Solid aneurysmal bone cyst on the cervical spine of a young child.

INTRODUCTION: Solid aneurysmal bone cyst (S-ABC) is a variant of aneurysmal bone cyst (ABC), an uncommon benign bone tumor. There are few cases described in the cervical spine in kids up today. We treated a recurrent case with neurological involvement that needed multiple surgical procedures and radiotherapy. CASE PRESENTATION: We report a case of C4 located S-ABC concerning a 2-year-old boy treated surgically by anterior and posterior approach. Three months after the initial procedure appearance of a tetraparesis led to diagnose a local recurrence treated by sclerotherapy and a second surgery. The patient had a full neurological recovery. Three months later, a follow-up CT scan showed a second recurrence requiring a new surgical revision by anterior approach and radiotherapy. OUTCOME: At 6-year follow-up after four surgical procedures, sclerotherapy and radiotherapy, the aneurysmal bone cyst has been healed. Patient had neurological impairment after a local recurrence but had full recovered after final revision surgery.

Distal humerus lateral condyle fracture in children: when is the conservative treatment a valid option?

INTRODUCTION: Distal humerus condyle fracture in children is rare. These fractures often mislead the emergency physician or surgeon. However, treatment adapted to the degree of displacement achieves excellent clinical and radiographic results. The objective of this study was to clarify indications for conservative treatment of lateral humeral condyle fracture in children. MATERIALS AND METHODS: Twenty-two children who had sustained lateral humeral condyle fracture between January 2007 and January 2010 were reviewed in April 2010. At this consultation, the children underwent clinical and radiological examination. The Hardacre functional score was used to determine objective clinical outcome. RESULTS: Conservative treatment was exclusive to cases of lateral condyle displacement equal to or less than 1mm. All other fractures were managed by surgical open reduction and fixation using cross-pinning. There was no statistically significant difference in clinical or radiological outcome between conservative and surgical management. DISCUSSION: Lateral humeral condyle fracture is difficult to diagnose in children. The majority of poor results reported in literature relate to inadequate initial treatment. Given a radiological aspect of hemarthrosis of the elbow, the emergency physician prescribes multiple X-ray views of the affected elbow (anteroposterior, lateral and internal oblique). The clinical aspect of lateral humeral condyle fracture is often characteristic (ecchymosis facing the head of the radius). Nondisplaced or minimally displaced lateral humeral condyle fracture can be managed conservatively under close survey. However, secondary displacement under the cast is often difficult or impossible to detect, and outpatient surgery is therefore being increasingly indicated in our department.

[Torticollis in children: diagnostic approach]. / Le torticolis de l'enfant: démarche diagnostique.

Torticollis is an abnormal head posture. Clinical presentation includes ipsilateral tilt and controlateral rotation, and translation. Aetiologies are various including muscular entities, traumatic, inflammatory, infectious, tumour and non-muscular entities ocular, ORL or digestive. Majorities are minor and generally, a complete physical examination is sufficient to eliminate serious entities. Concretely, it is important to separate acute and chronic form. Traumatic torticollis justifies a systematic standard radiograph and then 15 days after dynamic evaluation. Septic torticollis evokes otolaryngological infection or spondylodiscitis. Chronic torticollis is congenital, postural or malformative. In case of recurrent form or torticollis with neurological abnormalities, TDM or RMI are necessary to eliminate tumoral diseases.

Influence of propofol concentrations on multipulse transcranial motor evoked potentials.

BACKGROUND: Motor evoked potentials can be affected by propofol anaesthesia. We studied how increasing target concentrations of propofol altered transcranial motor evoked potentials (tcMEP) during scoliosis surgery. METHODS: Fifteen patients undergoing surgery for scoliosis were anaesthetized with remifentanil and propofol without nitrous oxide or neuromuscular blocking agents (BIS<60). tcMEP were elicited by transcranial electric multipulse stimulation of the motor cortex and recording of compound action potentials from the anterior tibialis muscle. tcMEP were obtained before surgery with propofol target values set from 4 to 8 mg litre(-1), and then during surgery. Arterial propofol concentrations were measured for each tcMEP recording. RESULTS: Before surgery, increasing propofol reduced tcMEP amplitude in a dose-dependent manner, with no effect on latency. During surgery, at equivalent propofol concentrations, tcMEP were not statistically different from those obtained before surgery. In all except one patient, tcMEP signals were present during the entire procedure. In this patient the loss of tcMEP was unfortunately related to an anterior spinal cord lesion, which was confirmed by a wake-up test. CONCLUSION: We found that, although propofol had a dose-dependent effect on tcMEP amplitude, anaesthesia could be maintained with remifentanil and propofol to allow recording and interpretation of tcMEP signals.

[Value of orthopedic treatment of distal fractures of the forearm in children. Apropos of 152 cases]. / Place du traitement orthopédique dans les fractures du quart inférieur des deux os de l'avant-bras chez l'enfant. A propos de 152 cas.

