can reduce fatal injuries by 71% for infants younger than 1 year old and reduce fatal injuries by 54% for toddlers 1 to 4 years old. The character of injuries in restrained children is different compared to those unrestrained, with fewer fractures occurring but with higher proportion of femur, spinal, and pelvic injuries. Appropriate use of child safety car seats, combined with sitting the child in the rear seat (center position ideally) and never in the front seat with an airbag, is critical for the prevention of injury in a motor vehicle accident. All parents should be made aware of the safety guidelines for child restraints in motor vehicles established by the American Academy of Pediatrics, not only to minimize the risk of injuries in motor vehicle crashes, but also to facilitate adherence to state and federal guidelines for safe transportation of children. Like adult bone, the diaphysis of long bones is comprised of dense cortical bone and the metaphysis is comprised of spongy, cancellous bone. There are four distinct areas that are associated with growth and remodeling processes. The epiphysis is the site of secondary bone ossification that determines the size and shape of the articular surface. The articular surface enlarges via the small area of endochondral ossification that is located in the subchondral area. The epiphysis is also the resting site of osteoprogenitor cells, or chondrocytes, that develop into the components of the physis. Ligaments take their origin from or insert into the epiphyses at many joints, such as at the knee or ankle. Apophyses enlarge bones by appositional growth but do not significantly contribute to longitudinal growth. Physeal growth and the appearance of the secondary ossification centers occur in a predictable manner as the child matures. The physis, or growth plate, is a narrow band of cartilage that lies between the epiphysis at the end of the bone and the metaphysis. The physis or growth plate is the most important feature that differentiates bones of children from that of an adult. Longitudinal bone growth occurs primarily through the replacement of a cartilage anlage by a process termed endochondral ossification. The physis is highly organized at the cellular level into columns that span the epiphyseal end and the metaphysis. The germinal zone is closest to the articular surface and contains the resting chondrocytes, the precursors of new bone. Guided by local and systemic growth factors, these cells divide, forming the proliferating zone (27). In the hypertrophic zone, adjacent to these cells, the chondrocytes enlarge and mature. As these cells begin to degenerate, vascular budding from the adjacent metaphysis triggers the dystrophic calcification of the matrix producing the so-called zone of provisional calcification. Because the cartilage cells in this area of the physis are degenerating, they can no longer prevent the precipitation of the calcium and phosphate salts in the matrix. It needs to be emphasized that this process of calcification is degenerative and does not contribute directly to the ossification process. As the metaphyseal vessels migrate into this dead cartilage and its degenerated matrix, they bring in either chondroclasts or osteoclasts that reabsorb the dead cartilage cells and replace them with osteoclasts to produce osteocytes and a truly ossified tissue. With further vascular ingrowth, this zone remodels rapidly and becomes mature metaphyseal (lamellar) bone to form the diaphysis. Extracapsular physes are more richly vascularized by vessels that penetrate directly into the periosteum and the capsular attachments that surround them. Because of this, intracapsular epiphyses are more susceptible to vascular disruption from physeal fractures or osteoarticular infections. Serious growth disturbances, manifesting as articular surface deformity, angular deformation, or limb-length inequalities, may occur in younger children from these etiologies. It must be also remembered that underlying the articular cartilage is a small area of endochondral ossification that contributes to the growth of the cartilage of the articular surface. Any injury to this area of endochondral ossification can result in the development of a defect in the articular surface. Another unique characteristic of growing bone is its thick, vascular, and highly osteogenic periosteum. With the exception of these sites, fracture displacement in children causes muscles and ligaments to separate from the outer fibrous layer of periosteum, leaving behind the inner osteogenic layer. Additionally, this thick periosteum is rarely torn circumferentially and frequently is left intact on the compression side of an injured bone. The partially intact periosteal sleeve limits fracture displacement to some degree and may be exploited by the surgeon to achieve and maintain fracture reduction. Periosteum, however, may also inhibit fracture reduction if a torn end becomes interposed between the fragments or if the bone ends button-hole through a longitudinal tear in the periosteum. Failure of closed reduction is sometimes the result of entrapment of the bone end outside the periosteal hole when reduction with longitudinal traction is attempted. Fractures to the immature skeleton, like in the adult, are described by location and fracture pattern. Many of these fracture patterns are similar to adult fractures, but others are unique to the growing child. Because of its lower density, growing bone has a lower modulus of elasticity, diminishing its strength and response to bending forces but allowing it to absorb greater energy before failure.

