Evaluation of risk factors associated with fragility fractures and recommendations to optimise bone health in children with long-term neurological condition

INTRODUCTION@#The growing years are paramount for bone growth and mineral accrual. Children with long-term neurological condition (LTNC) have multiple risk factors for poor bone health and fragility fractures. In Singapore, this has not been studied systematically. Therefore, we aimed to evaluate the risk factors associated with fragility fractures in children with LTNC.@*METHODS@#In this study, the search for fragility fractures was done by a retrospective review of patients with LTNC on follow-up in the paediatric neurology clinic and patients who presented with fracture to the paediatric orthopaedic clinic. Information on patients' demographics, medical history, intervention, biochemical bone markers and fracture history was collected.@*RESULTS@#In a tertiary clinic population of 136 patients with LTNC, 65% were dependent on mobility (Gross Motor Function Classification System [GMFCS] V), 60% were underweight and 60% were fed via gastrostomy or nasogastric tube, or were on oral pureed diet. Furthermore, 60% were on anticonvulsants. The fracture rate was 3% in this population and was associated with low-impact activities such as transfer and dressing. Only 7.4% and 33% of the patients had undergone measurements of vitamin D and calcium levels, respectively.@*CONCLUSION@#The local prevalence of fragility fractures in children with LTNC on follow-up at the neurology clinic was found to be 3%. Risk factors identified were limited ambulation and compromised nutritional status associated with feeding difficulty. Recommendations to optimise bone health in children with LTNC were made. These include promoting weight-bearing activities, looking out for underweight children, avoiding vitamin D deficiency and ensuring adequate calcium intake.

Developmental dysplasia of the hip: why are we still operating on them? A plea for institutional newborn clinical screening

INTRODUCTION@#Developmental dysplasia of the hip (DDH) is a common orthopaedic condition at birth. Non-surgical management with the Pavlik harness can effectively treat DDH in the newborn by providing an early clinical diagnosis, but open surgeries continue to be performed. We aimed to elucidate the reasons for this.@*METHODS@#A retrospective review was performed of all open surgeries related to DDH from 2006 to 2016. Patients were either born at our institution (Group 1) or outside of it (Group 2). All Group 1 newborns were routinely screened for DDH at birth.@*RESULTS@#27 patients (Group 1: n = 5, Group 2: n = 22) presented at age 25 ± 19 months. Left-sided DDH (n = 21, 77.8%) and female infants (n = 22, 81.5%) were more common. The mean age at surgery was 40 ± 31 months. The most commonly performed procedure was soft tissue release open reduction with acetabuloplasty (n = 20, 74.1%). Gender, site, median age at presentation and at surgery, and prevalence of risk factors were similar for both groups. Both groups were mostly made up of late presenters (> 3 months; p = 0.34). A few patients had undergone prior treatment (p = 0.64). Newborn screening was the only significantly different variable between the groups (p < 0.01).@*CONCLUSION@#Lack of institutionalised newborn clinical screening appears to be the root cause of late presentation of DDH leading to open surgery for its management. We recommend quality institutionalised newborn clinical screening to reduce the number of late presentations.

Pattern of Fractures in Non-Accidental Injuries in the Pediatric Population in Singapore

BACKGROUND: Fractures as a result of non-accidental injuries (NAI) are not uncommon among children. The purpose of our study was to describe the incidence, demographic characteristics, and associated risk factors in patients with NAI in a multiethnic Asian cohort. METHODS: A retrospective record review of patients admitted to our hospital between September 2007 and 2009 with the diagnosis of NAI was conducted. RESULTS: A total of 978 children were reported with suspicion of NAI. Among them, 570 patients (58.28%) were diagnosed with NAI. Fractures were observed in 35 children (6.14%). NAI fractures were highest among female infants (73.3%). The biological father was the most common known perpetrator of NAI (n = 155, 29.0%). The most common perpetrator sadly remained unknown (n = 14, 40%). All NAI fractures were closed (n = 35, 6.14%), and the most commonly affected bone was the humeral shaft (n = 10, 28.57%) with an oblique configuration. Age < 1 year and parental divorce were significant risk factors associated with these fractures. CONCLUSIONS: The skeletal injury pattern and risk factors highlighted in our study will help treating physicians identify patients susceptible to NAI, as many of these patients are young and vulnerable. Protective measures can be initiated early by recognizing these injuries and preventing further physical and psychological harm to the child.

