International Interdisciplinary Consensus Meeting on the Evaluation of Developmental Dysplasia of the Hip.

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management.

Median nerve entrapment and ulnar nerve palsy following elbow dislocation in a child.

This report presents a rare case of a child who presented with neglected intra-articular entrapment of the median nerve, ulnar nerve palsy, and intra-articular incarceration of the medial epicondyle following closed reduction of an elbow dislocation. In the present case, as in most other cases, the diagnosis and treatment were delayed. Careful initial and postreduction neurological examination, as well as careful interpretation of the plain radiographs, is necessary for early detection of any nerve complications and associated fractures of an elbow dislocation. The authors' opinion is that a child with an elbow dislocation, which is initially neurologically intact but advances to a median or ulnar nerve deficit after the reduction, must undergo early surgical exploration, especially when the dislocation is associated with a medial epicondyle fracture.

Initial diagnostic approach of the irritable hip in childhood: is ultrasound really useful?

The acutely painful hip is a common complaint in childhood and has numerous significant causes. This prospective study explored the use of ultrasound as an adjunct to medical history and clinical examination in children with an irritable hip attending a department of orthopaedic emergencies over the course of 8 months. One hundred thirty four children met the inclusion criteria. A provisional diagnosis was made after history, clinical examination and ultrasound scan and this initial diagnosis was compared with the final diagnosis after a 3-year follow-up. The nature and number of further investigations required to reach the final diagnosis were reviewed. The use of ultrasound reduced the number of early radiographs by 84% and in conjunction with history and clinical findings had a diagnostic accuracy of 92%.

Late compartment syndrome of the hand due to wasp sting in a child.

We report a 6-year-old girl, with no history of previous anaphylactic reaction, who sustained a wasp sting to the volar aspect of her left hand. The child did not present any symptoms at the beginning. She was first examined at the emergency department with developed compartment syndrome, after more than 24 hours later and she was urgently taken to the operating theatre. The midpalmar, thenar, and hypothenar spaces were decompressed, and the transverse carpal ligament was released. At the 11-month followup, she presented with normal function of the hand and normal 2-point discrimination in all fingers. Although the accurate mechanism of the development of compartment syndrome after a wasp sting in children is not thoroughly clear, the treatment seems to be the same as in all other cases of compartment syndrome; urgent fasciotomy. It is very important to keep in mind the possibility, even if it is extremely low, of compartment syndrome after a wasp sting in children; even of those with no history of anaphylactic reaction.

Flexible intramedullary nailing in paediatric femoral shaft fractures.

This retrospective study aims to evaluate the efficacy of flexible intramedullary (IM) nails as a fixation device of paediatric femoral shaft fractures. A total of 36 children with 37 closed fractures were treated by this method. The patients ranged in age from 7.2 to 13.5 years and the mean follow-up was 25.5 months. All patients had open femoral growth plates at the time of surgery. All fractures united and none of the patients needed re-operation. Complications included pain/irritation at the insertion site, superficial wound breakdown and one case of delayed union. No major complications were recorded. After nail removal, all children had full range of hip and knee motion. At final follow-up, although radiographs revealed that 44% of the children had malalignment at the fracture site in one or both planes, none of the children presented with clinical malalignment of the fractured limb. Maximum angulation that was calculated on the coronal plane was 5 degrees into varus and on the sagittal plane 7 degrees of anterior angulation (apex posteriorly). Leg-length discrepancy was assessed clinically and radiographically when needed. A total of 50% of the children had a leg-length inequality but none of them complained of a functional problem. Flexible nailing of diaphyseal fractures of the femur is a reliable method with a small learning curve and allows early mobilisation. Most of our minor complications were technique related and could be avoided.

Popliteal artery pseudoaneurysm secondary to osteochondroma in children and adolescents: a case report and literature review.

Osteochondroma is the most frequent bone tumor and can rarely cause vascular complications. False aneurysms of the popliteal artery due to an osteochondroma are not common in the pediatric population. The case of an 11-year-old boy who presented with a painful mass on the posterior aspect of his distal thigh is described. Radiologic studies revealed an osteochondroma of the distal femur and a pseudoaneurysm of the popliteal fossa. A combined orthopaedic and vascular surgery was undertaken. The exostosis was excised and the popliteal artery was repaired by performing a venous patch angioplasty technique. A review of the literature regarding this vascular complication in young patients is also reported.

Intraosseous pseudotumour of the talus in a child with severe haemophilia.

We report a case of a large pseudotumour in the right talus of an 11-year-old boy with severe haemophilia A. The described intraosseous lesion was treated with surgical curettage and autologous bone grafting. Twenty months postoperatively computed tomography scan showed no signs of recurrence. Forty months postoperatively radiological studies confirmed satisfactory incorporation of the graft, no evidence of bone growth disturbance and improvement of Pettersson score of the ankle joint. At the same time, regarding his clinical situation, he was able to fully participate in his daily activities, presenting painless and almost full range of motion of his right ankle joint. Surgical intervention seems to be the best option in treating a big pseudotumour of the talus during childhood. As conservative management in the treatment of large lesions may fail, disastrous complications like a pathological fracture may happen. Anatomical reconstruction of a talus when pseudotumour and pathological fracture coexist is a major challenge for an orthopaedic surgeon.

Correction of adolescent hallux valgus by proximal crescentic osteotomy of the first metatarsal.

Thirty nine surgical hallux valgus corrections in 32 adolescents (7 bilateral) performed between 1994 and 2001 were retrospectively studied. The mean age at the time of surgery was 14.2 years. The operation consisted of a proximal dome osteotomy of the first metatarsal, excision of the medial protuberance, lateral capsular and adductor release, and distal medial soft tissue plication. The patients were followed for an average of 42 months (range 32 to 62). Post-operative evaluation was based on the duPont bunion rating score. The result was excellent in 11 feet, good in 22 cases, fair in 5 and poor in 1 case. Using subjective criteria of the duPont score, such as cosmesis and discomfort, a satisfactory result was achieved in 35 feet (90%). Our opinion is that correction of the angle between the 1st and 2nd metatarsal as well as preservation of the length of the first metatarsal are of crucial importance in the surgical treatment of adolescent hallux valgus.