B: Intraoperative arthrograms demonstrating hinging on the lateral aspect of the acetabulum in abduction (left) with good congruity in adduction (right) medications with weight loss side effect order remeron without a prescription. At 7-year follow-up symptoms diagnosis buy remeron, the patient was free of pain medications 222 buy 15 mg remeron free shipping, with 40 degrees of abduction symptoms xanax withdrawal order 30mg remeron with visa, 20 degrees of adduction medicine interactions buy online remeron, flexion to 130 degrees medicine used to induce labor buy cheap remeron 30 mg, and 20 degrees of internal and external rotation. Standard treatment algorithms are based on radiographic features of the various disease classification schemes. Under these protocols, no treatment is warranted in patients with a good prognosis. These would include patients with Catterall groups 3 and 4 disease, Salter-Thompson type B disease, and lateral pillar type C disease. There is another large group of patients whose prognosis is indeterminate; these patients require careful follow-up, because they may need treatment at a later date. This group includes patients with Catterall group 2 disease (good prognosis in 90% of cases), patients with lateral pillar type B disease, and some B/C border patients. Because we have learned that the two major prognostic factors in outcome are deformity of the femoral head and age of the patient, these two factors must be taken into account in the decision-making process. Patients with deformity (arthrographically and/or clinically documented by persistent loss of motion, particularly abduction) younger than 8 years should be considered for treatment. Patients older than 8 years, especially girls, should be considered for treatment even in the absence of deformity. In the absence of treatment, such patients have a poor prognosis (71, 267, 316) because their growth potential is insufficient for any deformity of the proximal femur to be compensated for by a corresponding change in the shape of the acetabulum. If the patient is already in the reossification or healing stage of the disease, little further deformity ensues, and no treatment is indicated unless the patient has symptoms (see the section Treatment Options in the Noncontainable Hip and the Latepresenting Patient with Deformity later in this chapter). The earliest treatment methods used weight relief until the femoral head was reossified. These methods were based on the premise that weight relief would prevent the mechanical deformation of the head and early degenerative joint disease (89, 317ͳ19). These modalities included prolonged, strict bed rest, often in the hospital, and bed rest with or without various periods of traction on special frames or in spica casts. These methods of treatment were associated with disuse atrophy of muscles, osteopenia, shortening of the involved extremity, loss of thoracic kyphosis, urinary calculi, social and emotional problems, and high hospital costs (167, 215, 216, 278, 320ͳ27). The concept of weight relief as a treatment for Legg-Calvꑥrthes syndrome was challenged as early as 1927, when Legg stated that, "while the process suggesting weakness of bone structure is going on it is theoretically sound to allow no weight bearing but in practice relief from weight bearing in no way affects the end results" (328). In addition, prolonged immobilization and bed rest do not influence the radiographic course of the disease (237, 256, 258, 329ͳ31). Harrison and Menon (324) pointed out, as had Pauwels and others (167, 332, 333), that even at rest or during minimal activity significant forces act on the femoral head. The cornerstone of treatment for Legg-Calv鮐erthes syndrome is referred to as containment. Clinical abduction is to 10 degrees; adduction is to 40 degrees with the hip in extension. A: Anteroposterior view of pelvis showing total femoral head involvement in reossification stage of disease. C: Arthrogram in neutral position showing considerable flattening of femoral head and slight impingement on lateral edge of the acetabulum. E: Arthrogram in adduction demonstrating reasonable congruity between femoral head and acetabulum; note normal contour of lateral acetabular edge. F: Abduction osteotomy allowing 45 degrees of abduction and 0 degree of adduction. Patient is pain free with 45 degrees of abduction, 10 degrees of adduction, and good rotation. Harrison and Menon (324), Petrie and Bitenc (279), Salter (124, 334), and others (335ͳ40). The essence of containment is that, in order to prevent deformities of the diseased epiphysis, the femoral head must be contained within the depths of the acetabulum, thereby equalizing the pressure on the head and subjecting it to the molding action of the acetabulum. Containment is an attempt to reduce the forces through the hip joint by actual or relative varus positioning (341). The femoral head represents more than three-fourths of the sphere and the acetabulum only half of the sphere. Therefore, no method of containment can provide for a totally contained femoral head within the acetabulum during all portions of the gait cycle (156, 339, 340, 343). The primary goals in the treatment of Legg-Calv鮐erthes syndrome are to prevent deformity (Stulberg classes 3, 4, and 5) and stop growth disturbance, thereby preventing degenerative joint disease. Attainment