Pulse Oximetry for the Diagnosis and Prediction for Surgical Exploration in the Pulseless Perfused Hand as a Result of Supracondylar Fractures of the Distal Humerus

BACKGROUND: The management of the pulseless perfused hand in association with a supracondylar humerus fracture following operative stabilisation remains controversial. Previous authors have suggested the use of color-flow duplex monitoring, magnetic resonance angiography and segmental pressure monitoring as objective steps to ascertain blood flow following adequate internal fixation. We examine the use of the waveform of the pulse oximeter in objectively determining a perfused limb and in predicting the need for surgical exploration in patients who present with a pulseless perfused hand after operative stabilisation for supracondylar fracture of the humerus. METHODS: A retrospective review of all supracondylar fractures over a 60 month duration (2005-2009) in our instituition was performed. Each electronic record was reviewed and limbs which had absent radial pulse following admission were identified. X-ray films of each of the patients were reviewed. A search using the Pubmed database was performed with the following keywords, supracondylar humerus fracture, pediatric, pulseless, vascular injury, arterial repair. RESULTS: In this series of pulseless perfused hands following operative fixation of supracondylar fracture, a total of 26 patients were reviewed. All were Gartland grade III extension type fractures. Postoperative pulse oximeter waveforms were present in all but 4 patients. These patients subsequently had exploration of the brachial artery with significant findings. In the remaining 22 patients, waveforms were present and the child had return of the radial pulse soon after operative fixation without any further need for surgical exploration. At 24 months follow-up, all children were well with no neurovascular compromise. CONCLUSIONS: The presence of a waveform on a pulse oximeter is a sensitive and easily available modality in determining vascular perfusion as compared to other more complex investigations. The high sensitivity of this test will allow surgeons to objectively determine the requirement for surgical exploration of the brachial artery.

Common lower limb sport-related overuse injuries in young athletes

<p><b>INTRODUCTION</b>Sports injuries in children and adolescent present a unique challenge to the physician. They are often seen for clinical conditions unique to their age group. This paper highlights the epidemiological aspect of sports-related overuse injuries in this age group.</p><p><b>MATERIALS AND METHODS</b>This retrospective study reviewed all the paediatric patients diagnosed with overuses injuries during a 5 years and 7 months period. The overuse injuries were anterior superior iliac spine avulsion fracture, Osgood-Schlatter disease, Sinding-Larson-Johansson disease, osteochondritis dissecan and Sever's disease. We reviewed the literature and attempted to give an overview for each condition and the anatomical differences that contributed to their occurrence in this age group.</p><p><b>RESULTS</b>A total of 506 cases of the overuse injuries were seen during the study period. Seventy-three per cent were male patients. The knee joint was the commonest affected joint while the hip was the least affected joint. The mean age at diagnosis was younger in female compared to male for all conditions except in Sinding-Larson Johansson syndrome. Female was diagnosed at a mean age of 11.7 years while male at 10.8 years. Osgood-Schlatter disease was the commonest among the overuse injuries. There was no discernible racial predilection for these conditions except in the patients with anterior superior iliac spine avulsion.</p><p><b>CONCLUSIONS</b>Overuse injuries are not uncommon in children and adolescent. An adequate understanding of the anatomy of the sports the children participated in as well as the anatomical differences between adult and children may assist the primary care providers better meet parents' and coaches' expectations.</p>