Anterior approach for pediatric supracondylar humerus fractures: A systematic review.

BACKGROUND AND PURPOSE: Open reduction is rarely performed in pediatric supracondylar humerus fractures. However, clear evidence is lacking regarding the optimal open approach to achieve satisfactory results. The anterior approach provides direct visualization of the fracture and excellent exposure to neurovascular structures, although its utilization is less common. The objective of this study was to review the indications, outcomes, and complications associated with the anterior approach for open reduction of these fractures. METHODS: Our protocol was registered at PROSPERO: CRD42023446923. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to search date (December 2023) and screened in duplicate for relevant studies. Data were collected regarding patient demographics, indications for open reduction, Flynn's functional and cosmetic outcomes, and complications. Study quality was assessed using the Methodological Index for Non-Randomized Studies Criteria. RESULTS: A total of 19 studies involving 483 patients were included. One study was classified as Level 2 evidence, ten as Level 3, and eight as Level 4. The mean MINORS score was 13.05±3.47. The primary indication for open reduction was failed closed reduction, observed in 46% of patients. 97.7% and 98.6% of patients achieved Flynn's functional and cosmetic satisfactory results, respectively. The postsurgical neurovascular injury rate was 1.4%. One patient required reintervention. CONCLUSION: The anterior approach is safe and effective for managing pediatric supracondylar humerus fractures requiring open reduction. LEVEL OF EVIDENCE: Systematic review of Level 2-4 evidence studies.

Transverse Anterior Approach to the Elbow for Pediatric Displaced Lateral Humeral Condyle Fractures.

BACKGROUND: The anterior approach to the elbow for pediatric lateral condyle fractures (LCF) would provide a better visualization of the articular fracture resulting in better functional results, less complications and a more cosmetically-appealing scar than usually seen with the lateral approach. METHODS: Retrospective study of children undergoing an open reduction and internal fixation of a displaced LCF via an anterior approach with a transverse incision. Bilateral elbow range of motion (ROM), upper limb alignment and complications were registered. A 4-point ordinal Likert-type scale was employed for parents to rate their level of satisfaction with the cosmetic appearance of the scar. RESULTS: Eighteen children of mean age 76 months (range 27 to 101 months) were included. Fractures were classified as Jackob's Type II in 14 cases and Milch's type II in all cases. Mean follow-up was 12 (range 4 to19) months.Successful condral fracture visualization and reduction was achieved in every case. No intra-operative or post-operative complications occurred. In all cases bone union was obtained 4 to 5 weeks after surgery and at final follow-up, active elbow ROM of at least 90%, was obtained. All parents claimed to be "very satisfied" with their child's scar. A lateral spur was identified in 66.7% o patients. CONCLUSION: The anterior approach to the elbow was both a feasible and safe allowing full anatomical cartilage reduction. Complications after this technique might decrease compared to the lateral approach but need future comparative studies. The rate of lateral spur did not decreased. Cosmetic scar results seem to be a clear advantage of this approach compared to the classical lateral approach.

Peromelia - congenital transverse deficiency of the upper limb: a literature review and current prosthetic treatment.

Peromelia or congenital transverse deficiency describes a truncation of the upper limb below various limb levels. Recommendations regarding treatment vary and are mainly based on expert opinions. This paper summarizes the current literature regarding the aetiology, pathogenesis and specifically treatment algorithms for children with peromelia. We performed a non-systematic review of the current literature from MEDLINE/PubMed to obtain comprehensive up-to-date information about peromelia, focusing on current recommendations for the treatment of peromelia (e.g. prosthetic fitting, external stump lengthening). The current literature lacks clear evidence as to whether prosthetic treatment is superior to prosthetic non-usage. However, based on the available studies, children with transradial or transhumeral peromelia should preferably be fitted with passive/cosmetic prostheses at the age between six and 24 months, followed by active/myoelectric devices at the age of 2.5 to four years. It remains controversial whether early myoelectric prosthetic fitting can reduce prosthesis rejection times; however, cognitive readiness and the ability to absolve a guided training programme are seen as important prerequisites for myoelectric fitting. Children with very short stumps may benefit from stump lengthening using external fixators and prosthetic modification. The treatment of children with peromelia generally requires a guided, multidisciplinary team approach. A training programme is essential to optimize individuals' performance in the execution of activities of daily living and decrease rejection risks whenever a myoelectric device is prescribed. Myoelectric fitting should preferably be commenced at no later than four years of age. However, long-term reports on the benefits of prosthetic treatment are still pending.

Transfer of the musculocutaneous nerve branch to the brachialis muscle to the triceps for elbow extension: anatomical study and report of five cases.

We report the study of the anatomical feasibility of transferring the nerve to the brachialis muscle to the upper medial head motor branch that innervate the triceps, and outcomes of such transfers in restoring elbow extension in five patients with posterior cord lesion of the brachial plexus. The length of the branches to the brachialis muscle measured 7.6 cm and the triceps upper medial head motor branch was 5 cm in 10 adult cadavers. Five male patients were treated with this transfer 5 months after the injury (range 4 to 6 months) after posterior cord injury of the brachial plexus with a mean follow-up of 31 months (range 28 to 36 months). Elbow extension scored M4 in all cases. No complications occurred. These preliminary results suggest that transferring the nerve to the brachialis muscle is an effective technique for the reconstruction of elbow extension after posterior cord brachial plexus injuries. LEVEL OF EVIDENCE: IV.

