To provide a comprehensive radiographic, clinical, and functional description of the shoulder in Apert Syndrome.

A cohort of nine Apert Syndrome patients (ages nine to twenty-seven) followed at a tertiary care facility was included in this prospective study. Patients were clinically assessed with physical examination and completion of two validated functional assessment tools, the Shoulder Pain and Disability Index (SPADI) and AAOS Paediatrics Questionnaire (PODCI). Radiographs were obtained of both shoulders and a standardised protocol MRI was performed on the dominant shoulder of all participants.

All patients had some degree of functional impairment attributable to their shoulder pathology. Physical examination consistently revealed reduced forward flex-ion and abduction. Radiographic findings were similar to previous reports, with pervasive osseous dysplasia of the shoulder joint. Medial humeral head hypoplasia was seen in eight out of nine patients and greater tuberosity overgrowth in seven out of nine patients. MR imaging of the shoulder, not previously performed in a cohort of Apert patients, allowed better delineation of abnormalities seen radiographically such as a central glenoid cleft, seen in eight out of nine patients. It also revealed a new finding of inferior glenoid inclination (seven out of nine patients), which has not been described in the literature. Very few soft tissue or degenerative abnormalities were demonstrated.

The findings of this study confirm that patients with Apert Syndrome are functionally impaired by their shoulder pathology, which may have a similar clinical impact as the more well-described hand and foot anomalies. The global functioning of patients with Apert syndrome is equivalent to patients with juvenile rheumatoid arthritis. The shoulder range of motion in Apert patients is decreased, most significantly in flexion and abduction. Radiographs confirmed previous imaging findings of glenohumeral dysplasia. The novel MRI component demonstrated consistent inferior glenoid inclination, which may be a significant factor in their shoulder impairment. MR imaging revealed no significant soft tissue or degenerative abnormalities to account for their clinical disability. These findings have potential relevance in the surgical and clinical management of these patients.

Supracondylar fractures of the humerus in children are among the most common paediatric fractures, and yet present one of the greatest technical challenges for management. Traditionally treated as surgical urgencies, recent literature calls that belief into question. The purpose of this study was to determine the influence of the elapsed time from injury to surgery of Gartland Type III supracondylar fractures on operative time and quality of reduction.

A retrospective review of all Gartland Type III supra-condylar factures treated by closed reduction and percutaneous pinning at our hospital between January 2003 and April 2006 was performed. Subjects in this consecutive series underwent a formal chart review to extract necessary data. The intra-operative fluroscopic images were utilised to assess the quality of reduction. All images were analyzed by three independent blinded reviewers on two separate occasions. Parameters measured on the AP images included: Baumann’s Angle, Humerocapitellar angle, Gordon Index, Griffet Index one and two.

Of the one hundred and forty-one charts reviewed, twenty-nine were excluded for various criteria. Of the remaining sample (N=112), sixty-one patients were treated in less than eight hours (Group one), and fifty-one treated after eighthours (Group two). There were sixty-one girls and fifty-one boys, with a mean age of six yrs. There were no cases of compartment syndrome. No subjects required conversion from closed to open reduction. The mean time from injury to surgery was six hundred and seventy minutes (min = 128, max = 3117). The mean for Group one was three hundred and forty-one minutes and one thousand and sixty-five minutes for Group two. The mean operative time was 33.29 minutes, (min=ten, max =eighty-two). The mean operative time in Group one was 33.13 minutes and 33.38 minutes in Group two. Two t-tailed t-test demonstrates no significant difference between the two groups. Radiographic analysis revealed the following means: Baumann’s angle (m = 70.26), humero-capitellar angle (m= 36.19), Gordon Index (m=33.78), Griffet Index 1 (m=0.88) and Griffet Index 2 (m=2.55). Comparison of the radiographic parameters and indices demonstrated no significant difference between the two groups.

This study demonstrates delaying surgery beyond eight hours led to no difference in operative time or quality of reduction. Previous studies have demonstrated no difference in rate of compartment syndrome, presence of complications or need for open reduction between these two groups. Our findings combined with previous retrospective studies support the need for further prospective study and support the surgeon’s clinical judgment in determining the urgency of surgical intervention in this patient population.

Avascular necrosis (AVN) of the femoral head is a devastating complication of slipped capital femoral epiphysis (SCFE). The reported prevalence of AVN following unstable SCFE has ranged between fifteen and forty-seven per cent in the literature. The explanation for this discrepancy is not clear. The inter-observer and intra-observer agreement between Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE has not been reported. It is the objective of this study to estimate these parameters between two experienced pediatric Orthopaedic surgeons for the radiographic diagnosis of AVN following SCFE.

A retrospective review of all one hundred and three cases of SCFE treated at a Canadian pediatric referral center between 1995 and 2005 was performed. Of these, eight were diagnosed, by the treating surgeon, with AVN. Each of these eight children and a random sample of fifteen of the remaining children, who were not diagnosed with AVN, were included in this study. The most recent anteroposterior and lateral radiographs were digitised and presented to two experienced pediatric orthopaedic surgeons in a blinded, random order. Each surgeon reviewed the radiographs independently and recorded which radiographs they believed to be consistent with AVN. The surgeons were told that each patient had SCFE and that some developed AVN, however neither the classification of the slip, nor the proportion who developed AVN were divulged. Each observer repeated this process two weeks after the initial review in order to determine intra-observer agreement. The kappa value was determined to assess inter-observer and intra-observer agreement.

The first observer recorded eight cases of AVN at the initial and seven cases at the second observation time. The intra-observer agreement was 0.9. The second observer recorded six cases of AVN at the initial and five cases at the second observation time. The intra-observer agreement was 0.88. The inter-observer agreement was determined at the first observation time and was 0.79.

On the basis of the results of this study, both the inter-observer and intra-observer agreement for the radiographic diagnosis of AVN following SCFE, amongst experienced pediatric Orthopaedic surgeons, was very high. It is unlikely that the reported discrepancy in prevalence of AVN following SCFE is due to a lack of inter-observer agreement, on the basis of the findings of this study. The inter-observer agreement between less experienced observers requires further study to determine if this may be the source of the variability in the reported prevalence of AVN following SCFE.