Displaced Distal Fibular Epiphysis in a Child: A Clinical and Radiological Evaluation of a Rare Injury Hidden From the Initial Radiological Examination.

Fractures of the lateral malleolus are common in children. Isolated lesions of the distal fibula physis commonly comprise nondisplaced or minimally displaced fractures. An isolated, completely displaced epiphysiolisthesis of the distal fibula is an extremely rare lesion. This study introduces the case of an 11-year-old boy presenting an extremely rare lesion of an isolated, completely displaced distal fibular epiphysis that was difficult to diagnose on X-ray. Initial radiographic examination of the injured ankle showed normal configuration of the tibia and fibula on AP projection, with soft tissue swelling of the lateral malleolus. On the lateral projection, the talus completely covered the distal fibular epiphysis, and particular attention was required to reveal the complete displacement of the distal fibular epiphysis. A CT scan confirmed the diagnosis of an isolated, completely displaced distal fibular epiphysiolisthesis. The patient was treated with a closed reduction and made an uneventful recovery. This report highlights the importance of accurate clinical and radiological assessment of an isolated, completely displaced, distal fibular epiphysiolisthesis.

X-linked hypophosphatemia due to a de novo novel splice-site variant in a 7-year-old girl with scaphocephaly, Chiari syndrome type I and syringomyelia.

X-linked hypophosphatemia (XLH) is a rare X-linked dominant inherited disorder caused by loss-of-function variants in the PHEX gene and characterized by renal phosphate wasting, hypophosphatemia, abnormal vitamin D metabolism, growth retardation and lower limb deformities. We describe a case of XLH-rickets in a 7-year-old girl with scaphocephaly, Chiari syndrome type I and syringomyelia, with a de novo non-canonical splice variant (c.1080-3C > G) in intron 9 of the PHEX gene, that has not been previously described.

Enhancing Meniscal Repair: Investigating the Impact of an Exogenous Fibrin Clot.

This study conducted a comparative analysis of meniscal rupture repair, evaluating outcomes with and without the application of an exogenous fibrin clot to enhance meniscus repair. The research incorporated a relatively large sample size (24 patients) and employed a randomized control group with similar age characteristics and morphological types of meniscal ruptures as the study group. Notably, two postoperative follow-up times, at the third and 12th postoperative months, were utilized, distinguishing this study from related research. In the third postoperative month assessment, the fibrin clot technique demonstrated a significant advantage over simple stapling, as evidenced by markedly improved Tegner Lysholm Knee Scoring Scale (TLKSS) and Modified Cincinnati Rating System Questionnaire (MCRSQ) clinical assessment scores. Subsequent MRI scans at 12 months post-treatment revealed a high rate (91.67%) of complete healing in menisci treated with a fibrin clot, with only 4.17% exhibiting incomplete healing. This study expanded on previous research by including longitudinal ruptures and bucket-handle ruptures in addition to radial ruptures. The findings highlight a notable early improvement (third postoperative month) in the clinical assessment of longitudinal and bucket-handle ruptures treated with a fibrin clot during meniscus repair. This research contributes valuable insights into the efficacy of fibrin clots in enhancing meniscus repair, suggesting positive clinical and radiological outcomes, especially in the early stages postoperatively.

Neonatal Transphyseal Separation of the Distal Humeral Epiphysis: Early Diagnosis and Immediate Treatment with Radiographic Evaluation.

Introduction: Epiphyseal separation of the distal humeral epiphysis is an extremely rare injury. Both clinical and radiological examinations are unclear and delayed diagnosis is reported. The absence of the ossification center of the capitellum complicates the radiological diagnosis and often it is reported as elbow dislocation. Case Report: We are reporting a case of a distal humeral epiphysis separation, diagnosed in the maternity hospital. The neonate had severe discomfort and reduced mobility of the affected arm. We confirmed the diagnosis with the conventional radiological examination, with the medial displacement of the olecranon and the articulation of the radius with the medial humeral condyle. We performed immediate reduction of the lesion and evaluated the restoration of the normal elbow anatomy with the correct articulation of the radius with the lateral humeral condyle. The neonate was followed for a year and there is normal development of the affected elbow. Conclusion: Knowledge of this rare neonatal fracture is essential to diagnose properly the lesion. Plain radiographic evaluation enabled us to diagnose the epiphysiolesthesis. We have treated our neonate with no invasive procedures and the final result was the normal development of the elbow joint.

