Soft-tissue necrosis complicating tibial osteotomy in a child with Proteus syndrome.

INTRODUCTION: Proteus syndrome is a rare congenital hamartomatous disease frequently responsible for musculoskeletal deformities. The results and complications of surgical treatment are not well documented owing to the scarcity of reported cases. CASE REPORT: The authors report a case of poor evolution of valgus proximal tibial osteotomy in a 6-year-old girl with Proteus syndrome. The surgery was complicated by extensive deep wound necrosis exposing the tibial bone, necessitating surgical excision, antibiotherapy and controlled wound healing. At 1 year postoperatively, the deformity recurred. DISCUSSION: The possibility of serious wound complications and of recurrence must be kept in mind when operating on a limb deformity in patients with Proteus syndrome. Potential complications should be taken into account in selecting the surgical correction technique: epiphysiodesis may be preferable to osteotomy.

[Hematogenous osteomyelitis of the calcaneus in children: 26 cases]. / L'ostéomyélite hématogène du calcanéum chez l'enfant: à propos de 26 cas.

PURPOSE OF THE STUDY: Osteomyelitis is rarely observed in the calcaneus; about 3 to 10% of the bone infections in children. The diagnosis is often established late because of the less pronounced symptoms in long-bone localizations. We report a series of 26 cases of osteomyelitis of the calcaneus observed in children. MATERIAL AND METHODS: We studied the clinical history, the diagnostic process and the treatments delivered. Outcomes were assessed in terms of complications, anatomy and function at mean two years follow-up (range one to seven years). RESULTS: There were 15 boys and 11 girls, mean age was seven years (range one month to 13 years). Mean time from symptom onset to consultation was 13 days and mean time from consultation to hospital admission was four days, range one to 29 days. The clinical presentation was not specific. Body temperature was not above 38.5 degrees C in 45% of patients. Symptoms were fever, pain in the rear foot and functional impotency of the lower limb. Eight patients (30%) complained of moderate pain, 18 (70%) of intense pain. The pain was focused far from the calcaneus in six patients, retarding the diagnosis. Laboratory tests did not always reveal signs of inflammation. White cell counts above 10,000 were noted in only 61% of patients. The diagnosis of osteomyelitis of the calcaneus was based on: the plain X-ray, which revealed a defect in the calcaneus (n=12), ultrasound (performed in 19 patients) which revealed calcaneal subperiosteal detachment (n=6), collections in the rear foot (n=3) and soft-tissue thickening (n=4). Bone scintigraphy was performed in one child and showed intense uptake in the calcaneus. Magnetic resonance imaging, performed in one patient, demonstrated an anomalous signal in the calcaneus (high-intensity T(2) and low-intensity T(1) with presence of a subperiosteal abscess). Bacteriology was positive in 53% of the children. Medical treatment was delivered for all patients and 23 underwent a surgical procedure. For one of the three patients treated medically, the diagnosis of osteomyelitis of the calcaneus was clinical, since the plain X-ray was normal, the ultrasound yielded no evidence of abscess formation and the bacteriology was negative; but after two months of antibiotic treatment, bone remodelling was in favour of osteomyelitis of the calcaneus. For the two other patients treated medically, the plain X-ray showed a defect in the calcaneus, which had filled after two months of antibiotics. For the 23 patients treated surgically, the procedure was an evacuation of a subperiosteal abscess for 13 (n=6 nonruptured and 7 ruptured). Surgery revealed a bone lesion in nine children allowing curettage of the defect. Articular involvement was noted in eight cases: subtalar osteoarthritis (n=6) and tibiotarsal arthritis (n=2). Two surgical explorations failed to find any abscess formation; blood cultures confirmed the diagnosis and enabled isolation of the causal germ. Outcome was assessed with a mean follow-up of two years, range one to seven years. Nineteen patients (73%) were free of sequelae. Seven patients (27%) presented poor outcome with significant limitation of motion in the rear foot and ankle ankylosis. Seven patients developed chronic fistules, with persistent discharge at last follow-up. The poor results were observed in patients treated late with mean 17 days before consultation. Six of the seven cases of poor outcome were associated with arthritis involving a calcaneal joint (subtalar and tibiotarsal in two patients and subtalar in four). DISCUSSION: The same pathophysiological phenomenon as observed in long-bone localizations is noted for osteomyelitis of the calcaneus; the calcaneus has an apophysis, which is equivalent to the metaphyseal region of long bones, leading to the bone's vulnerability to hematogenous infection. Late diagnosis can be related to the notion of trauma, the manifestations of osteomyelitis being attributed to ligament injury. The positive diagnosis of osteomyelitis of the calcaneus is often established late because of late consultation (13 days in our series) or the minimal expression of general signs. Magnetic resonance imaging contributes significantly to diagnosis by showing an abnormal bone signal; it can also disclose associated abscess formation. Authors differ in their descriptions of the complications. The analysis of our results shows that the prognosis of osteomyelitis of the calcaneus is related to early diagnosis and management. Associated septic arthritis is an element of poor prognosis.

