Clinical Characteristics and Outcomes of Limb Fractures in Saudi Children.

BACKGROUND:  Children's bones are at high risk of fracture as they grow. The clinical characteristics of fractures in children differ from those in adults. Studying fractures in healthy children is critical for identifying cases of fragility fractures. The aim of this study was to assess the clinical characteristics of limb fractures as well as clinical indicators of fracture healing outcomes in healthy Saudi children seen in an emergency room. METHODS: A retrospective review of the treatment course of all pediatric fractures and related factors treated at King Abdullah Specialist Children's Hospital (KASCH) in Riyadh between 2016 and 2018 was conducted. Children with a primary bone disorder or chronic comorbidities known to affect bone health were excluded. RESULTS:  The study included 143 patients (mean age ± SD = 8.23 + 3.76 years), and 71% (n = 102) were males. Motor vehicle accidents (MVAs) were the most common mechanism of injury, accounting for 50 (35%) cases, followed by fall injuries, sports injuries, and pedestrian accidents at 45 (31.4%), 16 (11.2%), and 13 (9.1%), respectively. A total of 178 fractures were reported, with the femur (n = 75, 42.1%) being the most common of the reported fracture sites, followed by the forearm (n = 44, 24.7%). The most common type of fracture was transverse fracture (n = 96, 54% of patients). Vitamin D levels were measured in 53/143 cases. Of these, vitamin D deficiency was found in 38 (71.7%) patients. The average time for fracture healing was 32.9 ± 30.2 weeks. The mechanisms of injury, including MVAs and sports injuries, as well as femur and forearm fractures, were clinical factors that were independently associated with a longer duration of fracture healing time (p < 0.001), but age, gender, and vitamin D status were not associated with that outcome. CONCLUSION:  MVAs and fall injuries were the most common causes of fracture in our patients. MVAs and sports injuries were associated with prolonged healing time. Large prospective, multicenter, or field studies may be required to further explore clinical characteristics, outcomes, and environmental factors.

The Use of Visual Analysis for Gait and Foot Posture in Children with Developmental Dysplasia of the Hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) is recognized as a leading cause of significant long-term complications, including inaccurate gait patterns, persistent pain, and early regressive joint disorder, and it can influence families functionally, socially, and psychologically. METHODS: This study aimed to determine foot posture and gait analysis across patients with developmental hip dysplasia. We retrospectively reviewed participants referred to the pediatric rehabilitation department of KASCH from the orthopedic clinic between 2016 and 2022 (patients born 2016-2022) with DDH for conservative brace treatment. RESULTS: The foot postural index for the right foot showed a mean of 5.89 (n = 203, SD 4.15) and the left food showed a mean of 5.94 (n = 203, SD 4.19). The gait analysis mean was 6.44 (n = 406, SD 3.84). The right lower limb mean was 6.41 (n = 203, SD 3.78), and the left lower limb mean was 6.47 (n = 203, SD 3.91). The correlation for general gait analysis was r = 0.93, presenting the very high impact of DDH on gait. Significant correlation results were found between the right (r = 0.97) and left (r = 0.25) lower limbs. Variation between the right and left lower limb p-values was 0.88 (p < 0.05). DDH affects the left lower limb more than the right during gait. CONCLUSION: We conclude that there is a higher risk of developing foot pronation on the left side, which is altered by DDH. Gait analysis has shown that DDH affects the right lower limb more than the left. The results of the gait analysis showed gait deviation in the sagittal mid- and late stance phases.

Developmental Dysplasia of the Hip: Prevalence and Correlation with Other Diagnoses in Physiotherapy Practice-A 5-Year Retrospective Review.

(1) Background: The objective of this study was to assess the prevalence of Developmental Dysplasia of the Hip (DDH) as a primary or secondary diagnosis during physiotherapy practice. No other studies have investigated the prevalence and associations of DDH within the practice of pediatric rehabilitation. (2) Methods: This retrospective review was performed on 12,225 physiotherapy referrals to the King Abdullah Specialized Children's Hospital (KASCH), Riyadh, Kingdom of Saudi Arabia, from May 2016 to October 2021. Only DDH referrals for conservative treatment were included in the study. The plan for brace treatment was carried out by the pediatric orthopedics clinic in KASCH. The diagnostic methods were either a pelvic radiograph or ultrasound, depending on the participant's age. DDH is considered one of the most common secondary complications for children with other medical diagnoses. (3) Results: The most common indication for referral was neurological diagnosis (44%), followed by orthopedic (28%), genetic (19%), cardiac (5%), ophthalmologic (3%), dermatologic (1%) and rheumatologic (0.5%) diagnoses. (4) Conclusion: The prevalence of DDH among all referrals in this study was 6%. In physiotherapy practice, neurologic, genetic, and orthopedic primary or secondary diagnoses were the most prevalent when DDH referrals were investigated. A relatively high prevalence of DDH in the pediatric rehabilitation clinic at KASCH in Riyadh was reported in this study.