of these goals requires that each patient be assessed clinically and radiographically. Clinically, the patient is evaluated for clinical at-risk signs such as loss of motion, contracture of the joint, and pain. B: Abduction, external rotation, and slight flexion (the position that would be maintained by an abduction Scottish Rite-type orthosis). C: Abduction and internal rotation (the position that would be maintained by a varus derotation osteotomy or innominate osteotomy). If treatment is to succeed in controlling subsequent deformity, it should be initiated in the initial or fragmentation phase of the disease (76, 284). Treatment is not indicated if the child demonstrates none of the clinical or radiographic at-risk signs; if he or she has Catterall group 1 or 2, Salter-Thompson type A, or lateral pillar type A disease; or if the disease is already in the reossification stage. A child who demonstrates clinical or radiographic at-risk signs regardless of the extent of epiphyseal involvement should receive treatment (286). Even patients with Catterall group 2 disease (or lateral pillar type B disease) who are at risk may have poor results without treatment (72) (W. The first principle of treatment regardless of the definitive method of treatment chosen is restoration of motion. Motion of the joint enhances synovial nutrition and cartilage nutrition (344, 345). The series that recorded the greatest success in treating patients for extensively involved femoral heads is that of Brotherton and McKibbin (335). The end results in these patients were superior to those in another longterm study of patients treated with bed rest and containment on a frame (215, 216). The only difference between the two treatment regimens was that in the former series motion was always maintained. Restoration of motion can be accomplished by bed rest alone, or with skin traction and progressive abduction to relieve the muscle spasms. The author recommends bed rest at home with nonsteroidal antiinflammatory drugs on a round-the-clock basis and then reassessment in 1 week to assure that range of motion has considerably improved (to at least 45 degrees of abduction). Restoration of motion allows abduction of the hip, which reduces the forces on the hip joint and allows positioning of the uncovered anterolateral aspect of the femoral head in the acetabulum. Mobilization of the hip joint can also be achieved by rest followed by the use of progressive abduction plasters to stretch the hip adductor muscles while allowing hip flexion and extension. A full or almost full range of motion is usually obtainable within 7 to 10 days of treatment. Because of early deformity, complete abduction and internal rotation may not always be obtainable. Persistence of an adduction contracture is always associated with a serious femoral head deformity and will not respond to bed rest or to bed rest with traction (145). Arthrography can reveal any flattening of the femoral head that may not be seen on plain radiographs. Demonstration of the hinge abduction phenomenon, or the inability to contain the hip, is a contraindication to any type of containment treatment. This also provides an opportunity to examine whether muscle spasm, contracture, or mechanical deformity is responsible for any apparent fixed deformities. Although operative treatment is becoming increasingly popular, there is considerable debate about the benefits of each operative procedure. The shortage of natural history studies for comparison of the results of different modalities of treatment is another reason for the difficulty in resolving this controversy. In addition, the variability of criteria for inclusion of patients in studies, the use of different measurements to assess outcomes of treatment, the lack of interobserver and intraobserver reliability data, and the lack of untreated control groups make comparisons difficult. In the earlier editions of this book, considerable space was devoted to describing the use of abduction bracing in the treatment of Perthes disease. Over the years, this modality has been replaced by more promising surgical interventions and is now rarely used by pediatric orthopaedic surgeons. It is mentioned in this edition for the historical perspective of the evolution of methods of treatment. Today the most widely used methods to maintain containment are femoral osteotomy, innominate osteotomy, and the use of a procedure earlier regarded as a salvage procedure, namely, lateral shelf acetabuloplasty. There is also growing interest in combined femoral and innominate surgical procedures. This series proved that weight bearing, with the femoral head contained, was not harmful. This method of treatment allows for weight bearing and maintenance of range of motion of the hip in the contained position. Petrie casts are currently used by some surgeons after muscle-release procedures and capsulotomies for reducing femoral heads that are deformed and subluxated (348), or for maintaining containment after surgical treatment. To avoid the repeated hospitalizations necessary for regaining knee and ankle motion, and to avoid the occasional flattening of the femoral condyles seen in patients treated with broomstick plasters, orthopaedists turned to the use of removal abduction orthoses, as typified by the Newington abduction brace (278), the Roberts orthosis (349), the