Lateral-Only Kirschner-Wire Fixation of Type-3 Supracondylar Humerus Fractures in Children with a Special Attention to Technical Issues.

BACKGROUND AND AIMS: Lateral-only Kirschner-wire pinning of supracondylar humerus fracture is superior in avoiding surgery-related ulnar nerve injury. Their disadvantageous effects on stability may be a consequence of inappropriate surgical techniques. We analyzed whether the surgeon's preference for lateral-only fixation is associated with his or her orthopedic competence. We also analyzed the surgical technique-related risk factors of redisplacement. MATERIALS AND METHODS: All children, aged <16 years, with a distal humerus fracture in 2000-2009 were preliminary included (N = 861). Altogether, 24 of the 165 type-3 supracondylar fractures were operated by lateral-only pinning. Loss of reduction in the follow-up was the main outcome, while the close characteristics of the surgical technique and treating surgeon's orthopedic competence were the explanatory variables. RESULTS: Orthopedic surgeons used lateral-only method in 23.5% of the type-3 fractures (N = 16/68), and other surgeons in 8.2% (N = 8/97)(difference = 15.3%, 95% confidence interval = 4.6%-27.6%, p = 0.005). One-third of the lateral-only treated fractures (29.2%, 95% confidence interval = 12.6%-51.1%) redisplaced. Lateral-entry pins that crossed at the level of the fracture were associated with failure (87.5%), while no patient with appropriate pin configuration failed (difference = 87.5%, 95% confidence interval = 52.1%-97.8%). A shorter distance (<5 mm) between the entry points of the pins was associated with redisplacement (80% vs. 15.8%, difference = 64.2%, 95% confidence interval = 16.1%-86.9%). Open reduction (p = 0.07), insufficient (<4 mm) bone contact (p = 0.28), monocortical pins (p = 0.569), low diverging angle (p = 0.13) or parallel pins (p = 1.0), residual coronal displacement (p = 1.0), >5° changed Bauman angle (p = 0.11), rotational displacement (p = 0.25), and the experience or specialty of the surgeon were not associated with redisplacement. CONCLUSION: Lateral-only pins resulted in poor stability in one in three of the patients. Appropriate configuration of the pins was associated with good fracture healing, but crossing the pins at the fracture level and introducing them close to each other were associated with redisplacement. Surgeons with more orthopedic competence selected lateral-only fixation more usually.

Treatment of Distal Forearm Fractures in Children.

BACKGROUND AND AIMS: Distal forearm is the most common fracture location in the growing skeleton. The aim of this article is to describe the current practice of these fractures. MATERIALS AND METHODS: Case series accompanied by experts' opinion. RESULTS AND CONCLUSION: Most of these injuries are benign incomplete distal metaphyseal torus fractures best treated with a dorsal below elbow splint for 2-3 weeks with no follow-up. Completely displaced metaphyseal fractures in prepubertal children can be either immobilized in bayonet position after axial alignment or fixed with K-wires after reduction. Complete fractures of distal metaphysis in adolescents should heal in near anatomic alignment because remodeling is uncertain. We advocate reduction of most greenstick and complete fractures at the distal metaphyseal diaphyseal junction and radiographic follow-up to monitor fracture alignment. Physeal fractures in adolescents and intra-articular fractures in children of all ages should be anatomically reduced. We perform most of our osteosyntheses with K-wires.

Reduced Number of Pediatric Orthopedic Trauma Requiring Operative Treatment during COVID-19 Restrictions: A Nationwide Cohort Study.

