[Osteoarticular infection in children: evaluation of a diagnostic and management protocol]. / Infections ostéo-articulaires de l'enfant: étude de deux séries consécutives et évaluation d'un protocole de diagnostic et de traitement.

PURPOSE OF THE STUDY: The purpose of this study was to evaluate a diagnostic and management protocol for osteoarticular infection in children which was developed at the Rouen University Hospital in 1993. We studied the technical aspects of the protocol allowing improved certain diagnosis and bacteriological documentation as well as the reduction in intravenous treatments and hospital stay. MATERIAL AND METHODS: Two successive series were compared. The first constituted from May 1984 to February 1992 was a retrospective series of 106 children with osteoarticular infections. The second series was prospective an included 104 children with osteoarticular infection treated after institution of the protocol (January 1995 to December 1998). All children were treated in the same unit. Files were reviewed at a minimum follow-up of 18 months following the end of treatment. We analyzed: clinical, biological, and radiological data at admission; elements of the bacteriological study and their contribution to identification of the causal agent; duration of intravenous antibiotic therapy; total duration of antibiotic therapy, and hospital stay; complications and sequelae. RESULTS: After institution of the protocol, we observed significant progress: certain diagnosis of acute osteomyelitis improved from 67% to 85% after institution of a more comprehensive diagnostic program; bacteriological identification improved from 37.5% to 72.2% for acute osteomyelitis and from 41.6% to 59.5% for septic arthritis, with a growing number of recognized cases of Kingella kingae infections causing acute osteomyelitis (n=2) or septic arthritis (n=4) due to technical progress in sampling and culturing. Mean duration of intravenous antibiotic therapy (15 days versus 9.95 days), mean duration of total antibiotic therapy (47.3 versus 33.8 d) as well as length of hospital stay (17.5 d versus 12.5 d) were significantly improved. The shorter antibiotic therapy did not led to any supplementary morbidity. CONCLUSIONS: A systematic bacteriological diagnostic protocol has enabled an improvement in treatment and hospitalization. The protocol has been further updated and simplified in light of these findings and observations of insufficiencies, taking into account recent data in the literature and epidemiological features of osteoarticular infection in children.

[Epidemiological survey of wrist fractures in children]. / Les fractures du poignet de l'enfant: étude épidémiologique.

PURPOSE OF THE STUDY: The incidence of wrist fractures is increasing in children. We undertook an epidemiological survey in western France to determine characteristic features. MATERIAL AND METHODS: A prospective multicentric study was conducted over one year in five university hospital centers in western France. The survey included 839 wrist fractures in children aged 6 to 16 years. The following criteria were recorded: age and gender, date and energy of the trauma, side and description of the fracture. Displacement was measured on the AP and lateral radiographs. RESULTS: The boys were older than the girls at the time of the wrist fractures, generally during the summer season (May to October). The left wrist was involved in 55% of the fractures; 83% were metaphyseal fractures. Fractures with epiphyseal detachment were more frequent in adolescents and occurred after high-energy trauma. Metaphyseal fractures were more common in girls than in boys. Displacement was greater in older children, particularly in case of epiphyseal detachment. DISCUSSION: We did not observe the male predominance often reported in our country. The girls probably practice sports as much as boys.

[Failure of primary management of developmental dislocation of the hip: 31 years experience in Normandy]. / Echecs de la prise en charge initiale de la maladie luxante de la hanche en Haute-Normandie: analyse sur une période de 31 années consécutives (1968-1998).

PURPOSE OF THE STUDY: Primary management of developmental dislocation of the hip involves a series of events (clinical screening and detection, choice and interpretation of imaging studies, indication and proper execution of treatment). Each event has an important effect on outcome and failure may result from inadequate attention to any one. We analyzed the causes of failure observed over 31 years experience in our region. MATERIAL AND METHODS: We analyzed the files of children hospitalized in the Rouen Infantile Surgery Department from 1968 to 1998 for management of congenital dislocation of the hip diagnosed late (> 3 months) or for revision after inappropriate treatment. We identified 353 files. This series was retrospective from 1968 to 1985 (283 cases) and prospective from 1986 to 1998 (70 cases). RESULTS: Up through 1981, failed detection of developmental dislocation of the hip was identified in 10 to 27 children per year (mean 21.5). Since 1982, this rate has varied from 1 to 10 (mean 6.5). The number of children treated before the age of one year was 10.5 per year up through 1981 then 4.5 per year after 1982. The number of children treated after the age of one year was 11 per year through 1981 then 2 per year after 1982. Since 1986, treatment was undertaken for failure of primary management in 57 children after clinical diagnosis, in 3 children after radiological and ultrasonographic diagnosis, and in 11 children during the course of treatment. Standard x-ray studies systematically obtained at four months corrected the diagnosis in 24 children. The diagnosis was corrected after repeating the examination in 14 children before the age of one year. Correct diagnosis was established after the age of one year in 18 children. DISCUSSION: Although our University Department was the only referral center for pediatric surgery in our region during this period, these figures cannot be compared with the annual birth rate in the region (24,000 births/year) because the number of infants managed in other centers is unknown. Nevertheless, organizing regular follow-up by a pediatric orthopedic surgeon of all infants screened positive in the maternity ward enabled a 70% reduction in the number of failures since 1982. Systematic clinical screening, repeated regularly during the first year of life, has reduced the mean age of diagnosis. Neither ultrasonography nor radiography has replaced physical examination. Care must also be taken to avoid over reliance on ultrasound findings which do not correspond to clinical findings. Amongst the children treated late, 14% had undergone an inappropriate treatment for dislocation correctly identified during the neonatal period. Referring all children screened positive to a pediatric orthopedic surgeon should help reduce this rate.

Posterior arch bifocal fracture of the atlas vertebra: a variant of Jefferson fracture.

Fracture of the atlas vertebra is rare in children. We report two paediatric cases of bifocal pedicular fracture of the posterior arch of C1. Evaluation was performed by nonenhanced computed tomography scan, which successively confirmed both diagnosis and healing. In both cases, nonoperative management was successful.

[Kingella kingae osteoarticular infections in children. A report of a series of eight new cases]. / Les infections ostéoarticulaires à Kingella kingae chez l'enfant. A propos d'une série récente de huit cas.

UNLABELLED: Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent. METHODS AND RESULTS: We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful. DISCUSSION: Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection. CONCLUSION: This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.

[Hip dislocation. Organization of screening and follow-up]. / La maladie luxante de hanche. Organisation du dépistage et de la prise en charge.

Early detection and low-risk treatment are the two main objectives of the management of developmental dislocation of the hip. The best way to evaluate neonatal hips is to perform clinical and ultrasound examinations at the same time, and to confront their results. Early diagnosis allows to restrict treatment to infants with neonatal dislocation who do not improve by 4 weeks of age. On the other hand, neonates with reductible dislocated hips must be treated at birth and followed at the joint consultation. Early diagnosis and management must not decrease later efforts to detect dislocated hip until walking age.