PURPOSE OF THE STUDY: Distal forearm fractures in children are frequent. Management is conservative except in rare cases which will be discussed. MATERIAL AND METHODS: Retrospective analysis of 152 distal forearm fractures after 10 and a half months (6 to 48 months) of follow-up was carried-out. Age ranged from 2 to 16 years (mean 10 years). Orthopaedic treatment was proposed in each case, but in 5, surgical treatment was required at onset. Clinical and radiological fracture reduction analysis was conducted immediately post op and during follow-up. 92 per cent of these fractures had a posterior or posterolateral angulation (with a mean angulation of 28 degrees 5). Among these cases, 64 per cent had instability criteria. Degree of translation when present (79 cases) was at 100 per cent in 55 cases (70 per cent); greater than 50 per cent in 11 cases (14 per cent) and less than 50 per cent in 13 cases (16 per cent). In 12 cases (8 per cent), the displacement was anterior with a degree of translation greater than 50 per cent in 6 cases and an angulation always greater than 30 degrees in the 6 remaining cases. RESULTS: In 5 cases, surgical treatment was necessary due to initial instability and/or irreducibility. In 147 cases, analysis of instability criteria, reduction and cast quality, and of fracture location showed displacements in cases of non-adapted and incorrect X-ray work up (6 cases of 6); in 18 cases of 24 when the cast was adapted but with incorrect X-ray work-up; in 5 cases of 10 when the cast was non-adapted with correct X-ray work-up, in 3 cases of 7 when the fracture was superiorly located; and in 6 cases of 6 when cast was prematurely opened. DISCUSSION: Close reduction is possible for fractures with large displacement but must be done perfectly and the cast must be adapted. If instability, irreducibility and/or incorrect reduction exist, management must include posterolateral and intrafocal percutaneous pinning, especially in older children. While rare, this indication must be known.

Monitoring of the motor pathway during spinal surgery.

Paraplegia caused by irreversible lesions of the spinal cord is one of the major possible complications after scoliosis surgery. Several monitoring methods have been proposed but none are completely satisfactory. Since 1986 the authors assessed motor pathways during scoliosis surgery, using electrical stimulation of the motor cortex and lower limb muscle recordings (tibialis anterior muscle). Twenty-seven patients were included in this study: 25 with idiopathic scoliosis and 2 with dorsal kyphosis. Recordings in anesthetized patients with hypothermia were performed before and after spinal derotation during the surgical procedure. Magnetic cortical stimulation was carried out in ten awake patients before and after surgery. Reproducible responses were obtained in 22 patients under anesthesia. In eight patients no difference of the latency of the muscle response was detected before and after the correction of the spinal angulation. In 14 patients the increase of latency ranged from 0.4 ms to 5.2 ms. No correlation was found between the slowing of motor conduction and the magnitude of spine correction. No central neurologic complications were seen after surgery. The authors concluded that their study demonstrated that motor pathway assessment in anesthetized patients can be performed at different times during the surgical procedure. This technique should help in the future monitoring spinal function during scoliosis surgery.

[Flat feet in children]. / Les pieds plats de l'enfant.

Flat feet are common in children. Loss of the medial arch may be due to intrinsic or extrinsic abnormalities of the foot. Physical evaluation usually suffices to identify the various growth stages which modify alignment and joint mobility, thus affecting foot function. Flat feet not caused by intrinsic structural abnormalities are right considered benign since they only exceptionally cause discomfort in adulthood. Shoe inserts provide only improved comfort during walking. Surgery is used in the extremely small proportion of patients with severe arch loss or deformities secondary to another condition.

[Effects of isoflurane and halothane on motor evoked potentials in the rabbit]. / Effets de l'isoflurane et de l'halothane sur les potentiels évoqués moteurs chez le lapin.

The effects of isoflurane or halothane on motor evoked potentials (MEPs) were assessed and compared in the rabbit, in order to contribute to devise a rigorous human anaesthetic protocol to be used for monitoring of MEPs in corrective spinal surgery. Ten black adult New Zealand rabbits were anaesthetised twice at a month interval, once with isoflurane and once with halothane. Once a control cortical stimulation had been carried out after the animal had breathed pure oxygen for three minutes, the following concentrations of anaesthetic agent were given for 3 min each: respectively 0.3 vol %, 0.5 vol % and 1 vol % of isoflurane, and 0.5 vol % and 1 vol % of halothane. Cortical stimulation was carried out every minute. The signs of anaesthesia (diameter decrease of the pupil, eye covered by the nictating membrane), muscle relaxation (ears drop) and breathing rate were recorded. MEPs were recorded 1, 2, 3 and 5 minutes after the end of anaesthesia. Isoflurane had a stronger effect on MEPs than halothane. The effect was more pronounced on amplitude than on latency. MEPs remained present whatever the concentration of halothane. In 70% of cases, MEPs, discontinued with isoflurane, more rapidly, more deeply, and for a longer time. Mean latency was more constantly increased in the isoflurane than in the halothane group. The effect of volatile halogenated anaesthetics on mean latency of MEPs seemed to be more delayed than that on amplitude. One should also take into account an individual sensitivity, it is concluded that the interpretation of MEPs during anaesthesia with volatile halogenated agents should be carried out with caution.