BACKGROUND AND AIMS: The coronavirus outbreak significantly changed the need of healthcare services. We hypothesized that the COVID-19 pandemic decreased the frequency of pediatric fracture operations. We also hypothesized that the frequency of emergency pediatric surgical operations decreased as well, as a result of patient-related reasons, such as neglecting or underestimating the symptoms, to avoid hospital admission. MATERIALS AND METHODS: Nationwide data were individually collected and analyzed in all five tertiary pediatric surgical/trauma centers in Finland. Operations related to fractures, appendicitis, and acute scrotum in children aged above 16 years between March 1 and May 31 from 2017 to 2020 were identified. The monthly frequencies of operations and type of traumas were compared between prepandemic 3 years and 2020. RESULTS: Altogether, 1755 patients were identified in five tertiary hospitals who had an emergency operation during the investigation period. There was a significant decrease (31%, p = 0.03) in trauma operations. It was mostly due to reduction in lower limb trauma operations (32%, p = 0.006). Daycare, school, and organized sports-related injuries decreased significantly during the pandemic. These reductions were observed in March and in April. The frequencies of appendectomies and scrotal explorations remained constant. CONCLUSION: According to the postulation, a great decrease in the need of trauma operations was observed during the peak of COVID-19 pandemic. In the future, in case similar public restrictions are ordered, the spared resources could be deployed to other clinical areas. However, the need of pediatric surgical emergencies held stable during the COVID-19 restrictions.

Pediatric primary synovial chondromatosis of the shoulder, biceps tendon sheath and subcoracoid bursa.

A child with shoulder pain and great palpable mass without any injury history is an emergent case until the diagnosis is confirmed. We report the clinical findings, imaging features, surgery and histological analyses of primary synovial chondromatosis in glenohumeral joint, biceps tendon sheath and subcoracoid bursa in a child, aged 14. Primary synovial chondromatosis is characterised by multiple calcified nodules in joints, tendons or bursa areas. The condition is more usual in large joints, in particular in lower extremities. It may be symptomless until the volume of chondromatosis has increased to such an extent that it results in pain, locking symptom or palpable mass. The treatment is removal of the loose bodies and potentially synovectomy, in means of open or arthroscope-assisted surgery. Postoperative follow-up is recommended due to the risk of recidivism and potential malignant transformation. The disease is more common in older patients and there are only isolated cases in pediatric population.

The Measurement Methods of Movement and Grip Strength in Children with a Previous Upper Extremity Fracture: A Comparative, Prospective Research.

BACKGROUND AND AIMS: Decreased range of motion of the elbow and forearm and decreased grip strength are potential findings following a childhood upper extremity fracture. Clinical follow-up is essential because spontaneous improvement is seen several months after the injury. Freehand measuring with a goniometer and hydraulic dynamometer is used to evaluate clinical result. The new methods are justified in avoiding human typewriting errors, thus improving patient safety. Nevertheless, their feasibility in child patients is unknown. This study aimed to evaluate congruence between the computer-assisted and the free-hand measuring methods. MATERIALS AND METHODS: A total of 59 children with a previous supracondylar humerus fracture were clinically examined by means of free-hand (transparent goniometer and hydraulic dynamometer; Jamar, Lafayette Ltd.) and computer-assisted (E-Link System Packages, Biometrics Ltd.) methods. The range of motion and grip strength were measured separately using both methods. Agreement between the measurements was evaluated using the Bland-Altman method. RESULTS: The results between the two methods were incongruent and the differences between measurements increased along with the mean of measurements in all categories except elbow extension. Rotational range of motions were smaller and grip strength was weaker while measuring with the computer-assisted method. The mean discrepancy was 0.97° (95% confidence interval = -2.46 to 0.53) for elbow extension and 7.97° (95% confidence interval = 6.60-9.33) for elbow flexion. CONCLUSIONS: Grip strength is used to evaluate impairment of hand function. The study method showed slightly lower results in grip strength. Range of motion is essential when evaluating the outcome of supracondylar humerus fracture, while >10° of change in elbow range of motion associate with impaired function. As compared with the gold-standard goniometer, the methods were not congruent. However, all differences were under 10° and probably beyond clinical importance. Because of its advantages in recording the outcomes to electronical charts, the computer-assisted method is recommended option in performing the follow-up of complicated pediatric supracondylar humerus fractures.

Confirmed and Suspected Foreign Body Injuries in Children during 2008-2013: A Hospital-Based Single Center Study in Oulu University Hospital.

