Premature epiphyseal growth plate arrest after isotretinoin therapy for high-risk neuroblastoma: A case series and review of the literature.

BACKGROUND: Vitamin A-derived retinoids have been reported to cause skeletal abnormalities ranging from hypercalcemia to premature epiphyseal closure. Isotretinoin is a retinoid used as standard therapy for high-risk neuroblastoma and has been reported to cause premature epiphyseal growth plate arrest. PROCEDURE: We identified patients from the Children's Hospital Los Angeles (CHLA) database with high-risk neuroblastoma diagnosed from 1991 to 2018 who experienced premature epiphyseal growth plate arrest and compared their characteristics to other patients with high-risk neuroblastoma. We then performed a literature review of this complication. Data collection included diagnosis age of neuroblastoma, presentation age, agent of exposure, dose, exposure range, and skeletal deformity. RESULTS: Among 216 patients, high-risk neuroblastoma was diagnosed before age of five years (n = 165), between ages of 5 and 10 years (n = 41), and after 10 years of age (n = 13). Three out of 216 patients developed premature epiphyseal growth arrest after isotretinoin exposure (overall incidence = 1.38%). The incidence of bony abnormalities was significantly higher in patients diagnosed in 5- to 10-year age group than in other two groups (P = 0.014). Literature review identified eight additional patients with neuroblastoma who presented with retinoid associated skeletal abnormalities. The median range of isotretinoin exposure for these 11 patients was between 6.5 and 7.625 years (range, 2-14) with no cases of isotretinoin therapy completion before age 5 years. CONCLUSION: Bone toxicity associated with isotretinoin exposure is a concern. Growth plate arrest is a serious adverse effect that is attributable to isotretinoin therapy. Our findings suggest the prepubescent growth plate may be most at risk, and we recommend special attention to this population.

The Outcome of Surgical Treatment of Multidirectionally Unstable (Type IV) Pediatric Supracondylar Humerus Fractures.

BACKGROUND: The outcome of multidirectionally unstable (type IV) supracondylar humerus fractures (SCHF) has been rarely described. We aimed to describe several aspects related to the diagnosis, treatment, and outcome of this complex injury. METHODS: We analyzed the clinical and radiographic data on 130 completely displaced SCHF in children, which was collected prospectively over a 6-year period (2007 to 2013), as part of an IRB-approved study. A minimum follow-up of 6 weeks was required. We compared the outcome of type IV SCHF (n=12, group 1) with that of type III SCHF (n=118, group 2) by assessing the need for open reduction, length of operative time, recovery of range of motion (as compared with the normal, contralateral side), and rate of complications. RESULTS: An open reduction was required in 17% and 2% of fractures in groups 1 and 2, respectively (P=0.04). A medial pin was added to supplement the fixation in 42% and 17% of fractures in groups 1 and 2, respectively (P=0.05). An acceptable reduction was obtained in all fractures. Surgery was longer for fractures in group 1, by a mean of 22 minutes (P=0.0001). No patient in either group required a reoperation. There was no significant difference between groups with respect to the latest range of motion of the treated side, as compared with the normal contralateral side (98% vs. 97%, respectively, P=0.4). Satisfactory outcomes were found in 92% and 98% of patients in groups 1 and 2, respectively (P=0.6). CONCLUSIONS: The results of this study suggest that a satisfactory outcome can be expected when treating type IV SCHF in a child. Although these fractures are associated with increased levels of technical difficulty, given the increased need for open reduction, utilization of medial pins, and longer surgical times, adequate reductions and satisfactory mid-term to long-term outcomes can be achieved. LEVEL OF EVIDENCE: Level II.

Elbow dislocation with an associated lateral condyle fracture of the humerus: a rare occurrence in the pediatric population.

BACKGROUND: In the pediatric population, reports of a concomitant lateral condyle fracture (LCF) of the humerus and an elbow dislocation are rare. METHODS: From 2007 to 2013, we identified a group of 12 children who presented to our institution with a concomitant LCF and an elbow dislocation. This subset of fractures (group 1), all of which were managed surgically, is the subject of the present report. Their outcome was compared with that of all LCFs that were treated surgically at our institution during the study period (group 2, n=179). The length of surgery, recovery of range of motion (ROM), lateral spur formation, and the presence or absence of neurological or vascular complications, pin-tract infection, loss of fixation, and avascular necrosis or nonunion of the lateral condyle were used to describe the outcome of the fracture. RESULTS: A concomitant elbow dislocation and LCF of the humerus was observed in 12 patients with a mean age of 5.5 years (range, 2 to 8), and a mean follow-up of 51 weeks. A posteromedial dislocation of the elbow was observed in most patients. The recovery of ROM appeared to be slower for patients with an associated elbow dislocation, but a full recovery of ROM was obtained in the long term. Lateral spur formation was seen in all fractures in group 1 and only in 72% of fractures in group 2 (P=0.02). A satisfactory outcome was observed in 92% of fractures in group 1 and in 88% of fractures in group 2 (P=0.58). CONCLUSIONS: Concomitant LCF of the humerus and an elbow dislocation are rare. Satisfactory outcomes can be expected when prompt reduction of the elbow dislocation and timely anatomic reduction and fixation of the fracture is obtained. A delayed recovery of elbow motion is common among this population, but a full recovery of ROM can be expected in the long term. LEVEL OF EVIDENCE: Level II-retrospective.