[Pyloric stenosis in infants. Contribution of ultrasonography and video-surgery]. / Sténose du pylore du nourrisson. Apport de l'échographie et de la vidéochirurgie.

Hypertrophic pyloric stenosis is the commonest condition requiring abdominal surgery in infancy. The Fredet-Ramstedt pyloromyotomy gives a very rare morbidity rate as shown by a review of 300 personal cases. The diagnostic value of sonography is gaining significance over contrast roentgenography, a pyloric diameter of more than 14 mm and a muscular thickness of more than 4 mm being required for the diagnosis. Over the last 18 months, we performed extramucosal pyloromyotomies using laparoscopy in 19 infants. This new surgical technique using laparoscopy with precautionary measures for the pneumoperitoneum appears to be very promising and should become a widespread technique in the future.

[Pyloric stenosis in infants. New surgical approaches]. / Sténose du pylore du nourrisson. Nouvelles orientations chirurgicales.

Pyloromyotomy as described by Fredet and Ramstedt is still widely used for the treatment of infantile hypertrophic pyloric stenosis, with a very low mortality rate. Three hundred case-records of patients treated using this technique were reviewed. Pyloromyotomy can benefit from the use of videosurgical methods. The creation of a pneumoperitoneum requires special precautions in infants. Nineteen infants were treated using laparoscopic Fredet-Ramstedt pyloromyotomy, a technique which can be expected to gain widespread acceptance during the next few years.

[An unusual germ causing a limp: Eikenella corrodens]. / Un curieux germe pour une boiterie: l'Eikenella corrodens.

A case of retroperitoneal appendicular abscess due to Eikenella corrodens is reported. This facultative anaerobe is normally found on the respiratory and intestinal mucosa and may be responsible for opportunistic infections. Culture is difficult and growth is slow. There have been few previous reports of the localization reported herein. A limp was the first manifestation of the infection. The differential diagnosis and pathophysiology of this symptom are discussed.

[Single preoperative intravenous dose of metronidazole for appendectomy in children]. / Antibioprophylaxie par dose unique de métronidazole pour appendicectomie chez l'enfant.

One hundred children were prophylactically treated with 15 mg/kg-1 of metronidazole immediately before appendicectomy and retrospectively compared with 100 other patients without any antibioprophylaxis. No statistically significant difference was found between the two groups as regards age, weight, sex and macroscopic appearance of the appendix. The overall incidence of complications was 1% in the antibioprophylactic group and 9% in the control group. Furthermore, a single pre-operative intravenous dose of metronidazole was as effective as conventional antibioprophylaxis.

[Antibiotic prevention with a single dose of metronidazole in appendectomy in children]. / Antibioprophylaxie par dose unique de métronidazole pour appendicectomie chez l'enfant.

One hundred children were prophylactically treated with 15 mg/kg-1 of metronidazole immediately before appendicectomy and retrospectively compared with 100 other patients without any antibioprophylaxis. No statistically significant difference was found between the two groups as regards age, weight, sex and macroscopic appearance of the appendix. The overall incidence of complications was 1% in the antibioprophylactic group and 9% in the control group. Furthermore, a single pre-operative intravenous dose of metronidazole was as effective as conventional antibioprophylaxis.

[Traumatic epiphyseal separation of the lower end of the femur]. / Décollements épiphysaires traumatiques de l'extrémité inférieure du fémur.

Forty-one children suffering from displacement of the distal femoral epiphysis were reviewed with a five year follow-up. This is a rare lesion, caused by severe trauma. It is seen at all ages, four of the cases being neonatal, but principally in adolescence, in 22 cases. The Ogden classification is preferable to the Salter-Harris classification for these fractures, which are usually in type II (39 cases). The prognosis is related to the severity of the initial displacement and to the quality of the reduction and its maintenance. Epiphysoidesis developed frequently and early, in 15 cases. It seemed to be due to an initial vascular injury rather than to mechanical compression. The results were not very satisfactory with 23 good, 11 fair and 7 bad results. It is recommended that an anatomical reduction should be maintained by percutaneous crossed pins. In adolescents aged 15 years or over, primary surgical epiphysiodesis of the whole growth cartilage seems to be a reasonable possibility.

Congenital hypo- and hypermyelination neuropathy. Two cases.

Two young patients were referred recently to the authors for investigation of a peroneal atrophy syndrome. Since the first symptoms were observed in infancy, a congenital hypomyelination neuropathy was suspected, and superficial peroneal nerve biopsies were taken. Signs of severe and widespread demyelination/remyelination were observed. These features appeared morphologically similar to those observed in the globular or tomaculous neuropathies. The mechanism of the hypermyelination is discussed.