[Acute hematogenous osteomyelitis of the obturator rim in seven children]. / L'ostéomyélite aiguë hématogène du pourtour du foramen obturé chez l'enfant : à propos de sept cas.

PURPOSE OF THE STUDY: Acute osteomyelitis of the rim of the obturator foramen is rarely reported. The clinical presentation is atypical, making diagnosis a difficult task. We report a series of seven cases of osteomyelitis of the obturator rim which illustrate the different features of this localization. MATERIAL AND METHODS: The series included seven boys with osteomyelitis involving the obturator foramen. We reviewed the clinical history, the diagnostic approach and management. Complications and anatomic outcome were noted at mean three years follow-up (range one to 10 years). RESULTS: Mean age was 9.5 years (five to 12 years). Bilateral involvement was noted in one boy. Mean time from symptom onset to consultation was five days and mean time from consultation to hospitalization was eight days. No specific clinical presentation could be identified. Fever was not a constant feature. Mean body temperature was 38.6 degrees C and was not greater than 38.5 degrees C in four children. Symptoms were limited to hip pain in five cases and abdominopelvic pain was noted in two. Physical examination failed to trigger exquisite ischial or pubic pain in two patients. The osteomyelitis involved the ischiopubic ramus in four cases, the ischium in two with one bilateral case, and the pubis in one. Certain diagnosis was established as follows: MRI findings plus isolation of the pathogenic agent (n=4) ; the plain x-ray showed a defect in the ischiopubic ramus, MRI showed signs favoring osteomyelitis of the ischiopubic ramus and surgery evacuated a purulent collection (n=1) ; strong uptake of the obturator rim on scintigraphy (n=2). Medical treatment was given in all cases and surgery was performed in six patients. Outcome was noted at three years follow-up, range one to 10 years. All patients recovered normal function. There were no complications. DISCUSSION: Hematogenous osteomyelitis of the pelvis is exceptional (2-11 % of cases of osteomyelitis). Localization in the obturator rim is rare. We discuss the specific diagnostic and therapeutic features of this localization. Despite the controversy concerning the treatment of pelvic osteomyelitis and in particular cases involving the obturator rim, prognosis is generally good. No complications have been described in the literature specifically associated with osteomyelitis of the obturator rim.

[Acute hematogenous osteomyelitis of the neck of the femur in children: 28 cases]. / L'ostéomyélite aiguë hématogène du col du fémur chez l'enfant : à propos de 28 cas.

