In 15 consecutive patients with slipped capital femoral epiphysis we recorded height, weight and skeletal maturity. Sexual maturity was assessed clinically and biochemically, and Harris's hypothesis that there is an increased ratio of serum growth hormone to oestrogen was tested in comparison with 15 age and sex matched controls. We found no difference in skeletal or sexual maturity between the groups, or any overt endocrine abnormality in the patients. However almost half the patients with slipped epiphysis were over the 90th weight percentile, suggesting that mechanical factors such as obesity are more important aetiologically than endocrine abnormalities

We have reviewed 15 cases of triplane fracture of the distal tibia. The mechanism of injury is lateral rotation and the anatomical pattern of the fracture depends on the state of the growth plate at the time of injury. In seven of our cases the anteromedial part of the growth plate was fused, but in eight children the plate was completely open. In six of these eight children there was a hump or projection of the medial growth plate. It is suggested that this hump stabilises the anteromedial part of the epiphysis in a manner similar to the partial anteromedial fusion seen in older children, and that this accounts for the occurrence of triplane fracture in the presence of an open growth plate

The intermittent administration of cortisone in both the young and the mature rabbit is associated with appositional bone growth on the periosteal surfaces of the cranium, premaxilla and middle of the shaft of the femur; each new layer of bone is separated from the next by a darkly haematoxylin-staining "reversal" line. The internal architecture of the bone also changes in consequence of the repeated waves of resorption and deposition of bone round vascular spaces. Cartilaginous growth at the epiphysis in the young rabbit is also affected. The long columns of metaphysial cartilage are replaced by a layer of new bone which partly seals the epiphysial cartilage from the marrow spaces

We report overuse injuries in 14 elbows of ten elite young gymnasts. In 12 elbows of eight patients aged 11 to 15 years there was a spectrum of radiological abnormalities including widening of the olecranon physis and fragmentation of the epiphysis. The radiographs were compared with those of normal elbows matched for age and sex. The radiograph appearances were very similar to those of the Osgood-Schlatter lesion of the tibial tuberosity. Two older boys, aged 18 and 19, had stress fractures through the olecranon growth plate. Conservative management was successful in all except one case of stress fracture which required internal fixation

The frequency of slipping and osteoarthritis of the contralateral hip was recorded in 260 patients with slipped upper femoral epiphysis between 1910 and 1960. Twenty-three of these patients (9%) had primary bilateral slipping, 32 (12%) had a contralateral slip diagnosed later during adolescence and a further 104 (40%) had signs of contralateral slipping at follow-up 16 to 66 years later, giving a total of 159 cases (61%) with bilateral slips. Of the 104 slippings diagnosed at follow-up, 25% showed osteoarthritis. It is concluded that, with a slipped epiphysis, prophylactic contralateral pinning should be performed to avoid slipping and to reduce the risk of osteoarthritis

Fourteen cases of pseudarthrosis of the tibia in childhood presented at a hospital in Burma over a period of eight years. The ages of the patients ranged from one month to seventeen years. Nine were treated by a pointed graft driven into the medullary cavity of the distal tibia, and usually across the ankle joint into the body of the talus, before fixation to the proximal tibia. In six of the nine union was secured, but one case required a second grafting. Transarticular segments of graft showed a marked tendency to undergo absorption. No significant deformity was observed to follow central penetration of the growth plate and epiphysis of the lower tibia

1. A simple calculation for the timing of epiphysial arrest to correct leg length discrepancy is described. An assumption is made that growth ceases at a constant chronological age of sixteen years in boys and fourteen years in girls. It is further assumed that the lower femoral epiphysis provides three-eighths of an inch and the upper tibial epiphysis one-quarter inch of growth each year. 2. Whilst the assumptions made are known to be approximations, analysis of the results of fifty-three epiphysial arrests in forty-four children shows that the errors cancel themselves sufficiently to make this method accurate. The simplicity of the calculation makes it useful to confirm or modify the timing of arrests calculated on the basis of skeletal age, or as an alternative method