INTRODUCTION: Foreign body injuries are common in children. Most of them are not serious but they can be fatal. A suspected foreign body injury in a child results in a high rate of hospitalizations, exposure to radiation, and need for intervention. This study aimed to analyze the current epidemiology of in-hospital or out of hospital treated foreign object injuries and suspected foreign body injuries in children. MATERIAL AND METHODS: All children <16 years of age (N = 152) who suffered or were suspected to suffer (N = 63) from a foreign body injury and were treated in a pediatric trauma unit of Oulu University Hospital, Oulu, Finland, over a 6-year study period (2008-2013) were included. A comprehensive chart review was completed in order to evaluate injury history, age at the time of trauma, treatment and characteristics of the foreign objects. RESULTS: The majority (57.9%, N = 88) of the injuries were found in children <3 years of age. There was a male predominance (60.5%, N = 92). The most common anatomical site where the foreign body was found was the nose (28.9%, N = 44), followed by the esophagus (20.4%, N = 31) and the eye (11.2%, N = 17). Foreign objects were also found in the lower airways (10.5%, N = 16), ear (10.5%, N = 16), bowel (9.9%, N = 15), throat (3.9%, N = 6), stomach (3.9%, N = 6), and urethra (0.7%, N = 1). Various household items were the most common foreign bodies (33.6%, N = 51). Toys in particular caused 22.4% (N = 34) of the injuries. In-hospital intervention was necessary for 38.5% of the patients (N = 58). Intervention was needed in 39.7% (N = 25/63) of the patients who were suspected to suffer from foreign body but did not. There were no fatalities. CONCLUSION: Foreign body injuries treated at the pediatric trauma unit were most common in the youngest children (<3 years of age). Majority (61.8%, N = 94) of the patients were treated non-operatively, without any in-hospital intervention.

The long-term outcome of childhood supracondylar humeral fractures: A population-based follow up study with a minimum follow up of ten years and normal matched comparisons.

AIMS: We present the clinical and radiographic outcome of 81 children with Gartland type I to III supracondylar humeral fractures at a minimum follow-up of ten years (mean 12.1 years; 10.3 to 16.1) following injury. PATIENTS AND METHODS: The clinical and functional outcomes are compared with normal age- and gender-matched individuals. The population-based study setting was first identified from the institutional registries; the rate of participation was 76%. Controls were randomly selected from Finnish National Population Registry. RESULTS: According to Flynn's criteria, most fractures (75.3%) resulted in a satisfactory ("good or excellent") outcome. Satisfactory recovery was achieved in 75.0% of type I fractures treated by closed splinting (p = 0.013). Type II fractures were associated with both satisfactory (57.7%) and unsatisfactory (42.3%) results, regardless of the type of treatment, although the numbers were small in the sub groups. Most type III fractures were treated operatively, and most (76%) had a satisfactory outcome according to Flynn's criteria (p = 0.015). Compared with none among the normal subjects, flexion of the elbow was reduced by > 10° at long-term follow-up in 20 cases (24.7%, p < 0.001) and 9 (11.1%) had a reduced flexion of > 15° (p = 0.004). In patients who had sustained a type III fracture, the carrying angle was decreased by 35.7% (from 9.8° to 6.3°; p = 0.048). All patients achieved an excellent Mayo Elbow Performance Score (mean 96.4 points). CONCLUSION: The long-term outcome of extension-type supracondylar humeral fractures is generally good, but not exclusively benign, with the potential for long-term pain and ulnar nerve sensitivity, and a decrease in grip strength and range of movement in type II and type III fractures. Bony remodelling cannot be relied upon to correct any residual deformity. In particular, type II fractures have impaired long-term recovery and justify individual consideration in their treatment. Cite this article: Bone Joint J 2016;98-B:1410-17.

Ulnar nerve morbidity as a long-term complication of pediatric supracondylar humeral fracture.

