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Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 40-42| Soumya Paik, Rujuta Mehta, Alaric Aroojis, Dominic D´Silva Authors : Soumya Paik [1],*, Rujuta Mehta [1], Alaric Aroojis [1], Dominic D´Silva[1] [1] Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India. Address of Correspondence Dr Soumya Paik Bai Jerbai Wadia Hospital for Children, […]

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 35-39|Aakash Mugalur1, Binoti A Sheth2 Authors :Aakash Mugalur[1], Binoti A Sheth[2] [1] Narayani Hospital and Research Centre, Vellore, India [2] Dept of Orthopaedics, LTMGH, Sion, Mumbai, India Address of Correspondence Dr Aakash Mugalur, #492, 9th Cross, 8th Main, T K Layout, Mysore, Karnataka-570009. India Email: […]

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

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Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 40-42| Soumya Paik, Rujuta Mehta, Alaric Aroojis, Dominic D´Silva

Authors : Soumya Paik [1],*, Rujuta Mehta [1], Alaric Aroojis [1], Dominic D´Silva[1]

[1] Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, Maharashtra, India.

Address of Correspondence
Dr Soumya Paik
Bai Jerbai Wadia Hospital for Children, Acharya Dhonde Marg, Parel, Mumbai- 400012, Maharashtra, India.
Email: soumyapaik2006@gmail.com

Abstract

Background: Dysplasia epiphysealis hemimelica is a rare non hereditary epiphyseal disorder characterized by irregular overgrowth of cartilage in the epiphysis. The disease mainly targets distal long bones of the lower extremities e.g. ankle joint and tarsal bones. The guidelines for treatment of dysplasia epiphysealis hemimelica are sparse in literature due to the rarity of the syndrome. We report one such case manifesting in the right knee of a 5-year-old girl, a site which is not commonly reported and therefore prone to missed diagnosis and hence recurrence, along-with its surgical challenges , addressing all the anatomical and biomechanical derangements along with limb length discrepancy and to restore movements.
Keywords: Dysplasia epiphysealis hemimelica , irregular overgrowth , epiphysis, rarity.

Introduction
Dysplasia epiphysealis hemimelica (DEH) is a rare non-hereditary epiphyseal outgrowth of unknown etiology that mimics synovial chondromatosis of the joints [1]. The disease mainly targets long bones of the lower extremities and tarsal bones[1-3] . We report one such case from our institution manifesting in the right knee of a 5 year-old girl. Literature shows approximately 70 cases reported around the knee region since its first description 88 years ago.

Case Report
In February 2013, a 5-year-old girl presented with a 1½ year history of a gradually increasing swelling [Figure 1a] at the right knee and painless limp. There was no other remarkable history: family or past history. Patient had a history of a previous excision on the lateral side of the same knee with recurrence of deformity within six months. However, there was no history of loss of movement at the time of previous surgery. On examination, there was an irregular bony swelling 15 cm by 10 cm by 10 cm on the antero medial aspect of right distal femur and proximal tibia. It was associated with a 1.5 cm shortening of each of the right femur and right tibia. There were no warmth, tenderness or skin changes over the swelling and the knee had 60º fixed flexion deformity [Figure 1b] with further painless motion up to 120º associated with crepitus. The patient also had a genu valgum of 20 degrees which was chiefly femoral. The patella was small and dislocated laterally. There was no distal neurovascular deficit. There were no deformities at the ipsilateral hip and ankle nor at the contralateral hip, knee and ankle. Radiographs [Figure 1c] showed an ossified mass over anteromedial aspect of right knee. 3D CT[ Figure 1d] and MRI [Figure 1e] showed a distinct plane of separation between the lesion and the normal epiphyseal bone.
Arthroscopy revealed that menisci and both the cruciate ligaments were intact and medial proximal tibial articular surface in the weight bearing domain was involved. The mass was too large for piecemeal excision and hence open surgery was performed immediately. Through an anterior mid line approach the right knee extensor mechanism was exposed [Figure 2a] which was found to be dislocated laterally by the mass. A 5cm by 3cm mass was found protruding out of the inter-condylar notch [Figure 2b] which was excised. The excised material [Figure 2c] was a globular bony mass covered by a smooth white glistening cartilage surface. There was involvement of the medial tibial articular surface as well in the form of 1.5cm by 1cm small mass [Figure 2d] which was shaved off. Lateral release and medial plication [Figure 2e] was done to realign the extensor mechanism before closure [Fig 2f]. A back slab was given post operatively for 15 days and then physiotherapy was started. The patient was discharged 22 days after surgery. At the time of discharge there was a 20º flexion contracture with further ROM upto150º and active knee extension from 90º to 60º was achieved. At 2 years follow up the patient was found to be almost completely relieved from the deformity [Figure 3a] and further correction of limb length discrepancy [Figure 3b] is planned.