Concentric Circles: A New Ultrasonographic Sign for the Diagnosis of Normal Infantile Hip Development.

Ultrasound (US) of the infant hip is used to diagnose developmental dysplasia of the hip (DDH). We present a new sonographic sign that describes the periphery of the femoral head and the acetabulum as two concentric circles.During 2008−2019, 3650 infants were referred for diagnosis of DDH. All underwent a clinical and US examination. We recorded the femoral head as the inner circle, within a fixed external circle, which was identified as the acetabulum. We analysed the clinical signs and risk factors. The US sign of two concentric circles was normal in 3522 infants and was classified as normal hip development. The alpha angle was >60° in 3449 (95%) infants. For the remaining 73 (5%) infants, the alpha angle was 50−60° and underwent further follow-up examination until the alpha angle was normalised. In 128 babies (3.5%), we detected the disruption of the concentric circle sign; the femoral head was found outside the acetabulum, which appeared with an upward sloping roof and the alpha angle was <50°. These infants had DDH and received appropriate treatment. Infants with a concentric circle sign and normal alpha angle are normal, whereas those with a disrupted sign are considered as having DDH.

Osteochondritis Lesions of the Ischiopubic Area in Young Adolescents.

Osteochondritis of the ischiopubic area is a rare disease of children that presents with hip pain and limping. Careful examination and appropriate investigations are essential to establish a definite diagnosis. We report a case series of four children, ages 10-14-year-old, with osteochondritis of the ischiopubic area. Plain X-ray examination showed an area of diffuse irregular calcification of the ischium in two of the children, while in the other two there was an asymmetrical enlargement of the ischiopubic synchondrosis. MRI investigation was the most helpful examination. Bone edema was found in all four children. A calcified mass separated from the host ischium was found in the first two children. The cortex was normal, without irregular destruction. Bone edema of both the ischium and pubic alongside the synchondrosis was found in the following two children, with intact cortices and asymmetrical enlargement. Osteochondritis lesions of the ischium and the ischiopubic area have radiological findings similar to several severe diseases. Bone edema on MRI investigation in children must be properly evaluated. Appropriate radiological examination enabled us to confirm the diagnosis of the osteochondritis and to avoid unnecessary procedures. We want to draw attention to the rare diagnosis of osteochondritis of the ischiopubic area, and the clinical significance, as a cause of hip pain and limping in children.

Anatomical Structures Responsible for CTEV Relapse after Ponseti Treatment.

Relapse of deformity after a successful Ponseti treatment remains a problem for the management of clubfoot. An untreated varus heel position and restricted dorsal flexion of the ankle are the main features of recurrences. We analyze the anatomical structures responsible for these recurrences. Materials and methods: During 5 years, 52 children with CTEV (Congenital Talipes Equino Varus) were treated with casts according to the Ponseti method, with a mean number of 7 casts. Closed percutaneous tenotomy was performed in 28 infants. Children were followed monthly and treated with the continuous use of a molded cast. We had 9 children with relapsed clubfeet. During the standing and walking phase, they had a fixed deformity with a varus position of the heel and dorsal flexion of the ankle <10 d. They were surgically treated with the posterolateral approach. Results: In all patients, we found a severe thickening of the paratenon of the Achilles in the medial side, with adhesions with the subcutaneous tissue. The achilles after the previous tenotomy was completely regenerated. The achilles was medially displaced. Conclusions: A severe thickening of the paratenon of the achilles and adhesions with the subcutaneous tissue are anatomical structures in fixed relapsed cases of clubfoot. We treated our patients with an appropriate surgical release.

Impressive Remodeling of the Fractured Femur with Transposition of the Fractured Parts, Treated Conservatively with skin Traction, in a 3-Year-Old Boy.