BACKGROUND: Supracondylar humeral fractures are common in children. We studied long-term ulnar nerve symptoms secondary to these fractures and analyzed the treatment for ulnar neuropathy. MATERIALS AND METHODS: The cohort included 91 patients with a supracondylar humeral fracture in childhood, on average 12 years previously, in the geographic catchment area. All the cases were reexamined in regard to ulnar nerve morbidity. Cases with secondary ulnar neuropathy were treated nonoperatively and operatively. RESULTS: Ulnar neuropathy was present in four cases (4.4 %). They all had suffered from a dislocated fracture, and they had been operated primarily. Another three patients had slight ulnar nerve symptoms. Hence, the total prevalence of secondary ulnar nerve morbidity was 7.7 %. A jumping nerve was seen in 9.9 %; 51.6 % had a diminished axial angle. CONCLUSIONS: We report a defined pattern of long-term ulnar nerve morbidity after pediatric supracondylar humeral fracture. The prevalence of neuropathy is alarming in the young population (<25 years of age).

A new mini-invasive technique in treating pediatric diaphyseal forearm fractures by bioabsorbable elastic stable intramedullary nailing: a preliminary technical report.

BACKGROUND AND AIM: Operative treatment is often indicated in unstable pediatric diaphyseal forearm fractures. Recently minimally invasive reduction and elastic stable intramedullary nailing have been of increasing interest, instead of open reduction and internal fixation with plates. There are several disadvantages of metallic intramedullary implants, such as soft-tissue irritation and a risk of disturbing later imaging. Thus, they are generally removed in later operations. We aimed to develop a new technique to stabilize pediatric forearm fractures by the bioabsorbable intramedullary nailing. MATERIAL AND METHODS: We developed a new, two-stage mini-invasive surgical technique to stabilize the unstable diaphyseal fractures in children. The procedure is bioabsorbable elastic stable intramedullary nailing. Ultra-high-strength bioabsorbable intramedullary nails of poly(lactide-co-glycolide) were manufactured for our purpose. The material has been widely proven to be biocompatible and stable enough for fracture treatment as screws and pins. We have used the new technique in the unstable both-bone diaphyseal forearm fractures in children between the ages of 5 and 15 years. We report the technique and our clinical experience in the series of those three cases that have been followed up for at least 12 months. The present series has been randomized for the procedure instead for titanium elastic stable intramedullary nailing, and the series represents a part of ongoing randomized trial. RESULTS: The reported cases operated by the new technique referred good union in the fractured bones and acceptable alignment in the follow-up. Removal of the implants was not required. No troubles with the procedure or implant per se were noticed, indicating good feasibility. One high-energy refracture occurred half year after the primary trauma. Traditional titanium implants were used to control the refracture. CONCLUSIONS: We report our preliminary experience of a new surgical mini-invasive procedure to stabilize the unstable pediatric forearm shaft fractures by bioabsorbable elastic stable intramedullary nailing. Our clinical experience suggests that the procedure combined with long-arm casting is feasible in treating the pediatric forearm fractures. The technique may bring benefits to handling these challenging fractures. The disadvantages of metallic implants may be avoided. In addition, removal of the implant will not be required. There was one refracture in the series, but it was due to new high-energy trauma. According to our understanding, it was not related to the type of former osteosynthesis. However, ignoring the good preliminary experience, still we do not have results of the superiority of the procedure over traditional elastic stable intramedullary nailing. Our ongoing randomized multicenter study is aimed to determine its long-term outcome against the present golden standard. Nevertheless, due to encouraging preliminary results, we see it necessary to report the technique.

Persistent scrotal pain and suspected orchido-epididymitis of a young boy during pinworm (Enterobius vermicularis) infection in the bowel.

AIM: Pinworm (Enterobius vermicularis) is the most common parasite among mankind. Ectopic pinworm infections in number of organs are broadly reported. The aim of this report is to review the pinworm infection in the scrotum on the basis of our case. METHODS AND RESULTS: Our patient is a young boy with persistent pain in the scrotums together with abdominal symptoms. He underwent several urgent operations. Pinworm was finally found in appendix vermiformis. We hypothesize that concurrent unresponsive orchido-epididymitis was caused by pinworm as well. Eradication happened finally with pyvrinembonate. CONCLUSION: Pinworm is a parasite that lives usually in the bowel. Many ectopic locations, like scrotum, are known. Orchido-epididymitis by pinworm has to be kept in mind when treating boys with persistent scrotal pain.