Discussion
The incidence of this entity was reported as 1 in1000,000[4] . It was first described as tarsomegalie in 1926 by Mouchet and Belot[5] . Trevor used the term tarso-epiphyseal aclasis in 1950[6] . Since then this abnormality is commonly referred to as Trevor’s disease. The term dysplasia epiphysealis hemimelica (DEH) was coined by Fairbank [1] in 1956. The word hemimelica is derived from 2 Greek words, hemi (half) and melos(limb). According to Fairbank , DEH is confined to the medial or lateral half of an epiphysis of a single limb it has a male-to-female ratio of 3:1 [4].
The etiology of DEH is unknown. There is no strong evidence to suggest a hereditary component . It has been hypothesized that this condition represents a fundamental defect in the regulation of cartilage proliferation in the affected epiphyses. Azouz et al [8] introduced a 3-group classification: group 1, localized, in which only one epiphysis is affected; group 2 (most common), classic, in which more than one epiphysis in the same limb is affected; and group 3, generalized, in which the whole lower limb is affected. Our patient in discussion fits into group 2.
Epiphyseal cartilage capped benign over growth is the unique feature of DEH. Struijs et al [9] showed the rarity of this disease in this location in a systematic review. They found a total of 48 studies having 138 patients with 255 lesions. Most lesions were located in the ankle or foot (139 of 255), and the talus was the most frequently affected bone. Rosero et al [10] showed only 21% distal femur and 11% proximal tibia were involved in their study of 57 patients.
The most common presenting symptom is a painless mass around the affected joint. The diagnosis can be guided by imaging studies. Initially radiography shows stippled calcification at epiphysis region. Eventually it looks like exostosis. It is possible that the earlier surgeon in this case confused it as a simple exostosis and excised it through a lateral approach. 3D CT scan should be done to assess the continuity of the lobulated mass with the underlying epiphysis. MRI is mandatory for identifying the extent of epiphyseal involvement, joint deformity and any effects on surrounding soft tissues. Teixeira et al. (2001) [11] reported the role of bone scintigraphy as increased uptake in the pathological epiphyseal area. It is useful check for other sites of involvement.
DEH is benign and its prognosis is favourable; no malignant transformation has been reported [6, 12].
Histopathologically, it was not possible to distinguish DEH from osteochondroma [3] . But genetic expressions (EXT1, EXT2) can be helpful [13].
The literature shows evidence that recurrences are more likely in patients with open physes at the time of surgery or after incomplete resection[1, 4] . There is no literature support to guide the management of limb-length discrepancy in this disease either by same limb lengthening or contralateral limb epiphysiodesis. It is also not described how to manage residual deformity. So the patient was counselled regarding the need for a long follow up with the possibility of further intervention.

Conclusion
Dysplasia epiphysealis hemimelica is a relatively rare disease, but the numbers of reported cases are gradually increasing. Hence, during the examination of a paediatric patient with a swelling of either the medial or lateral half of a joint, or a swelling that appears bony, painless and intra articular it is necessary to include DEH in the differential diagnosis. Provisional diagnosis can be made by clinical examination, surgical treatment is mandatory when symptoms like pain, joint impingement or deformation are present. Surgical prognosis is favourable when the mass is juxtaarticular or extraarticular. When the mass is intraarticular, early surgery may cause secondary osteoarthritis.