Avascular necrosis of the femoral head: Assessment following developmental dysplasia of the hip management.

OBJECTIVES: Avascular necrosis (AVN) of the femoral head is a major complication following treatment for developmental dysplasia of the hip (DDH). It is caused by excessive pressure over the femoral head, which compromises its blood supply. The rate of AVN following DDH treatment ranges from 6% to 48%. This study aimed to analyze the rate of AVN in DDH patients following different standard surgical treatments. METHODS: A retrospective cohort study was performed on patients diagnosed with DDH between January 2007 and December 2013. All idiopathic DDH patients who underwent standard surgical treatments were included in the study. Neuromuscular and teratologic patients and patients with previous surgical treatment outside the institute were excluded from the study. RESULTS: Overall, 204 hips in 143 pediatric patients were included in the study. The majority (84.8%) of the patients were female. Most patients (82.2%) received single treatment. The most commonly used surgical treatment was open reduction with pelvic osteotomy (82.8%). Type 4 Tonnis classification of DDH was found in 62.3% of patients. AVN was found in 14.3% of our study population. The majority (57.1%) of diagnosed AVN patients showed Grade 1 (Kalamchi) AVN classification. Patients who underwent closed reduction and hip spica showed a significantly higher rate of AVN compared to other treatments (14.3%, P = 0.044). CONCLUSION: Close follow-up of patients treated with closed reduction is mandatory as these patients have the highest risk of AVN. We recommend the introduction of national screening programs targeting all newborn children and including systematic follow-up at well-baby clinics during the early years of life.

Current practice and preferences to management of equinus in children with ambulatory cerebral palsy: A survey of orthopedic surgeons.

INTRODUCTION: The consensus among orthopedic surgeons on the management of equinus deformity in cerebral palsy (CP) children has not been reported previously despite being a prevalent deformity. The goals of this study were to examine the orthopedic surgeons' current practice regarding the management of equinus deformity in children with ambulatory CP, and analyze variations in current practice between general orthopedic and pediatric orthopedic surgeons. METHODS: We implemented a brief cross-sectional self-reported questionnaire that addressed the areas of clinical examination and decision-making skills of management of equinus deformity in CP children. We targeted a convenience sample of 400 participants. Surgeons that provided complete responses to the questionnaire were 223 with a response rate of 56%, of which 123 (55%) were general orthopedic surgeons, whereas 100 (45%) were pediatric orthopedic surgeons. The target population consisted of orthopedic surgeons who were further sub-classified in accordance with practice age, general versus pediatric, and exposure to children's orthopedics during the last three years of their practice. For analytical statistics, the Chi-Square test and Fisher's exact test were used to examine the relationship between two qualitative variables. RESULTS: The overall clinical practice preferences of all survey participants were unimpressive with discordant survey responses. Pediatric orthopedic surgeons generally demonstrated a statistically significant difference regarding clinical assessment skill items of the survey, in contrast to general orthopedic surgeons. However, we found no differences between pediatric orthopedic and general orthopedic surgeons regarding most of the decision-making/knowledge items. DISCUSSION: Generally, there are insufficient clinical practice trends of both general and pediatric orthopedic surgeons regarding equinus treatment in CP children. This may indicate a knowledge-practice gap with potential risks to CP children undergoing surgery for equinus. There is a need for a more competent exposure to CP in orthopedic surgeons' educational curricula and an updated health referral system.

Association analysis between four vitamin D receptor gene polymorphisms and developmental dysplasia of the hip.

Developmental dysplasia of the hip (DDH) is a congenital condition characterized by abnormality in acetabulum size and/or shape. The incidence rate of DDH differs between different populations with risk factors including positive family history, breech presentation, sex, firstborn status, side of the hip, mode of delivery and oligohydramnios. It is recognized that DDH has a genetic component that exhibit autosomal dominant patterns. Many candidate genes have been studied and found to be associated with the disease; most of them are normally involved in cartilage development and joint metabolism. In this study, the association of four single-nucleotide polymorphisms (SNPs) (rs731236, rs1544410, rs7975232 and rs2228570) in the vitamin D receptor (VDR) gene was studied by a case-control analysis. The study sample involves 50 cases with confirmed DDH presentation and 50 nonDDH controls. SNPs were genotyped using conventional polymerase chain reaction (PCR) and restriction fragment-length polymorphism (RFLP) techniques. Genotype and allele frequencies were analysed using SPSS software. No significant associations were found between the VDR polymorphisms analysed and DDH. Further work need to be performed using genomewide analysis to elucidate the genetic basis of DDH.

