Missed Monteggia Fracture Dislocation in a 10-year-old Child - A Step-by-Step Approach to Properly Solving a Complex Problem: A Case Report.

Introduction: Monteggia injuries are relatively rare in the pediatric population. They can be missed leading to complications arising from a chronic radial head dislocation. There is limited information about their proper management in the literature. Thus, their treatment remains controversial. Case Report: We present a case of a 10-year-old boy who was examined in the orthopedic outpatient clinic of our hospital, due to limited range of motion of his left elbow and difficulty in extending his left thumb, after a forearm injury which occurred 9 months before and was initially treated conservatively. After appropriate imaging was obtained, a Bado type I Monteggia lesion was diagnosed. This was treated by open reduction of the head of radius, osteotomy of the ulna and lengthening using an external fixator, as well as annular ligament reconstruction by the use of synthetic tendon graft. The patient was followed up for 18 months after surgery and during his last examination showed very good clinical and functional results. Conclusion: Missed Monteggia injuries in children are complex problems warranting a step-by-step approach. Their management with ulnar osteotomy, bone lengthening, and reconstruction of the annular ligament presents a viable option with excellent clinical, functional, and radiological outcomes.

Clinical Radiological and Molecular Profile of a Patient Affected With Multicentric Osteolysis Nodulosis and Arthropathy.

Multicentric Osteolysis Nodulosis and Arthropathy (MONA) is an ultra-rare multisystem autosomal recessive disorder characterized by progressive osteolysis, subcutaneous nodules and developing arthropathy. The characteristic radiological signs combined with symptoms resembling juvenile idiopathic arthritis (JIA) set the diagnosis, which is established either by measuring matrix metalloproteinase-2 (MMP-2) enzyme activity through electrophoresis (zymography) or genomic testing. We report the clinical and radiographic findings of a 14-year-old girl with molecularly proven MONA, who presented with painless osteolytic changes of the feet and upper extremities and developed hip arthritis. To this day, no specific therapy has been identified with proven long term relief and control of the disease progression.

Central Mirror Foot: Treatment and Review of the Literature.

Mirror foot is a rare abnormality which presents as a preaxial, postaxial, or central polydactyly of the foot. The latter is encountered infrequently. We describe the case of a central mirror foot. Our patient had eight digits of a central ray pattern type with fully developed metatarsal, proximal, middle, and distal phalanges, as well as a medial toe syndactyly. He had no tarsal bone duplications. He was treated by central ray resection via double V-shaped incisions on the dorsal and plantar aspects of the foot, while preserving the medial and lateral rays. The results were satisfactory. We describe the technique and attempt a review of the literature.

Retrograde Fixation of the Ulna in Pediatric Forearm Fractures Treated With Elastic Stable Intramedullary Nailing.

Introduction This study analyzes the outcomes of retrograde fixation of the ulna in pediatric forearm fractures treated with elastic stable intramedullary nailing (ESIN). Materials and Methods A retrospective analysis was conducted by reviewing patient records of forearm fractures treated with ESIN by retrograde fixation. The study included 30 children (26 boys and 4 girls). The mean age at the time of injury was 11.7 years (range: 6.6 to 14.3 years). The technique is described. All patients were followed up until hardware removal. Results The mean time for fracture healing was 5.3 weeks (range: 4 to 8.8 weeks). The mean time for nail removal was 6.6 months (range: 5 to 10 months). There were five cases with rotation deficits, one of which was a re-fracture. Conclusions When antegrade nailing is performed, the ulna is sometimes complicated by non-union as well as entry point irritation. We did not encounter such complications. Retrograde fixation of the ulna in pediatric forearm fractures treated with ESIN is a safe and effective alternative to common fixation (antegrade ulnar fixation) and offers technical advantages.

Does Cozen's phenomenon warrant surgical intervention?

PURPOSE: Proximal tibial metaphyseal fractures can be complicated by a late valgus deformity, referred to as Cozen's phenomenon. We studied children with such fractures to determine whether the child's age at the time of injury influenced the development of Cozen's as well as the occurrence of elongation. In addition, we explored whether the deformity resolved at long-term follow-up. METHODS: We conducted a retrospective study of 33 patients (six months to 14 years old). Mean follow-up was 8.8 years (3 to 25). We measured angulation of the fractured limb post-treatment, at maximum deformity and final follow-up, as well as elongation and compared them with the uninjured limb. RESULTS: Three of the fractures were treated surgically whereas the rest, nonoperatively. In all, 15 out of 33 fractures developed late valgus deformity between eight and 19 months (mean time 12.5 months). A total of 24 fractures developed elongation. We found no association of either of these with age. Angulation increased to a statistically significant level, from post-treatment to maximum deformity, and then decreased at final follow-up, leaving no statistically significant difference from the initial measurement. The difference in valgus between fractured and uninjured limb increased to a statistically significant level from post-treatment to maximum deformity and then decreased, leaving an excess from the initial measurement. CONCLUSION: In almost half the patients, late valgus deformity developed within two years post-fracture and corrected to the initial post-treatment angles. Patients should be warned of this possibility and reassured of its natural resolution. LEVEL OF EVIDENCE: IV.

Pediatric Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome: Diagnostic Challenges and Treatment Approach.

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare disease; however, more and more case reports have been published that increase the awareness of this disorder, especially in children. Clinically it presents as a combination of chronic recurrent multifocal osteomyelitis symptoms and skin manifestations. SAPHO treatment remains a challenge. In most cases, non-steroidal anti-inflammatory drugs are initially used, although a combination with other drugs is preferred. In addition, antibiotics, corticosteroids, bisphosphonates, and disease-modifying anti-rheumatic drugs are usually administered with varied success. There are also promising results from novel biological therapy. This paper emphasizes some non-specific symptoms of the disease, in order to increase the suspicion of SAPHO in all pediatric clinical doctors. We present the case of a 13-year-old boy with severe acne, who was admitted to our hospital due to fever of unknown origin, accompanied by arthralgia of the right ankle and left knee.