References

1. Fairbank TJ. Dysplasia epiphysialis hemimelica (tarso-ephiphysial aclasis). J Bone Joint Surg Br. 1956;38-B(1):237-57. Epub 1956/02/01. PubMed PMID: 13295331.
2. Timm C, Immenkamp M, Roessner A. [Disease picture of dysplasia epiphysealis hemimelica]. Z Orthop Ihre Grenzgeb. 1986;124(2):148-56. Epub 1986/03/01. doi: 10.1055/s-2008-1044540. PubMed PMID: 3087078.
3. Glick R, Khaldi L, Ptaszynski K, Steiner GC. Dysplasia epiphysealis hemimelica (Trevor disease): a rare developmental disorder of bone mimicking osteochondroma of long bones. Hum Pathol. 2007;38(8):1265-72. Epub 2007/05/11. doi: S0046-8177(07)00063-9 [pii] 10.1016/j.humpath.2007.01.017. PubMed PMID: 17490719.
4. Wynne-Davies R, Hall CM, Apley AG. Atlas of skeletal dysplasias: Churchill Livingstone Edinburgh; 1985.
5. Mouchet A, Belot J. La tarsomegalie. J Radiol Electrol. 1926;10:289-93.
6. Trevor D. TARSO-EPIPHYSIAL ACLASIS. Journal of Bone & Joint Surgery, British Volume. 1950;32-B(2):204-13.
7. Connor JM, Horan FT, Beighton P. Dysplasia epiphysialis hemimelica. A clinical and genetic study. J Bone Joint Surg Br. 1983;65(3):350-4. Epub 1983/05/01. PubMed PMID: 6841410.
8. Azouz EM, Slomic AM, Marton D, Rigault P, Finidori G. The variable manifestations of dysplasia epiphysealis hemimelica. Pediatr Radiol. 1985;15(1):44-9. Epub 1985/01/01. PubMed PMID: 3969295.
9. Struijs PA, Kerkhoffs GM, Besselaar PP. Treatment of dysplasia epiphysealis hemimelica: a systematic review of published reports and a report of seven patients. J Foot Ankle Surg. 2012;51(5):620-6. Epub 2012/07/24. doi: S1067-2516(12)00199-8 [pii] 10.1053/j.jfas.2012.05.008. PubMed PMID: 22819617.
10. Rosero VM, Kiss S, Terebessy T, Kollo K, Szoke G. Dysplasia epiphysealis hemimelica (Trevor’s disease): 7 of our own cases and a review of the literature. Acta Orthop. 2007;78(6):856-61. Epub 2008/02/01. doi: 790014159 [pii] 10.1080/17453670710014662. PubMed PMID: 18236195.
11. Teixeira AB, Sa de Camargo Etchebehere EC, Santos AO, Lima MC, Ramos CD, Camargo EE. Scintigraphic findings of dysplasia epiphysealis hemimelica: a case report. Clin Nucl Med. 2001;26(2):162. Epub 2001/02/24. PubMed PMID: 11201484.
12. Kuo R, Bellemore M, Monsell F, Frawley K, Kozlowski K. Dysplasia epiphysealis hemimelica: clinical features and management. Journal of Pediatric Orthopaedics. 1998;18(4):543-8.
13. Fletcher CD, Unni KK, Mertens F. Pathology & genetics: tumours of soft tissue and bone: World Health Organization; 2002. 229-30 p.

How to Cite this Article: Paik S, Mehta R, Aroojis A, D´Silva D. Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):40-42.

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Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 35-39|Aakash Mugalur1, Binoti A Sheth2

Authors :Aakash Mugalur[1], Binoti A Sheth[2]

[1] Narayani Hospital and Research Centre, Vellore, India
[2] Dept of Orthopaedics, LTMGH, Sion, Mumbai, India

Address of Correspondence
Dr Aakash Mugalur, #492, 9th Cross, 8th Main, T K Layout, Mysore, Karnataka-570009. India
Email: orthoaakash@gmail.com

