Analysis of the risk of a secondary displacement in conservati- vely treated paediatric distal radius metaphyseal fractures. A multicentric study.

OBJECTIVES: Distal radius fractures represent one of the most fre-quent injuries in children. The treatment of choice is a closed reduction followed by immobilisation in plaster cast; the immediate recourse to osteosynthesis with Kirschner wires is only reserved for certain cases. The displacement rate reported in the literature is 21-39%. The aim of this study is to retrospectively evaluate the risk factors for a secondary displacement of metaphyseal radius fractures in a paediatric population treated in three different centres. MATERIALS AND METHODS: The initial treatment for all 360 patients examined was a closed reduction under general anaesthesia and im-mobilisation in an above elbow cast for 4 weeks. The pre-operative displacement, residual post-reduction displacement and possible di-splacement at 7 and 14 days of follow-up were all assessed clinically and radiographically. RESULTS: A loss of reduction was reported in 102 cases; 51 under-went an additional reduction procedure - some followed by osteo-synthesis - while in the remaining 51 cases, the loss of reduction was acceptable in relation to the expectation of remodelling. The most statistically significant variable for the occurrence of a secondary displacement is a severe primary displacement. The association with the ulna fracture is not significantly correlated. The quality of the plaster cast is important for maintaining the reduction. There are a few things to consider as indicators for a second procedure: age, time elapsed from moment of fracture, fracture site and the absence of an acceptable reduction. CONCLUSIONS: In our experience, a reduction followed by osteo-synthesis with Kirschner wires should be considered the treatment of choice in fractures with a high risk of secondary displacement, namely those with severe initial displacement or unsatisfactory reduction.

Expanding the spectrum of Gorham Stout disease exploring a single center pediatric case series.

Gorham-Stout Disease (GSD), also named vanishing bone disease, is an ultrarare condition characterized by progressive osteolysis with intraosseous lymphatic vessel proliferation and bone cortical loss. So far, about 300 cases have been reported. It may occur at any age but more commonly affects children and young adults. The aim of this study is to retrospectively review our internal patient series and to hypothesize a diagnostic-therapeutic protocol for earlier diagnosis and treatment. Clinical datasets from our center were examined to identify all GSD patients for collection and analysis. We identified 9 pediatric cases and performed a retrospective case-series review to examine and document both diagnosis and treatment. We found that delay in diagnosis after first symptoms played a critical role in determining morbidity and that multidisciplinary care is key for proper diagnosis and treatment. Our study provides additional insight to improve the critical challenge of early diagnosis and highlights a multidisciplinary treatment approach for the most appropriate management of patients with rare GSD disease. Although GSD is an ultrarare disease, physicians should keep in mind the main clinical features since neglected cases may result in potentially fatal complications.

The treatment of femoral fractures in children with cerebral palsy.

OBJECTIVE: The purpose of this study is to retrospectively evaluate a group of children affected by cerebral palsy with a recent femoral fracture, and to analyse the results and complications in relation to the treatment used. MATERIALS AND METHODS: The analysis was performed on 36 children (21 M, 15 F, 8-14 years old) with cerebral palsy (7 diplegia, 28 tetraparesis, 1 hemiplegia) with a metaphyseal or a diaphyseal femoral fracture. The patients were subdivided into two groups according to their Gross Motor Function Classification System (GMFCS) level: level 2-3 (9 patients) and level 4-5 (27 patients), evaluating the presence of complications and malunions for each group at the end of each follow up. RESULTS: The fractures were displaced in 24 patients and nondisplaced in 12 patients. In 26 cases the treatment involved a closed reduction and immobilisation in a long leg hip spica cast for 7 weeks, while in 10 cases the treatment involved an open reduction-internal fixation (ORIF) followed by a 3-week period in a plaster coated fracture bandage. CONCLUSIONS: Taking into consideration the maximum possible recovery of function, an ORIF is preferable to prevent malunion, particularly in distal metaphysis and distal shaft fractures. In the GMFCS level 2-3 patients, surgery has allowed to recover, or at least maintain, the pre-fracture functional level, while in patients with GMFCS level 4-5, it has allowed to reduce the immobilisation times and prevent the development of decubitus lesions.

Assessment and therapeutic choice in septic arthritis of the hip in an intravenous drug abuser: case report at 14 years follow-up and review of literature.

INTRODUCTION: Osteoarticular infections are found frequently in drug addicted individuals, representing one of the main reasons for their hospitalization. Through inoculation, the pathogenic agents can enter the individual's system directly through the skin or parenterally, transmitted, that is, through syringes and other objects used during such practice. In these particular conditions, or when the medical history is vague, a warranted suspicion and the execution of targeted research can help in the diagnosis of high-risk patients such as addicts. DISCUSSION: With this paper, the Authors are presenting a case of septic arthritis in the hip joint, in a drug addicted patient with the habit of injecting narcotics into the femoral vein, in correspondence of the anatomical region known as the triangle of Scarpa. Following an examination of the bacterial culture samples taken by arthrocentesis, the S. Aureus infection was identified and a targeted antibiotic therapy (coxacillin and aminoglycosides) was prescribed. After one year, with clinical examination and medical scans resulting negative for infection, there was a remaining deformity of the femoral head and, therefore, a total hip arthroplasty (THA) was performed. The 14 year post-operative clinical examination and medical scan check-up showed a complete articular functionality and recovery of normal daily and work related activities.

