The Denis Browne abduction harness was used in the management of 127 abnormal hips in 104 children at Queen Mary's Hospital for Children from 1966 to 1980, both as the initial treatment for unstable hips recognised soon after birth, and for children presenting later and whose hips first required reduction by gradual abduction in traction. The incidence of significant avascular necrosis was 3.1%, and occurred only in the primary treatment group, emphasising again the need for gentle care of infant hips. There have been no other significant complications and the appliance has functioned well.
A study was made of knee stiffness after fractures around the knee in patients with spina bifida. Thirty-one patients with 45 fractures were followed up for 2 to 15 years after the fracture. Knee stiffness was found in 67% of patients; this amounted to loss of up to half the normal range of movement. The stiffness appeared at two months from the time of the fracture and was established by six months. However, in all patients it had resolved by three years, so that their mobility was not affected in the long term. It is concluded that though stiffness is common after fractures in patients with spina bifida, it should be treated expectantly as it will resolve within three years without specific treatment.
Ten children who had clinically stable hips at birth were radiographed at one month because they had factors predisposing to hip dislocation. In all cases one or both hips gave rise to a suspicion of dysplasia, though clinical abnormalities were slow to appear. Four of these hips subsequently dislocated. We believe that infants with late presentation of acetabular dysplasia and clinical abnormality belong to a different aetiological group from those with neonatal instability due to ligamentous laxity. The significance of this differentiation is that some infants presenting late have only recently dislocated, and the diagnosis has not necessarily been "missed" at neonatal examination.
The moulded baby syndrome comprises: head moulding (plagiocephaly); pelvic obliquity with unilateral loss of hip abduction in flexion; and occasionally scoliosis, torticollis and bat ears. The hips, however, are radiologically normal and do not require the treatment used in the management of congenital dislocation or dysplasia. A review of 67 hips confirms this finding.
Seventy-two posterior psoas transfer operations performed in forty-four children with lumbar myelomeningocele were reviewed one to eight years after operation in an attempt to assess its value. Muscle charting, an objective recording of the child's walking ability, and radiographic examination of the hips were done. Hip stability was improved: 49 per cent were stable at the time of psoas transfer and 94 per cent at review. Functional results depended mainly on the level of neurological activity present: 57 per cent of the children had an acceptable functional result. Usually, posterior psoas transfer should be done as soon after the age of nine months as the child's condition will allow. Over the age of two years it should be restricted to children with activity in the third and fourth segments of the lumbar cord.
1. It has been shown in fifty normal feet that the perpendicular static plantar pressures rise by about 35 per cent between the ages of five years and maturity. 2. It is very likely that similar increases in plantar pressures occur between two and five years of age. 3. The plantar pressures in seventy-eight feet of children with spina bifida were with a few exceptions substantially higher than those of normal children of the same age. It is likely that this is so, at least in part, because the feet of children with spina bifida are smaller than normal. 4. This increase in perpendicular static pressure during growth must be relevant in the production of trophic foot ulceration. 5. The existence and importance of "flail deformity" as a factor producing areas of increased pressure and ulceration in anaesthetic feet is postulated.
1. A conservative approach to the varus deformity of anaesthetic feet in infants with myelomeningocele is advocated. Thirty-three of thirty-five varus feet treated by this method, supplemented when necessary by a minor operation to correct equinus, responded satisfactorily in this prospective study of twenty-four infants treated from birth. 2. A rotation flap incision has proved of considerable advantage in the rare instances when an extensive medial release is required.
1. A case of arteniovenous fistula within the tibia of a girl is described. 2. Removal and replacement of a large part of the tibial diaphysis was followed by "re-formation" of the bone. 3. The literature of the condition is reviewed.