Outcome of diaphyseal pediatric forearm fractures following non-surgical treatment in a Level I Trauma Center.

OBJECTIVES: Pediatric diaphyseal forearm fractures are common injuries of childhood. Conservative modality of treatments is usually preferred when they are possible. We identified factors that may affect closed reduction success or lead to redisplacement in forearm diaphyseal fractures in children. METHODS: This was a retrospective study from a level I trauma center on patients up to 18 years of age who presented with forearm diaphyseal fractures from January 1, 2007, to December 31, 2015. Cases were obtained from medical records. Data were collected and confirmed by plain films and medical files. RESULTS: We included 145 patients in this study. The majority (86.2%) were boys. Around 29% of trials of closed reduction failed, and the patients were subsequently treated surgically. Following trials of closed reduction, 82.4% of both bone cases were successfully reduced compared to 42.9% of radius shaft cases (P = 0.006). Redisplacement following non-surgical treatment in the first follow-up was found in 32% of both bone cases and 13.3% of radial shaft cases. All Galeazzi cases that were successfully treated with closed reduction presented with no redisplacement on follow-up. CONCLUSION: Immediate surgical management might be considered in older children, especially above 12 years of age since they have a higher failure rate of closed reduction than younger ones. Fracture site should be taken into account when following pediatric diaphyseal forearm fractures following conservative treatments as cases with both bone involvement have a high success rate of closed reduction and considerably high rate of redisplacement compared to others.

Posterior shoulder dislocation in a 10-year-old child: Case report.

INTRODUCTION: Shoulder dislocation is the most common type of all joints dislocations. It occurs when there is separation in the glenohumeral joint. Posterior dislocation accounts for less than 4% of all shoulder dislocations. In fact, it is misdiagnosed in 60-79% of the patients in the initial presentation. In children a posterior shoulder dislocation is usually caused by a congenital anomaly or in those who have ligamentous laxity. Traumatic posterior shoulder dislocation without fracture of the proximal humeral epiphysis in children is very rare, and only few cases have been reported. CASE PRESENTATION: This report presents a rare case of a 10-year-old child with a traumatic posterior shoulder dislocation without fracture. DISCUSSION: this patient present with a rare posterior dislocation, which is direct and without fracture. It does not present with a marked deformity and it is hard to detect without a complete physical examination and radiographic series. CONCLUSION: Posterior shoulder dislocations are rare, and even more rare in children without fractures. It is easily missed and needs careful history taking, physical exam and correct x-ray view to reach the diagnosis.

Patterns of paediatric forearm fractures at a level I trauma centre in KSA.

OBJECTIVES: The current literature does not clearly elaborate the pattern of paediatric forearm fractures. This study aims to identify patterns of paediatric forearm fractures in KSA. METHODS: This retrospective study was conducted in a level I trauma centre. The study population comprised patients up to 18 years of age who presented with forearm fractures between 2007 and 2015. The demographic data of the recruited patients were obtained from medical files, and fractures were identified using plain films. Mean and standard deviations were used for continuous variables, whereas frequencies and percentages were used for categorical variables. RESULTS: This study included 318 patients, ranging in age from 1.2 to 18 years (average: 10.42 ± 4.56 years). The majority were boys (80.8%) and 53.1% were <12 years of age. Girls were significantly more prevalent in the <12-year-old group than in the ≥12-year-old group (p < 0.001). A fall was the mechanism of injury in the majority of patients (82.1%) in the <12-year-old group compared with the ≥12-year-old group (p < 0.001). There was no statistically significant difference in fracture site between the two age groups. The distal forearm was the most common site fractured (47.8%), followed by the distal third of the forearm diaphysis (34.2%). CONCLUSION: Forearm fractures are commonly seen in school-age boys. The distal radius is the most commonly fractured site reported in this study. A fall was the most common mechanism of injury, and safety measures should be implemented in places where children frequently gather.

Diagnosis and treatment of developmental dysplasia of the hip: A current practice of paediatric orthopaedic surgeons.

BACKGROUND: Developmental dysplasia of the hip (DDH) is one of the prevalent musculoskeletal conditions in young adults and is a leading cause of hip osteoarthrosis in this age group. The optimum age for surgical intervention when needed is not well established in the literature and the lack of management guidelines and standard practice of DDH leads to different practices worldwide. This study aims to investigate the current practice of paediatric orthopaedic surgeons in diagnosing and treating DDH worldwide and identify points of agreement and disagreement. METHODS: A cross-sectional study utilizing an online questionnaire was designed to examine the different points of view and current practice of paediatric orthopaedic surgeons worldwide regarding DDH diagnosis and treatment. RESULTS: Ninety-one surgeons responded, with an overall response of 45.5%. The vast majority of respondents use ultrasonography in children less than 3 months of age and pelvic radiography in over 3 months to diagnose DDH. Pavlik harness is the most popular DDH treatment for children younger than 6 months. For older children, closed reduction with hip spica cast is the most preferable treatment. The maximum duration of first-line treatment has a broad range. The treatment of bilateral DDH varies widely among surgeons. CONCLUSION: This study shows clearly that paediatric orthopaedic surgeons do not agree on the diagnosis and treatment protocol of DDH, hence different approaches to this common disease are practised. The lack of an international guideline should motivate paediatric orthopaedic surgeons to discuss and formulate a uniform and evidence-based protocol for the diagnosis and treatment of DDH.