Arthroscopic Technique for the Treatment of Localized Pigmented Villonodular Synovitis of the Knee.

Pigmented villonodular synovitis (PVNS) is caused by a proliferation of the synovial membrane and can be a rare cause of pain and locking of the knee. In its localized form, it can be removed arthroscopically. We describe in detail a step-by-step arthroscopic technique applied to treat a 27-year-old patient who had been suffering from pain and episodes of locking for a year and whose left knee MRI revealed an intra-articular mass. The formation was completely enucleated arthroscopically and histological analyses confirmed the diagnosis of localized PVNS. There were no complications, and the patient was symptom-free at the six-month follow-up with no clinical or radiological evidence of recurrence.

Type IV capitellum fractures in children.

Capitellum fractures represent 1% of elbow fractures. A coronal shear fracture which involves the trochlea is classified as a type IV McKee fracture. The combination of its rarity in the paediatric population as well as its unique appearance on X-ray make diagnosis of this fracture a challenge. We present the case of a 14-year-old boy who sustained this fracture falling from his bike. It was diagnosed from the double arc sign on X-ray. In addition, a CT scan was obtained to aid preoperative planning. It was treated by open reduction and fixation with two headless compression screws. Follow-up at 6 months showed no avascular necrosis. The patient could achieve full extension, while flexion was reduced only by 5°. Final follow-up was conducted at 15 months. Anatomic reduction and stable internal fixation are essential for a good outcome in these uncommon paediatric fractures.

Prospective Early Clinical, Radiological, and Kinematic Pedobarographic Analysis Following Subtalar Arthroereises for Paediatric Pes Planovalgus.

Introduction Arthroereises implants mechanically block eversion and limit subtalar motion. They are used in children with pes planovalgus in order to correct the valgus deformity. In this study, we aimed to objectively assess children with flatfoot before and after the insertion of the Kalix II implant, clinically, radiologically and by kinematic pedobarographic analysis. Materials and methods Six children (12 feet) were treated by the insertion of the Kalix II implant (Integra LifeSciences, Plainsboro, NJ). Patients completed the Manchester Oxford Foot Questionnaire (MOXFQ) preoperatively and at six months post operatively. Radiological outcome was assessed by lateral (L) and anterior posterior (AP) foot weight-bearing radiographs taken pre operatively and post operatively. Pedobarographic data was obtained pre operatively and at six months post operatively using a 1 meter RS Scan Footscan (RSscan International, Olen, Belgium) pedobarograph. In addition, patients underwent gait analysis pre and post operatively. Results Mean age was 11.05 +/-3.24 years (range 6.2 to 15.5 years). In all cases, screw removal was carried out at between 15 to 18 months post insertion. The mean pre op MOXFQ score was 55.3 +/-9.68 which reduced to 34.3 +/-15.66 post operatively with a p value < 0.00001 which was statistically significant. Mean Meary's angle preop was -15.21+/-5.51 degrees which corrected to -7.57+/-4.62 post op with a p value=0.00001. The mean calcaneal pitch before surgery was 11.96+/-3.8 which increased to 14.98+/-3.85 with a p value =0.00067. The first MTH: fifth MTH peak pressure ratio pre operatively was 4.53+/-2.78 which was found to reduce significantly post operatively to 1.35+/-0.97 (p=0.04), indicating a lateral shift of the foot pressures. Conclusion There were statistically significant improvements in the patient-reported MOXFQ, radiological improvements, and pedobarographic changes, indicating a lateral shift of the foot pressures. There were no complications.

Dysplasia epiphysealis hemimelica of the ankle: a fracture-like rare developmental disorder.

Dysplasia epiphysealis hemimelica is a rare developmental disorder which affects the epiphyses. We report a case of the disease located in the ankle joint, referred to our clinic with the initial misdiagnosis of a Salter-Harris 3 type fracture of the distal epiphysis of the tibia. After correct diagnosis, the patient was treated surgically with the excision of the cartilaginous masses. Taking an accurate medical history and performing adequate imaging studies is essential in diagnosing and treating this disease. Fracture-like epiphyseal configurations in patients with no history of injury should raise suspicion of periarticular developmental disorders.

Treatment of multiple myeloma bone disease: experimental and clinical data.

INTRODUCTION: Bone disease is present in the majority of patients with multiple myeloma and can seriously affect quality of life and survival rate. In addition to suppression of osteoclastogenesis, there have been developments made in terms of the therapeutic agents available, such as novel immunomodulating agents, proteasome and receptor activator of nuclear factor κB ligand inhibitors. AREAS COVERED: AREAS COVERED include in vitro, in vivo and clinical evidence was collected using MEDLINE (1950 - May 2014), EMBASE (1980 - May 2014) and Google Scholar (1980 - May 2014) databases. EXPERT OPINION: Bisphosphonates are the mainstay of myeloma bone disease treatment. Oral clodronate and intravenous pamidronate and zoledronic acid are currently used drugs and seem to have comparable results in preventing skeletal-related events of the disease. Zoledronate can also have survival benefits and based on the available evidence is the superior bisphosphonate; however, its side effects have to be monitored. Denosumab had comparable results with zoledronate on myeloma bone disease treatment; its use has not been completely proven yet. There is an expanding set of drugs, proteasome inhibitors, under investigation with great potential to reduce the negative effects of myeloma cells on bone. Future clinical studies should compare both the catabolic and anabolic effects of these agents on bone.