We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group. The early postoperative course was similar, but the FIN [corrected] group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections. At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5 degrees, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.

In 30 patients in whom osteomyelitis was suspected fine-needle bone biopsies (FNBB) were taken at the same time as bone was aspirated for bacteriological examination. The diagnosis of osteomyelitis was eventually confirmed in 15 patients; the other 15 had myositis (3), arthritis (3), trauma (2), microgeodic phalangeal syndrome (2), haematoma in a nonossifying fibroma (1), and Ewing's sarcoma (1). In three patients no pathology was found. The temperature, WBC and ESR at presentation did not help to distinguish osteomyelitis from other conditions. FNBB, however, proved to be a useful additional investigation with a sensitivity for osteomyelitis of 87% and a specificity of 93%.

A 28-year-old woman, gravida 7, para 6, was referred at 21 weeks' gestation to our ultrasound unit because of bilateral fetal lower limb edema diagnosed previously. Ultrasonography showed a constriction ring around both legs, and, with the aid of color Doppler, arterial flow was demonstrated in both legs beneath the constriction ring. Subsequent examinations during the 24th and 28th weeks revealed absence of flow below the constriction ring of the right leg and decreased flow in the left leg. This was followed by the gradual bending, breaking and resorption of the tibia and fibula of the right leg. Between weeks 30 and 34, gradual shrinkage of the remains of the right leg beneath the knee was recorded by serial ultrasonic observations. At the 38th week of gestation, a male infant was born by normal vaginal delivery. Examination at birth revealed amputation of the right leg below the knee, with a denuded end of the stump. There was a partial amputation of the left leg below the knee, with tissue continuity being maintained by the posterior neurovascular bundle, and a posterior strip of skin. The left foot was extremely edematous, with an area of necrosis dorsally. This case afforded us the opportunity of in utero following of natural limb amputation in the amniotic band syndrome.

We report the outcome of 19 children aged 5.2 to 13.2 years with 20 fractures of the femoral shaft requiring surgery, who were randomly assigned to have external fixation (EF) or flexible intramedullary nailing (FIN) (10 fractures each). The duration of the operation averaged 56 minutes for the EF group with 1.4 minutes of fluoroscopy, compared with 74 minutes and 2.6 minutes, respectively, for the FIN group. The early postoperative course was similar, but the EF group showed much more callus formation. The time to full weight-bearing, full range of movement and return to school were all shorter in the FIN group. The FIN complications included one transitory foot drop and two cases of bursitis at an insertion site. In the EF group there was one refracture, one rotatory malunion requiring remanipulation and two pin-track infections. At an average follow-up of 14 months two patients in the EF group had mild pain, four had quadriceps wasting, one had leg-length discrepancy of over 1 cm, four had malalignment of over 5°, and one had limited hip rotation. In the FIN group, one patient had mild pain and one had quadriceps wasting; there were no length discrepancies, malalignment or limitation of movement. Parents of the FIN group were more satisfied. We recommend the use of flexible intramedullary nailing for fractures of the femoral shaft which require surgery, and reserve external fixation for open or severely comminuted fractures.

No abstract

Removal of hardware in children after orthopaedic procedures is controversial. The authors retrospectively reviewed hospital charts and radiographs of 143 children who underwent removal of flexible titanium nails from the femur and the forearm. In 16 children the nails were removed because of protrusion, skin irritation, and some discomfort. Most of the patients were asymptomatic and underwent nail removal electively, according to the authors' policy for routine hardware removal in children. Complications included unsuccessful nail removal in three children and refractures after nail removal in two. Although the authors are still inclined to remove flexible titanium nails in most of the patients, the need for routine elective execution of this procedure may be questionable.

The Ilizarov external fixator has numerous advantages applicable to ankle fusion, including: stable fixation, respect for soft tissues, and the possibility of postoperative alignment 'fine-tuning'. Additionally, the ability to direct forces through or around skeletal elements allows varying of the load through the skeletal elements, allowing early weightbearing. The Ilizarov technique, with its high union rate, may be considered for any ankle arthrodesis but is especially useful in complex cases such as revisions, talar osteonecrosis, soft-tissue compromise, and infection. Early weightbearing is an added benefit.

We describe the treatment and follow-up of a case of hereditary multiple exostosis in a 16-year-old girl, who had intraarticular and extraarticular osteochondromas in the right hip joint which caused hip subluxation. These osteochondromas were excised, the femoral head was located concentrically, and the patient was put in a spica cast for 6 weeks. Six months later, hip magnetic resonance imaging showed no evidence of avascular necrosis. Three years after the operation the patient walked freely, without pain, and there was satisfying coverage of the femoral head. The authors emphasize that careful attention should be given to the surgical technique prior to extraarticular and intraarticular acetabular osteochondroma excision in order to avoid the development of avascular necrosis.