PURPOSE OF THE STUDY: Osteomyelitis of the neck of the femur is uncommon, often with a misleading clinical presentation. We report a series of 28 cases of osteomyelitis of the femoral neck to illustrate the particular clinical and imaging findings related to this localization. MATERIAL AND METHODS: This was a series of 28 children treated in our unit from 1990 through 2004: 17 boys and 11 girls, mean age eight years (range one month to 14 years). We analyzed the data in this series using a standard checklist, which noted the diagnostic and therapeutic measures. Results were analyzed by studying the complications, anatomic and functional outcome at mean follow-up of 3.5 years. RESULTS: Time from symptom onset to consultation was five days on average with a delay of 4.5 days from consultation to hospitalization. Intense pain was noted for eight patients (28%) and total functional incapacity of the limb was noted for 15 (53%). Hip stiffness was observed in 11 patients (39%). The diagnosis of osteomyelitis of the femoral neck was established on the basis of imaging (MRI or scintigraphy) in three patients with bacteriological proof in two, of operative findings which confirmed the neck localization in 19, and on changes in the X-ray image of the neck in six. A positive bacteriology was noted in 71%. The germ was isolated from blood cultures and local samples obtained by arthrotomy in five patients (same germ), only in blood cultures for four, and only in local samples in 11. Met-S Staphylococcus aureus was isolated in 18 patients, Met-R S. aureus in one and a Streptococcus in one. All patients were given medical treatment and 25 underwent surgery. There were five thromboembolic complications and five patients who developed femoral pandiaphysitis. Results were analyzed at mean 3.5 years (range four months to 14 years). Complete hip motion was recovered in 78%. There were four cases of hip stiffness and two cases of ankylosis. Partial cephalic necrosis was noted in two hips and total necrosis of the head and neck in two. DISCUSSION: Little data is available in the literature on isolated osteomyelitis of the femoral neck. Based on the pathogenic mechanisms known for osteomyelitis, an isolated localization in the neck of the femur, with no other site in the hip joint, is quite possible in an early stage of infection. We discuss the specific clinical and imaging features of this localization. Analysis of our findings show that the prognosis of femoral neck osteomyelitis is directly related to time to management. Outcome is poorer when treatment is started late. Prognosis is poor if pandiaphysitis develops.

[Preliminary results of surgical treatment of developmental dislocation of the hip in older children]. / Résultats préliminaires du traitement chirurgical de la luxation congénitale de la hanche après l'age de 5 ans: a propos de 26 hanches.

Reduction of developmental dislocation of the hip is difficult to achieve in children after walking age and particularly in older children. In fact, at this age the important retraction of the muscles around the hip associated with a marked acetabular dysplasia and elongation of the joint capsule explain the difficulty and instability of reduction and the frequency of complications. In this study we reviewed retrospectively the clinical and radiological results of 26 developmental dislocations of the hip treated by open reduction, pelvic osteotomy and femoral shortening in 21 children aged more than 5 years. Age at surgery ranged from 5 to 11 years (mean 7.5 years) with a follow-up of 1 to 8 years (mean 2 years 7 months). According to the clinical classification of MC Kay, 17 hips had a good result while 9 hips had a fair or poor result. According to the Severin classification system 18 hips had an excellent and good radiological result. Ten hips developed an avascular necrosis of the femoral head following the reduction.

[Febrile osseous pain in children with sickle cell disease: MRI findings]. / Douleurs osseuses fébriles chez l'enfant drépanocytaire: apport de l'IRM.

PURPOSE: The aim of this study was to report the MRI findings that can suggest a vaso-occlusive crisis in cases of febrile osseous pain in children suffering from sickle cell disease. MATERIALS AND METHODS: MRI (T1 and T2 weighted sequences and T1 weighted sequence with fat saturation before and after gadolinium injection) was performed in 10 children with sickle cell disease, presenting with febrile osseous pain. The diagnosis of vaso-occlusive crisis was made after fast improvement due to symptomatic treatment and negative bacteriological result. RESULTS: MRI was abnormal in all cases. A multifocal localisation was found in 2 cases. Bone marrow abnormalities were constant. In 10 cases, high T1 and T2 signal and metaphyso-diaphysial lesions were noted. Heterogeneous medullar enhancement with "ink stain" feature was constant. Early periosteal abnormalities were noted in 8 cases with inflammatory or stratified features. Cortical thinning was found in 1 case. Soft tissue abnormalities were observed in 5 cases with inflammatory features in 4. CONCLUSION: Multifocal synchronous localisation, medullar abnormalities resulting from hemoglobin degradation, heterogeneous enhancement, early periosteal abnormalities and associated soft tissues swelling are MRI findings suggesting acute vaso-occlusive disease.

[Acute osteomyelitis in children: early MRI diagnosis]. / Douleurs osseuses fébriles chez l'enfant: apport de l'IRM.