We compared 63 hips (Catterall Groups 3 and 4) contained by femoral osteotomy with 85 untreated hips and found that 50.7 per cent of treated patients developed congruous spherical femoral heads in contrast to 14.1 per cent of those untreated. We have also considered certain other features relevant to the outcome. We suggest that the indications should not be modified on the grounds of early age of onset. Relief from weight-bearing does not appear to improve the results of containment. We have assessed the shortening which follows femoral osteotomy and conclude that this is only significant when there is growth disturbance at the capital epiphysis. These changes are at least as frequent in untreated patients

1. Six cases of necrosis of articular cartilage complicating slipping of the upper femoral epiphysis are reviewed: histological examination in one case showed death of the superficial two-thirds of the articular cartilage, with survival of a layer of basal chondrocytes. In all six cases, after severe initial reduction of joint space as seen radiographically, there was gradual return of joint space, suggesting some regeneration of articular cartilage. The prognosis after cartilage necrosis is therefore not always so bad as has been supposed. 2. Various hypotheses concerning the cause of cartilage necrosis complicating slipped epiphysis are reviewed. The precise cause remains unknown, but there is substantial evidence against its being a consequence of ischaemia of the femoral head

It has recently been postulated that thrombophilia may have a role in the aetiology of Perthes’ disease. The published reports, however, remain conflicting. In this study a retrospective analysis of the coagulation parameters was made in 47 patients with Perthes’ disease and the results compared with the clinical data. Five patients with Factor V Leiden mutation were found (10.6%) and surprisingly four of them had a homozygous pattern. These four patients showed the most severe form of the disease, Catterall group IV, with flattening of the entire epiphysis, involvement of the metaphysis, shortening and broadening of the femoral neck, trochanteric overgrowth and developed mushroom-shaped aspherical laterally displaced femoral heads in dysplastic acetabula. We would like to suggest that the homozygous form of Factor V Leiden mutation has some role in the clinical course of Perthes’ disease and particularly its most severe form

We describe three children with symptoms of damage to the attachment of an anomalous ossific centre of the lower fibular epiphysis. All three were aged 8 to 10 years at the time of the initial injury, had suffered recurrent ankle sprains and had well localised and consistent tenderness precisely at the site of the anomalous ossific centre. All their symptoms were relieved by excision of the ossicle with reconstitution of the fibular collateral ligament. Whilst a separate secondary centre of ossification at the lower fibula is present in 1% of healthy children between the ages of 6 and 12 years, the condition described is extremely uncommon. Excision of the fragment should be reserved for those patients with recalcitrant symptoms and with consistent tenderness precisely at the site of the accessory ossicle

The proximal fibular epiphysis was transferred in young puppies using microvascular techniques. The study demonstrated, as have previous investigators, that free epiphysial transfer without vascular anastomosis results in death of the chondrocytes of the growth plate. Histologically, the chondrocytes do not take up labelled proline, indicating diminished metabolic activity; do not take up radioactive thymidine, indicating that they are not dividing; and there is eventual disruption of the normal histological picture. In contrast, where the microvascular anastomoses re-established the blood supply to the growth plate, the epiphyses demonstrated normal histological appearance, uptake of radioactive proline and thymidine and continued to grow but at a slightly diminished rate. It is concluded that continued growth can occur after free vascularised epiphysial transfer in the dog

In two cases of partial closure of an epiphysial plate causing angular deformity, one of a finger and one of the lower end of a femur, the deformities were corrected by growth after resection of a small peripheral bone bridge and its replacement with a free transplant of fat. This procedure has a firm basis on experimental work. Thus, when part of a growth plate in the rabbit is destroyed but the formation of a bone bridge uniting epiphysis and metaphysis is prevented, the destroyed part is replaced by regeneration of cartilage from the adjacent parts of the plate. Moreover, it has been proved in rabbits that when a bone bridge is induced and later resected and replaced with fat, recurrence of the bridge can be prevented and subsequent growth may correct the deformity