Introduction: Conservative management of femoral fractures in children in the preschool age is considered as the standard care. In the past years, there is an increase in the number of surgically treated children with IM nails, even in these young ages. Several papers report on the results comparing the final alignment of the fractures but there are no reports on the conservative treatment of a fracture with transposition of the fragments. Case Report: A 3-year-old boy was referred in our hospital with a spiral fracture of his right femur. There was transposition of the fragments, with the proximal part shifted medially and the distal part laterally. We informed the parents for the methods of treatment available for his fracture. After 1 week of hospitalization, the child was transferred home, with skin traction, with supervision of an orthopedic surgeon. The child was regularly evaluated with radiological examination, every 10 days. There was an uneventful healing of the fracture, with normal alignment of the leg and acceptable initial leg length discrepancy (LLD). One year after the fracture, there is an impressive remodeling of the fracture with restoration of the medullary canal and absent LLD. Conclusion: Conservative treatment of spiral fracture in a child younger than 3 years is an effective method. Remodeling in this young age can restore not only deviations on the frontal and sagittal plane but also correct the transposition of the fragments with restoration of the medullary canal.

Solitary Osteochondromas of the Metatarsal and Cuneiform, in an Adolescent.

INTRODUCTION: Solitary osteochondromas are extremely rare in the bones of the foot. In the growing skeleton, few cases affecting the metatarsals and the talus have been reported. At present, there have been no reports of osteochondromas affecting the cuneiforms. CASE REPORT: We report the case of a 13-year-old male patient. He presented with marked prominences in the plantar surface of his left foot and pain while participating in sporting activities. Radiological examination with X-rays, computed tomography (CT) scan, and magnetic resonance imaging revealed two solitary osteochondromas growing from the medial cuneiform and the head of the 1st metatarsal. The patient was treated surgically by excision of the osteochondromas. Histological examination confirmed the diagnosis of osteochondromas. He had an uneventful recovery and returned to his sporting activities. CONCLUSION: Solitary osteochondroma can present in the cuneiform and metatarsal of a growing adolescent. CT scan is useful for the accurate diagnosis and surgical removal of the tumor.

Schwannoma of the lumbar spine, presenting with pain of the knee, like an osteoid osteoma, in a 10-year-old girl.

Localized pain in the absence of local lesion may represent referred pain from the spine, in a child, arising from a benign spinal schwannoma. It can be diagnosed by MRI. Surgical excision of the tumor relieves the symptoms.

Reconstruction of limb deformity occurring after infantile meningococcal infection: a case report.

Introduction: Residual orthopedic deformities after meningococcal infection in infancy, including severe angular deformities and leg length discrepancy (LLD), affect patient quality of life. Case presentation: We report the case of an adolescent female with severe varus deformity and LLD of her right femur. We applied a preconstructed Ilizarov frame and initially corrected the varus deviation with different rates of rod elongation and appropriate hinges. We then completed the correction by performing usual lengthening procedures to address the LLD. Conclusion: Treatment with distraction osteogenesis with the Ilizarov frame enabled the restoration of the anatomical axis and severe LLD of the legs.

Diagnostic approach and arthroscopic treatment of septic arthritis of the knee, in an infant.

A 9-month-old baby presented with sudden inability to stand and unable to move his leg. Clinical examination showed edema and knee effusion. Blood tests and MRI confirmed septic knee arthritis without bone involvement. He was treated with arthroscopic lavage. He had a complete recovery and normal growth.

Bilateral femoral fractures during birth, in a neonate with malformation complex with stiffness.

Fetuses with prenatal diagnosis of reduced mobility and malformation are at increased risk to sustain neonatal femoral fractures. Labor difficulties even after an elective cesarean section may trigger the fractures of the long bones.

Osteoid Osteoma in Children Younger than 3 Years of Age.

We present a case series of four children, younger than 3 years old, with osteoid osteoma of the lower limb. Pain and limping were the main symptoms. With careful clinical examination, we could localize the affected area. Radiological evaluation revealed cortical thickening in 3 children. On MRI examination, we found extensive edema, with normal bony cortices. The central nidus was found in 3 children. CT scan was the most accurate examination which revealed the central nidus with surrounding sclerosis. Bone scans had positive uptake in the affected area. Our patients were treated with an intralesional excision biopsy, with simultaneous radiofrequency ablation in those affected in the femur. Pathological specimens confirmed the diagnosis of osteoid osteoma. There was uneventful recovery of our patients. This case series contributes to the limited description of osteoid osteoma diagnosed and treated in very young children.