Prevalence of Dietary Supplements Use among Gymnasium Users.

Background. Several studies showed that regular gymnasium users use various dietary supplements without comprehension of their potential risks. Objective. To determine the prevalence and dietary supplement intake and assess the awareness of supplement use among regular gymnasium users in Riyadh, Saudi Arabia. Methods. A descriptive cross-sectional study was conducted among regular gymnasium users in Riyadh, Saudi Arabia, between April 2015 and June 2015. A validated structured questionnaire was used. Results. The study included 299 participants. Of these 113 (37.8%) were dietary supplements users and this was more common among males than females (44.7% versus 16.4%). Gender based analysis showed that males were exercising more frequently than females and the type of cardiovascular exercise was more among them. The most commonly used supplements were whey protein (22.1%), amino acids (16.8%), multivitamins (16.8%), creatine (11.5%), and omega 3 (11.5%). The reasons for taking dietary supplements were to improve body shape (47.7%), increase health (44.2%), and improve performance (41.5%). Conclusion. Most of the information about supplements was obtained from unreliable sources. More studies are needed to better understand supplements use and their impact on health in Saudi Arabia.

Traumatic pediatric shoulder fracture dislocation treated with closed reduction and intramedullary nailing: A case report.

BACKGROUND: Although rare, pediatric proximal humerus fractures may coexist with glenohumeral dislocations. Most of these injuries are Salter -Harris type of injuries. The treatment usually consists of closed or open reduction and k- wires fixation. THE CASE: In this case report; a 10-year-old girl presented with a rare traumatic humeral surgical neck fracture with a posterior shoulder dislocation that was treated by closed reduction and flexible intramedullary nailing. CONCLUSION: Pediatric humerus fracture dislocations are rare. Treatment should keep in mind preservation of the growth plate.

Clubfoot management by the Ponseti technique in Saudi patients.

OBJECTIVE: To assess the effectiveness of the Ponseti technique in the treatment of clubfoot in Saudi children. METHODS: The data of 175 patients (235 feet), who presented with clubfeet from September 2002 to June 2008 and who were treated with the Ponseti technique at King Abdulaziz Medical City in Riyadh, Kingdom of Saudi Arabia were collected and studied retrospectively. The Pirani score for clubfoot evaluation was used in this study. RESULTS: Age ranged from one week to 48 weeks, with an average age of 6.5 weeks. The average follow up was 37 months (range one year to 6 years and 7 months). The average time to obtain correction was 5.3 weeks (range 4-10 weeks). Six patients (8 feet) (3.4%) were not corrected with initial casting and required early surgery. Full correction was obtained in 169 patients (227 feet) (96.6%). Tenotomies were performed in all but one patient (2 feet) (0.9%). Thirty-four patients (48 feet) (21.1%) relapsed. One hundred and seventy-nine feet (78.9%) required no further treatment, and only 4 feet (1.8%) required a more extensive posterior-medial release. Minor complications were noted in 14 patients (18 feet) (7.9%). CONCLUSION: The Ponseti technique is a safe and effective conservative treatment of clubfoot that decreases the number of surgical interventions needed for the correction of the deformation in our Saudi patients. It is an easy method to understand and to apply by most orthopedic surgeons.

Injuries associated with fracture of the femur secondary to motor vehicle accidents in children.

A retrospective review of the medical records of 149 children < 18 years old who sustained femur fractures secondary to a motor vehicle accident found 159 fractured femurs; 89.3% were closed. One hundred seventy-nine associated injuries occurred in 87 patients (58.4%). Associated fractures were common (50.3%), followed by soft-tissue injuries (18.5%) and head injuries (14%; 3 deaths). The lower limbs were most commonly involved with associated fractures (37.8%), 9 had a "floating knee." The incidence of intra-abdominal injury was 5%, with the liver most commonly lacerated followed by the spleen and intestine. Forty-seven children (43.1%) developed 1 or more complications. The Pediatric Trauma Score ranged from -3 to 11 (73.8% scored > or = 8, while 26.2% scored < 8). Fractures of the femur in children are commonly associated with other injuries, particularly other fractures.