Abstract

Background: The normal anatomical radial bow is of crucial importance to the normal range of motion of the forearm and to the strength generated by the muscles. The restoration of the normal amount and location of the radial bow is of crucial importance in functional outcome of forearm fractures. Few studies exist on characteristics of radial bow in Indians.
Materials and methods: In this prospective observational clinic-radiological study we aimed to establish the normal characteristics of the radial bow in the Indian population, and compare the radial bow of the injured limb with the normal contralateral side to establish a co-relation of the radial bow with rotational movements of forearm and to establish whether remodelling had any effect on the characteristics of radial bow. We used modified Schmetisch & Richards method to establish the characteristics of radial bow. The proposed sample size was 100 patients under the age of 14 years, but only 86 patients completed of the study.
Results: The mean of the site of maximum radial bow was at 61.68 % and that of the magnitude of radial bow was 7.62 % of the total radial length. The location and magnitude of radial bow have a significant correlation with forearm rotation .A negative correlation exists between the location of maximum radial bow and the magnitude of the radial bow but it is not statistically significant.
Conclusion: The characteristics of radial bow in our are comparable to that of the western literature. In forearm fractures every effort must be made to restore the radial bow close to the values of the normal limb for better functional outcome. Multicentric studies with larger sample size and a longer follow-up might add value to the available data.
Key Words: Radial bow, forearm, fracture, radius, ulna