Two cases of myositis ossificans in children, after prolonged immobilization.

Myossitis ossificans (MO) is a benign disorder characterized by heterotopic bone formation in skeletal muscle. It is divided in three types, fibrodysplasia ossificans progressive (FOP), myositis ossificans circumscripta or traumatica (MOT) and myositis ossificans without a history of trauma (non traumatic or pseudomalignant MO). Myositis ossificans is extremely rare in children younger than 10 years. We present the clinical and radiological findings of two 5-year-old children with pseudomalignant MO due to prolonged immobilization. Plain x-ray films and CT scan with their characteristic findings of mature bone in the periphery of the lesion with smooth contour and well separated from the bone, enabled us to diagnose the lesion. To the best of our knowledge, no such cases have been reported in the literature.

Melorheostosis in an Adolescent with Limb Length Discrepancy and Management with Epiphysiodesis with Eight Plates.

INTRODUCTION: Melorheostosis is a rare bone dysplasia. It is mainly a radiographic diagnosis with distinct findings of endosteal or periosteal sclerosis along the axis of long bones, resembling the flowing wax. It is usually polyostotic and monomelic. Clinical manifestations are pain, limitation of joint movements, deformities, and contractures. Leg length discrepancy may be found, usually the affected limb being shorter. CASE PRESENTATION: We present an adolescent boy, with melorheostosis of the lower limb. The affected limb was longer with equally divided discrepancy of the femur and tibia. There were no another symptoms. After a thorough investigation, we performed epiphysiodesis both medial and lateral of the distal femoral and proximal tibial growth plate, using8eight plates. At the end of the growth, there was almost complete equalization of the length of his lower limbs. CONCLUSION: Melorheostosis may be present with leg length discrepancy leg length discrepancy, with an exception, being that the affected limb is longer. Epiphysiodesis with eight plates is an effective method of limb length equalization.

A Case Report of Deformity Correction of a Limb with Congenital Distal Tibiofibular Diastasis.

INTRODUCTION: Congenital distal tibiofibular diastasis is an extremely rare disorder. The main feature at presentation is a clubfoot deformity with leg length discrepancy (LLD) due to a short tibia. Limb lengthening and reconstruction techniques today can correct the deformity, ending with a plantigrade and functional limb. CASE REPORT: We report a patient with congenital tibiofibular diastasis, who was initially treated with series of casts and later with ankle arthrodesis, but the deformity and LLDleg length discrepancy remained. We applied an Ilizarov frame and initially corrected the varus and equinus deformity of the foot. Then, we corrected the LLD leg length discrepancy with limb lengthening with distraction osteogenesis. We achieved a plantigrade stable limb, with a small amount of length inequality. CONCLUSION: Congenital distal tibiofibular diastasis can be managed with staged correction and lengthening with the Ilizarov method.

Solitary osteochondroma of the capitate, in a child.

Osteochondromas, are the most common tumors of the long bones in children. Osteochondromas are extremely rare in the carpal bones. They are diagnosed in adult life, in almost all cases in the literature. We report a 7 year old boy, who presented with a hard mass on the dorsum of his hand, with decreased wrist movements. Radiological examination showed a calcified tumor of the second row of the carpal bones, with spherical shape and covered with cartilage. He was surgically treated with removal of a cartilaginous mass that was arising from the capitate. Pathology confirmed the diagnosis of an osteochondroma.

Osteoid osteoma of the acetabulum: diagnosis and medical treatment.

We describe the medical management of an acetabular osteoid osteoma in an 11-year-old girl. There was a 2-year delay until proper diagnosis of the patient's pathology was made. Accurate localization of the nidus in the subchondral bone, involving the cartilage, is difficult on the basis of plain radiographs. All imaging methods, including computed tomography, MRI, and bone scintigraphy, were used to confirm the diagnosis. We proposed medical treatment to avoid possible severe complications from surgical intervention. At the patient's latest follow-up visit, after 2 years of medical treatment with NSAIDs, there is complete healing of the osteoid osteoma and there is no sign of recurrence.