Houston A-frame brace (350), and the Toronto Legg-Calv鮐erthes orthosis (176, 351). These devices were thought to provide for containment solely by abduction without fixed internal rotation (280, 283, 352, 353). Containment was provided by the abduction of the brace and the hip flexion required for walking with the legs in abduction. These devices are less cumbersome than other braces and are well tolerated by patients. The brace was worn on a fulltime basis until the femoral head was in the reossification stage, when there was no further risk of collapse. The negative aspects of bracing included prolonged treatment times and the need for compliance on the part of the patient. This type of treatment was also difficult for girls and older patients to accept (355). Although early radiographic anatomic results were comparable with those of previously used containment weightbearing methods (280, 353), follow-up reports of patients treated with these orthotic devices questioned the efficacy of this method of management (238, 356, 357). The mean age of the patients when first seen was 6 years, and the mean duration of follow-up was 7 years. At follow-up, applying the Mose criteria, no hip had a good result, 35% had fair results, and 65% had poor results. With respect to the lateral column, of the 20 hips in which collapse occurred, only 10% had Stulberg class 2 results, 35% had class 3 results, 45% had class 4 results, and 10% had class 5 results. By comparison, in the 14 hips in which collapse of the lateral column did not occur, 86% had Stulberg class 2 results and only 14% had class 3 results. The authors concluded that although containment is the most widely accepted principle of treatment of Legg-Calv鮐erthes disease, little clinical information supports the contention that bracing in abduction and external rotation, as provided by the Atlanta Scottish Rite orthosis and its modifications, is effective. At follow-up, there were no Stulberg class 1 results, 3 class 2 results, 24 class 3 results, 6 class 4 results, and 1 class 5 result. The same investigators also arrived at a similar conclusion concerning the use of this orthotic device in the treatment of Perthes disease. In both of these studies, the issue of compliance is not documented, and as with all studies of Perthes disease in the literature, control groups other than historic controls are absent. As expected, most patients with Perthes disease in both series were doing well clinically, as do most patients over the short term regardless of the extent of the deformity. The long-term prognosis for all but the Stulberg class 1 and 2 hips is guarded (358). In the light of these results, bracing is rarely used today by pediatric orthopaedic surgeons in the treatment of Perthes disease. Because of the nihilistic attitude that many physicians share with regard to treatment for Perthes disease, they have begun treating patients with only maintenance of range-ofmotion programs, including stretching exercises, nighttime abduction splinting, home traction, and other combinations. Long-term follow-up studies of these nonoperative range-ofmotion regimens are needed in order to determine their efficacy. Procedures used for obtaining or maintaining containment in Legg-Calv鮐erthes syndrome are those that were originally used in the treatment of problems associated with developmental hip dysplasia and dislocation. The discussion that follows relates only to hips that are "containable" (relatively full range of motion, congruency between the femoral head and the acetabulum) and in the initial or fragmentation phase of the disease. Varus osteotomy, with or without associated derotation, offers the theoretical advantage of deep seating of the femoral head and positioning of the vulnerable anterolateral portion of the head away from the deforming influences of the acetabular edge (127, 145, 247, 359ͳ61). The varus position reduces the forces exerted by the joint on the femoral head (341, 359). This procedure is thought to relieve the intraosseous venous hypertension and improve the disturbed intraosseous venous drainage reported in LeggCalv鮐erthes syndrome, thereby speeding the healing process (127, 128, 153, 358, 359, 362ͳ64). Surgical methods of providing or maintaining containment are advocated by many investigators. Surgical containment methods offer the advantage of early mobilization and the avoidance of prolonged bracing or cast treatment. This assessment usually requires arthrography if the femoral head is well into the fragmentation phase. The procedure must be performed early, in the initial or fragmentation stage of the disease, in order to have any effect on later femoral head deformity (186, 231, 359). Varus osteotomy, with or without derotation, usually requires the use of internal fixation and external mobilization in plaster for 6 weeks. The patient must incur the inherent risks and costs associated with at least one surgical procedure and most likely a second surgical procedure for hardware removal. The varus angle generally decreases with growth (197, 369, 370); however, if there has been physeal plate damage secondary to the disease, this remodeling potential may be lost, and the patient may have permanent shortening and temporary or permanent weakness of the hip abductors (153, 370ͳ74).

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