Introduction
Forearm fractures are the very common fractures in children and account for about 40 percent of all pediatric fractures. [1,2] Despite their apparent simplicity they still continue to be a challenge to the treating orthopedician owing to the treatment complexity and the risk of complications.[3] Most patients in the pediatric age group need not be and should not be treated by open reduction and internal fixation.[4] The aim of the line of management, whether conservative or operative is to achieve optimal reduction of the fracture and to restore functionality to the injured limb. Despite enormous remodelling potential in the paediatric population, malunion is not uncommon and has a strong bearing on functional outcome. Pronation and supination movements add to the dexterity of the upper limb and are very important in the activities of daily living. These are complex movements influenced by numerous factors. Of the many factors the normal anatomical radial bow is of crucial importance to the normal range of motion of the forearm and to the strength generated by the muscles.[5] Alteration of the normal bowing may result from forearm fractures. While axial deformities are easily recognised, changes of bowing may be subtle and minor fractures which may influence it are frequently missed. Apart from appropriate reduction and rotational alignment, it is equally important to restore the radial bow comparable to the normal side for optimal treatment of forearm fractures. Studies show that restoration of the normal radial bow is related to the functional outcome. A good functional result is associated with restoration of the normal amount and location of the radial bow.[6] Estimation of the radial bow of the unaffected forearm and comparison of the injured limb with it can be useful for optimising reduction by non operative or operative management. To the best of our knowledge we did not find any literature delineating the characteristics of the radial bow in the Indian population. In our study we aimed to establish the characteristics of the radial bow with respect to the Indian population, compare the radial bow of the reduced injured limb with the normal side and follow it up to establish a co-relation with remodelling, to measure rotational movements of the forearm and establish a co-relation between the radial bow and rotational movements. We also wanted to evaluate the effect of remodelling of the isolated ulna fractures on the radial bow.
Materials and methods: The study was a prospective observational study with the intended sample size of 100 patients in the paediatric age group( 0 – 14 yrs ) with forearm fractures .The study was conducted at our institute and parents of the patients gave a formal consent and were free to withdraw their children from the study at any given point of time. Clearance from the institutional ethics committee was obtained before starting with the study. The first 100 Patients aged less than 14 years with radius or ulna or both forearm bones fractures with no previous history of fractures in either forearm bones were included in the study. Patients aged more than 14 years, history of fracture of either bones of either forearm, patients with pre-existing deformity and co-existing elbow and wrist injuries, with neurological deficit affecting the forearms were primarily excluded from the study. The primary line of management was closed reduction and casting. The patients were followed up clinico-radiologically on weekly basis in the first one month to assess for loss of reduction and cast related complications. Since eight patients showed loss of reduction beyond the acceptable criteria, requiring surgical intervention they were secondarily excluded from the study to negate the effect of the possible stiffness arising of surgery. Six patients were lost to follow up over the period of time. The remaining Eighty six patients were followed up clinico-radiologically at 1, 3, 9 monthly intervals. At every visit a standardised anteroposterior view of the forearm was obtained. The point of maximum radial bow and maximum radial bow were measured as percentage of the total radial length for comparability using the modified Schemitsch and Richards method.[6] Two measurements were taken independently by two observers and a mean of the values were taken to avoid inter observer bias. The pronation–supination movements and deformity were also assessed clinically at follow up. The data was tabulated and analysed using SPSS13.0 software.
Results: We had 71 % male and 29 % female patients with 24% of the fractures occurring in the age group of four to six years. Fall on outstretched hand was the mode of trauma in majority of the patients ( 91 %). The characteristics of the radial bow and the pronation and supination movements in our study are enlisted in Table 1. There is a statistically significant positive co-relation between the maximum radial bow and the prono-supination movements (Table 2 & 3). There is a statistically significant negative co-relation between the point of the maximum radial bow and the prono-supination movements (Table 4). We found a negative co-relation between the maximum radial bow and the point of the maximum radial bow but it was statistically insignificant.(Table 5)
Discussion: In our study the male to female ratio was 2.448 to 1 with a significant male preponderance. The increased male preponderance in our study could be associated with increased outdoor and sports activity in male children in our subcontinent and hence increased risk and vulnerability for the fractures. 24 % of the fractures occurred in the age group of 4-6 years with no significant predilection to fracture in any specific age group in the rest of the study group. Forearm shaft fractures have been shown to occur most commonly in the 12 to 16 year old age group which are a challenging group to treat.[1] The difference in the distribution of the fractures when compared to other studies could be attributed to the low sample size and the sampling method of including the first hundred patients as the study group. In our study the predominant mode of trauma was fall on outstretched hands (91 %) while the rest were due to direct impact. This is in acceptance with the published data on the mechanism of injury in forearm fractures where the indirect transmitted force is implicated in most of the forearm fractures. The primary mechanism of injury associated with radial and ulnar shaft fractures is a fall on outstretched hand that transmits indirect force to the bones of the forearm.[7]With respect to the location and magnitude of the radial bow, our results are comparable with the results of M Firl[8] and Schemitsch.[6] The minor differences in values could be due to the differences in the study group. The study group of M Firl although had pediatric population they didn’t represent a normal population as they had suspected injury to forearm. The other contributing factor could be the difference in the race. Both the papers analysed Western population. We couldn’t find any published data on normal radial bow in the Indian population. We used the modified method of Schemitsch & Richards[6, 8] to measure the radial bow as we could express it as a percentage of the total radial length and the results could be compared. Measurement of the radial bow in a singular plane, although representing a simplification, gives clinically significant information[8] and can be applied in the clinical scenario owing to the simplicity and reproducibility. Measurement of the bow on the normal side and comparing it with the affected side can help to diagnose plastic deformation of the radius in the absence of obvious fracture of the radius and serve as a guide for optimum reduction in the treatment of the fractures of the forearm.( Figure 1 and 2) The mean supination in our study was 93 degrees and the mean pronation was 89.97 degrees. The mean values of pronation and supination is not comparable in various studies. The average arc of normal forearm motion for the Mayo[9] group was 68 degrees of pronation to 74 degrees of supination. In a study by Rickert et al[10] the arc of motion was from 75 degrees of pronation to about 100 degrees of supination. In yet another study by Boone and Azen[11] it ranged from 77 degrees of pronation to 83 degrees of supination. Though it has been traditionally taught that 50 degrees of pronation and supination represent adequate forearm motion [9], it has been observed that losing 20 to 30 degrees of either pronation or supination carries the potential for significant functional impact upon important activities of daily living [12]. Prono-supination movements assume even greater importance in the Indian scenario. An “all or none” phenomenon exists whereby a small deviation from the norm of the radial bow, a good functional result could be expected in terms of rotational movements of the forearm, but once a certain point was reached there was a rapid decline in the outcome.[6] Statistical analysis has shown that a change in the location of the maximum radial bow is of greater functional significance than a change in the value of the maximum radial bow.[7] We opine that both the location and magnitude of the radial bow have a significant correlation with forearm rotation and hence has a significant effect on functional outcome. We compared isolated ulna fractures with radius-ulna & radius fractures to evaluate the effect of isolated ulna fractures on radial bow if any. In our study we observed that there is no statistically significant difference between both the groups. We conclude that isolated ulna fractures do not affect the magnitude and location of the radial bow in a statistically significant manner. We in our study also analysed the relation between the magnitude and location of the radial bow. We observed a negative correlation between the location of maximum radial bow and the magnitude of the radial bow but it was not statistically significant. Even earlier studies have failed to establish a significant correlation between the magnitude and location of the maximum radial bow. However it must be noted that they are related to functional outcome and to each other to differing degrees.[6] We followed up the maximum radial bow and the location of maximum radial bow for a period of nine months. We did not find any significant change in the value of maximum radial bow or its location during this observation period either on the fractured side or on the normal side. Despite our short follow up of nine months we opine it is important to achieve the normal radial bow on the fractured side at the initial setting itself as the remodelling process does not alter the location or the maximum value of the bow significantly. M Firl et al[8] state that the length of the radius and the value of maximum radial bow clearly increase with age but the location of maximum radial bow remained a constant. One of the reasons which could be responsible for this discrepancy between our study and the available literature could be the short follow up period of nine months in our study. We found a negative correlation between the location of the maximum radial bow and range of supination. The corelation was statistically significant throughout the duration of the study. We also established a negative co-relation between the location of maximum radial bow and pronation. The correlation was negative at every follow up, but it was statistically significant at three and nine months. In our study we found a positive co-relation between the maximum radial bow and rotational movements of the forearm. The co-relation was positive at one, three and nine monthly intervals and it was statistically significant. To evaluate the effect of radial bow in further detail on forearm rotation requires further follow up and linear regression analysis. But that was beyond the scope of our present study. But it has been found that the relation between the radial bow and rotational movements is not linear.[6] Although we have established a correlation between the radial bow and rotational movements of forearm it must be noted that radial bow is not the only factor rotational movements of the forearm are dependent on. There are many other contributory factors which are difficult to be excluded completely in clinical scenario. Small sample size and a short follow-up were among the drawbacks of the study. Further we evaluated patients in a particular subset of Indian patients. Large multicentric studies with a larger sample size and a longer follow up are necessary to further delineate the characteristics of radial bow in Indian population.