Apophyseal and epiphyseal knee injuries in the adolescent athlete.

OBJECTIVES: In the context of pediatric sports injuries, the epiphyseal and apophyseal knee fractures represent rather peculiar lesions. The most frequently involved anatomical area is the knee. The peculiar function of the physis and the need to preserve their integrity, makes choosing what treatment methods to employ very important. Objective of this study is to assess the kind and the effectiveness of the most suitable treatment in the apophyseal and epiphyseal knee lesions occurring in the adolescents. MATERIALS AND METHODS: From 2006 to 2011, were treated 41 patients (34 M-7 F) between the ages of 10 and 15, with a diagnosis of traumatic knee injury caused by sports activities. Traumatic physeal fractures of the distal femur, the proximal tibia and its anterior tuberosity and the avulsion of the intercondylar eminence were the lesions that occurred most frequently. The treatment belonged to the type of lesion: closed reduction or percutaneous fixation with K-wires/ screws and a femoral-podalic plaster cast, ORIF with K-wires/screws, arthroscopic reduction and internal fixation using absorbable screws. All the patients were given the POSNA questionnaire at the end of the follow up. RESULTS: The follow up was on average 5 years (4-10 years). We considered as excellent the results obtained in 26 patients, as fair in 12 patients, in 1 case the result obtained was considered as poor. 2 caseswere lost during follow up. The average POSNA score at the end of the follow-up was 98.51. Any early complications recorded were the following: in 1 case infection of the K-wires 32 days after pinning and a reported compression of the popliteal neurovascular bundle, due to a displaced tibial physeal fracture. CONCLUSIONS: Since sport during childhood and adolescence is now practiced more and more frequently, also at a competitive level, thesekinds of fractures in children between the ages of 10 and 15 have been occurring more often, especially in male patients. Sports traumatology of the knee in this age group is characterized by a typology of injuries that are very particular. The knowledge of the anatomy and physiology of children, with an appropriate diagnostic assessment, is essential to identify the most appropriate treatment options for each specific injury. As the nucleus of proximal tibial growth plate progressively closes from posterior to medial side, in patients between 11 and 13 years of age with an apophyseal displacement of the tibial tuberosity, you should always perform a CT exam, to exclude an intra-articular physeal fracture.

Can early diagnosis and partial meniscectomy improve quality of life in patients with lateral discoid meniscus?

OBJECTIVES: To evaluate clinical and radiographic mid-term outcomes and improvement in quality of life in pediatric patients affected by LDM and who underwent partial or total/subtotal meniscectomy. MATERIALS AND METHODS: 28 patients (12 M, 16 F), mean age 8.3 years old (range: 6-13) affected by LDM with symptoms and/or meniscal tears, mean follow up: 2 years and 4 months (range: 24-52 months). Symptoms included: pain, swelling, articular block, limitation to knee extention, meniscal instability and formation of meniscal cysts. 23 patients treated with partial meniscectomy, 5 by total/subtotal meniscectomy. All of them have been clinically evaluated using the Ikeuchi scale and the POSNA questionnaire; for radiological evaluation we used the Tapper-Hoover grading scale. RESULTS: Ikeuchi: In 23 patients underwent partial meniscectomy: 21 excellent and 2 good; in 5 patients underwent total/subtotal meniscectomy: 1 excellent, 2 good and 2 average. POSNA presurgical mean score: partial meniscectomy: 70 (range 66.8-73.6), total/subtotal meniscectomy: 58.7 (56.9-62.2). POSNA presurgical mean score: partial meniscectomy: 92.4 (range 88.7-98), total/subtotal meniscectomy: 81.2 (range 78.3-85.6). Tapper-Hoover: in 23 patients underwent partial meniscectomy: 17 were classified grade I, 5 grade II, 1 grade III; in 5 patients underwent total/subtotal meniscectomy: 2 were classified grade II and 3 grade III. These ones evidenced further signs of chondromalacia on articular surfaces, in the lateral area of knee joint. DISCUSSION: Significant improvement in quality of life, evidenced in all patients (p = 0.048 in those underwent total/subtotal meniscectomy, p = 0.011 in those underwent partial meniscectomy), but especially in patients who underwent partial meniscectomy with absence of meniscal tears (p = 0.033), supports how important can be early diagnosis of LDM in childhood. We assert that early diagnosis and conservative treatment (partial meniscectomy) could reduce risks in development of chondromalacia, in those patients affected by LDM, because of its association with better clinical, radiographic and in quality of life mid-term results.

Anatomy of the lumbar spine in achondroplasia.

The authors analyze the achondroplastic lumbar spine in the pre-puberal and post-puberal periods until adulthood by means of standard X-rays, CT scan, MRI, and myelography. The small spinal canal in achondroplasts must be considered the result of developmental and congenital conditions. Orthopaedic and surgical possibilities are reviewed with the goal of reducing to a minimum the developmental factors.