Percutaneous correction of congenital overlapping fifth toe in paediatric patients.

The various available surgical methods for correcting congenital overlapping fifth toe deformity consistently require a skin plasty step, which can result in complications (necrosis, tight scar, unbecoming appearance). Here, we describe a percutaneous technique involving extensor tenotomy combined with release of the dorso-medial capsule and ligaments. No skin plasty is required. Percutaneous osteotomy of the first phalanx can be performed if needed. From 2006 to 2010, we used this technique in 16 patients (27 toes) with a mean age of 12.6years (range, 6-17years). Mean follow-up at last evaluation was 2.1 years. Osteotomy of the first phalanx was performed for 13 toes. The outcome was very good for 21 toes and good for six toes. No relapses or complications were recorded. This simple and safe technique deserves consideration in children with congenital overlapping fifth toe.

Fetoscopic release of umbilical cord amniotic band in a human fetus.

Umbilical cord amniotic bands occur in approximately 10% of cases of amniotic band syndrome and are a well-known cause of fetal death. An unexpected amniotic band encircling the umbilical cord was diagnosed during a fetoscopic procedure to release a leg constriction. Both bands were released fetoscopically using a YAG laser. We report the first case of an amniotic band involving the umbilical cord diagnosed and released prenatally.

Extremity amniotic band syndrome in fetal lamb. I: An experimental model of limb amputation.

OBJECTIVE: The objective of the study was to reproduce severe forms of extremity amniotic bands, which result in amputation or severe lesions. STUDY DESIGN: Right limbs of 5 60-day gestational age pregnant sheep were ligated with silk suture at the infracondylar level. Left limbs were used for paired comparison. The limbs obtained from term fetuses were analyzed morphologically, radiologically, and histologically. RESULTS: The ligated limbs showed an amputation or quasiamputation. Four extremities showed a necrotic pattern and 4 an edema pattern. CONCLUSION: A model of severe extremity amniotic bands that reproduces the effect of the extremity amniotic bands in the human fetus was developed. Future applications of this new model could be an experimental study of in utero salvage of limbs affected with severe extremity amniotic bands in the ovine fetus.

Clinical anatomy of the arterial supply of the human patellar ligament.

The arterial supply of the human patellar ligament has been systematized on 20 knee joints. After intravascular injection of colored natural latex, the blood supply to the extensor apparatus of the knee was studied by anatomical dissection and tissue transparentation techniques. Three arterial pedicles (superior, middle and inferior) were observed placed on each side of the patellar ligament. Medial pedicles had their origin from the descending and the inferior medial genicular arteries. The lateral pedicles took their origin from the lateral genicular arteries and the recurrent tibial anterior artery. Two main vascular arches anastomosed with these pedicles: the retropatellar and the supratubercular. Both arterial pedicles and anastomotic arches gave rise to a peritendinous network, characterized by a high vascular density next to poles of the patellar ligament. Only the anastomotic arches gave rise to collateral vessels that pierced the tendon, which revealed two vascular segments in the arterial supply of the patellar ligament (bipolar pattern). The upper segment was supplied by deep vessels from the retropatellar arch, whereas the inferior segment received superficial vessels from collaterals of the supratubercular arch. These intratendinous vessels anastomosed in the middle third of the patellar ligament.

Congenital tibial aplasia with preaxial polydactyly. A case report.

An anatomical study of a left lower limb with congenital tibial aplasia and preaxial polydactyly amputated at 10 months of age was carried out. The tibia was replaced by a fibrous band (a band of connective tissue) and there were four cuneiforms, six metatarsal bones and seven toes. The second metatarsal bone showed characteristics of the hallux. An intermuscular septum which showed an orifice for the anterior tibial artery was found on the medial side of the leg and foot. All the muscles of the leg and foot were present except for the tibialis posterior muscle, which was replaced by two atypical muscles. No muscular attachments reached the fibrous band. Several intertendinous connection bands were found. Also, an accessory muscular belly split from the tibialis anterior tendon and attached to the common flexor tendinous sheet of the foot. An unusual motor branch of the deep peroneal nerve ran together with this belly to supply the intrinsic muscles of the hallux. We also observed other minor anomalies of the nerve pattern. The arterial pattern was complete, except for some arteries which showed both an anomalous origin and course. The findings of this study suggest that the development of the skeletal elements plays an important role in the differentiation of the muscles, tendons, arteries and nerves. We postulate that a dysmorphogenic event involving the development of the tibial field of the limb could give rise to both defective histodifferentiation of the tibia and defective programmed cell death in the pre-hallucial anlage. These anomalies would determine secondary adaptations of muscles, tendons, vessels and nerves of the limb.