Conclusion:
The characteristics of the radial bow of the Indian population match that of the western population. Restoration of the radial bow characteristics is very important in the management of forearm fractures. Every effort must be made to restore the characteristics of radial bow in forearm fractures for a better functional outcome.

References

1. Cheng JC, Ng BK, Ying SY, et al. A 10 year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop 1999;19: 344-350.
2. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001; 26:908-915.
3. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop Relat Res 1976; 120: 172-184.
4. Canale ST. Fractures and Dislocations in Children:Canale ST, Beaty JH. Campbell’s Operative Orthopaedics, vol 2, 11th edition, Mosby Elsevier;2008. p.1545-1556.
5. Richards RR. Chronic disorders of the forearm. J Bone Joint SurgAm. 1996; 78-A: 916-30.
6. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint SurgAm. 1992; 74-A:1068-78.
7. Atkas S, Saridogan K, Moralar U, et al. Patterns of single segment nonphyseal extremity fractures in children. Int Orthop 1999;23:345-347
8. Firl M, Wünsch L. Measurement of bowing of the radius. J Bone Joint SurgBr. 2004;86-B:1047-9.
9. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal elbow motion. J Bone Joint Surg Am 1981; 63: 872-877.
10. Rickert M, Burger A, Gunther CM, et al. Forearm rotation in healthy adults of all ages and both sexes. J Shoulder Elbow Surg 2008; 17: 271-275.
11. Boone DC, Azen SP. Normal range of motion of joints in male subjects. J Bone Joint Surg Am 1979; 61: 756-759.
12. Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna: Beaty JH, Kasser JR et al. Rockwood and Wilkin’ Fractures in Children, 7th edition, Lippincott Williams & Wilkins; 2010. p.347-404.

How to Cite this Article:Mugalur A, Sheth BA. Clinico-radiological significance of restoration of radial bow in pediatric forearm fractures: An Indian perspective. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):35-39.

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Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Full Sized Blog Element (Big Preview Pic)

Dysplasia Epiphysealis Hemimelica of the Knee Joint: A Case Report

Authors : Soumya Paik [1],*, Rujuta Mehta [1], Alaric Aroojis [1], Dominic D´Silva[1]

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Authors :Aakash Mugalur[1], Binoti A Sheth[2]

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

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