1. A survey of 112 cases of residual poliomyelitis with leg shortening of 2·5 centimetres or more is reported. 2. In eighty-seven patients paralysed in early infancy the fibular shortening was greater than the tibial shortening. 3. The absence of the normal "to and fro" motion of the fibula causes delay in the appearance of the fibular epiphyses and retards fibular development. 4. The shortening of the fibula in infancy causes deformity at the ankle, in the tibia itself and at the knee. 5. At the ankle the poorly developed lateral malleolus causes wedging of the lower tibial epiphysis and valgus at the ankle, which is often unstable. 6. At the knee progressive genu valgum is produced and in the tibia lateral torsion occurs. 7. The clinical significance of these deformities in relation to reconstructive procedures is stressed

A case of osteochondritis dissecans complicating Legg-Calvé-Perthes' disease is reported. Despite four years of conservative treatment in an ischial-bearing caliper a part of the fragmented femoral head failed to unite with the rest of the epiphysis and has persisted as an intra-articular loose body. Freehafer (1960) listed the indications for surgical removal of this fragment in such cases: 1) persisting symptoms; 2) dislocation of the loose fragment into the joint with secondary arthritic changes inevitable; 3) a mechanical block to movement of the hip. Since our patient had a relatively symptomless hip with a full range of movement, surgical removal of the loose body was not advised. The prognosis for this hip is nevertheless guarded, and surgery can be reserved for the above indications or for reconstructive procedures should they be required in the future

1. Full recovery after fracture of the head of the radius in children may be expected in cases with tilting of the radial head from 30 to 60 degrees, whether treated by early manipulative or by operative reduction. 2. Manipulative reduction is facilitated by knowledge of the direction of displacement and tilting of the radial head, which can be determined by the study of appropriate radiographs. 3. When the upper radial epiphysis is completely displaced from the shaft, some permanent loss of movement is to be anticipated even when accurate reduction has been secured by operation. Early fusion and some deformity of the radial head are also to be expected. This is not surprising in view of the risk to the blood supply of the displaced head, particularly in those cases treated by operative reduction

Aims

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.

We made a prospective longitudinal clinical and radiological study of 18 children diagnosed as having dysplasia epiphysealis capitis femoris. Half the cases were bilateral. Boys were affected five times more often than girls. There were no symptoms or clinical signs in most but some of the bilateral cases had an inconsistent waddling gait. The imaging studies suggest that the cartilaginous proximal femoral epiphysis is hypoplastic, with delayed appearance of single or multiple ossification centres. Progressive improvement occurred and at an average age of five years and six months, there was complete fusion of all the ossific nuclei and normal density and texture of the epiphyseal bone. The end result was a round epiphysis with a slightly diminished height. The dysplasia is attributed to focal hypoplasia of the proximal femoral epiphysis

Between 1990 and 1998 we saw 21 children with primary subacute haematogenous osteomyelitis. Pain, swelling and a limp had been present for two to 12 weeks with little functional impairment. Laboratory tests were non-contributory. The lesions were classified radiologically into metaphyseal, diaphyseal, epiphyseal and vertebral. There were 24 sites involved, with most (20) being in the tibia; 17 lesions were in the diaphysis, five in the metaphysis and two in the epiphysis. The diagnosis was confirmed histologically in all cases. Staphylococcus aureus was cultured in six patients. Healing occurred in all patients after treatment with antibiotics for six weeks and radiological improvement was seen after three to six months. Subacute osteomyelitis develops as a result of increased host resistance and decreased bacterial virulence. The radiological features can mimic various benign or malignant bone tumours and non-pyogenic infections. Histological confirmation is necessary to avoid a delay in diagnosis

The levels of the active metabolites of vitamin D were measured in the callus and in the epiphyseal growth plate of chicks given radioactive cholecalciferol during fracture healing. Those levels were correlated with the histological findings. Three groups of chicks were studied: a control group with no fracture, chicks with fractures fixed by Kirschner wire, and chicks with unfixed fractures. A significant increase in the levels of the active metabolites was found in the callus during the first few days after fracture. The levels of 25-hydroxycholecalciferol [25(OH)D3] and of 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were higher when there was no fixation, while those of 1,25-dihydroxycholecalciferol [1,25(OH)2D3] were higher after fixation. The concentrations of these metabolites in the proximal epiphysis of the tibia were similar to those found in the callus. Based on these findings it is suggested that the active metabolites of vitamin D are directly involved in the process of fracture repair