PURPOSE: To assess the value of MRI for early diagnosis of osteomyelitis in children presenting with sepsis and acute onset of musculoskeletal pain. MATERIALS AND METHODS: MRI including fat suppressed T2W, and fat suppressed pre- and postcontrast T1W sequences was performed within 48 hours of admission in 26 children with clinical (fever and acute musculoskeletal pain) and biological (elevated WBC count and ESR in all cases, and elevated CRP in 12 patients) suspicion of acute osteomyelitis. None of the patients had sickle cell disease. RESULTS: MRI was normal in 7 children (26%). Bone marrow signal abnormality was noted in 19 cases (74%) consistent with acute osteomyelitis in 18 cases and metastatic neuroblastoma in 1 case. CONCLUSION: MRI is useful for evaluation of children presenting with sepsis and acute musculoskeletal pain, early diagnosis of osteomyelitis and to prevent unnecessary hospital admission and work-up.

[Tuberculosis of the knee: MRI findings in two pediatric cases]. / Tuberculose ostéo-articulaire du genou: aspects IRM de deux cas pédiatriques.

Osteo-articular tuberculosis is rare in infants. The MRI findings reported for adolescents and young adults mainly relate to spinal involvement. Two cases of osteo-articular tuberculosis of infants located at the knee are presented. Vaccination has been correctly done. Skin test and chest radiography were normal. Evolution was insidious for one case. Osseous, medullary, cartilaginous and soft tissue abnormalities revealed by MRI were suspicious for tuberculosis. Diagnosis was confirmed at histology for both cases and bacteriology for one case. The aim of this study is to report the MRI features of osteo-articular tuberculosis in pediatric patients.

Combined fracture of the distal radius and scaphoid in children. Report of 2 cases.

The authors report 2 cases of concomitant scaphoid and distal radial fractures, a rare combination of lesions in children. The first case was in a 13-year-old boy who presented a transverse midscaphoid fracture associated with a Salter type II distal radial fracture. The second concerned a 10-year-old boy who presented a bilateral wrist injury. On the left side, a distal forearm fracture with anterior displacement was associated with a transverse midscaphoid fracture. On the right side, there was only a distal forearm fracture. Scaphoid fracture associated with distal radial fracture seems to have been more frequently reported in the literature during the last decade, probably because it is more frequently recognised. In fact, children with distal forearm injury should be well examined both clinically and radiologically in order to search for an associated scaphoid fracture. Reduction of the radius fracture should be done carefully to avoid possible displacement of the scaphoid fracture.

[Brachial plexus paralysis of infectious origin: report of four cases]. / Paralysie du plexus brachial d'origine infectieuse: à propos de quatre cas.

BACKGROUND: Brachial plexus palsy (BPP) may occur after septic osteoarthritis of the shoulder. BPP is a rare, well recognized complication. The pathophysiology is thought to be either ischemic nerve damage secondary to occlusion of vasa nervorum or extrinsic compression. Early diagnosis and treatment of the infection are needed. CASE REPORTS: We report the cases of three infants aged less than three months and one six-day-old newborn infant who presented with an authentic BPP due to an osteoarthritis of the shoulder. The diagnosis of osteoarthritis relied on clinical, biological and radiological signs. In one case, the causal germ (Enterobacter) was isolated. The diagnosis of the palsy was based on clinical signs. EMG performed on one patient, showed signs of abnormal motor pattern. Following intravenous antibiotics and percutaneous drainage, all infants completely recovered.

[Unusual radiologic signs of bone echinococcosis in children]. / Signes radiologiques inhabituels de l'échinococcose osseuse chez l'enfant.

The authors report 2 cases of 2 children aging 11 and 12-years-old presenting hydatitosis in the upper extremity of 2 long bones femur and tibia. In 2 cases, radiological appearances were atypical. In the femur, plain radiographs revealed multiple lucencies, irregular, located in the superior extremity with a periostal reaction. The CT scan confirmed these data and showed a cortical rupture, extension to soft tissue with contrast enhancement. In the tibia, plain radiographys showed delimitated lucencies, confluent with a rim condensation in the proximal epiphyseal-metaphyseal area. Echography and CT are helpful when radiological appearances are unusual.