Ultrasound diagnostics of a rare injury of the unossified pediatric skeleton - case report.

Plain X-ray remains a standard diagnostic tool for evaluation of skeletal injuries in children. However, it provides inadequate imaging of unossified, cartilaginous parts of pediatric bones. Our article presents the possibilities of ultrasound imaging based on the case report of a seven years old patient with a rare injury of the unossified medial epicondyle of the humerus where the diagnosis and indication for osteosynthesis has been made based on ultrasound examination of the injured elbow. Ultrasound imaging is an ideal, accessible and affordable examination not stressful for the patient; this technique can be used to verify of skeletal injuries that cannot be diagnosed by plain X-ray. Ultrasound imaging should be a standard part of the diagnostic algorithm of skeletal injuries in the pediatric population where a discrepancy is present between distinctive symptoms and negative radiographs.

[Advantages and Pitfalls of Stabilisation of Supracondylar Humerus Fractures in Children by Lateral Approach Only]. / Výhody a úskalí stabilizace suprakondylických zlomenin humeru u detí pouze z laterálního prístupu.

PURPOSE OF THE STUDY Supracondylar humerus fracture (SCF) with dislocation is indicated for closed reduction and osteosynthesis. The method achieving the best stability is CRCPP (closed reduction and crossed percutaneous pinning), even though there is a risk of iatrogenic ulnar nerve injury. The CRLPP (closed reduction and lateral percutaneous pinning) method eliminates this risk at the cost of less stable osteosynthesis. The purpose of this study is to compare the SCF stabilisation by CRLPP with the stabilisation by CRCPP in rotationally stable fractures and to identify the risk of iatrogenic ulnar nerve injury, or the failure of osteosynthesis with recurrent dislocation of fragments. MATERIAL AND METHODS The prospective group of the patients with SCF type 1/2 (classification according to Havránek) treated in the period 2016-2018, in whom the method of osteosynthesis (number of implants, method of their insertion), resulting condition and complications (nerve injury, failure of osteosynthesis) were evaluated. In the second half of the study, in CRLPP one of the implants was inserted "quadricortically", i.e. through the olecranon fossa of the humerus (hereinafter referred to as fossa), while until then both the implants had been inserted through the radial column outside fossa. RESULTS In the period 2016-2018, 791 patients with SCF were treated at our department. In 225 cases (28.5%) the patients sustained the type 1/2 fracture and in all the cases closed reduction and percutaneous osteosynthesis were performed, namely CRCPP in 185 cases (82.2%) and CRLPP in the remaining 40 cases (17.8%). Signs of ulnar nerve injury after osteosynthesis were observed in 35 patients (15.6% of SCF 1/2), always after the use of at least one ulnar implant (18.9% of CRCPP). A failure of osteosynthesis occurred in 2 cases (0.9% of SCF 1/2), always when only lateral implants were used (5% of CRLPP). DISCUSSION In both the patients in our study in whom after CRLPP a failure of osteosynthesis with rotational dislocation occurred, the original CRLPP was performed by inserting both the implants through a single column outside fossa. Both the patients were indicated for revision reduction and osteosynthesis was subsequently performed through CRCPP. The patients healed with no further complications. In the group of patients with an ulnar nerve injury, the original condition was fully restored, after 3.6 months (range of 1-10, median 3) on average. The results of our study show the need to guide the implants inserted through the radial column divergently so that they are at the fracture line level as far apart as possible (with adequate fixation of fragments). One of the implants is inserted through fossa, i.e. quadricortically. Based on our experience, the compliance with these principles alone shall ensure adequate rotational stability of SCF of type 1/2. In CRLPP, after the insertion of implants the stability is tested under the Xray image intensifier intraoperatively so that a medial implant can be added in case of unstable osteosynthesis. CONCLUSIONS Based on the results of our study we recommend to stabilise the rotationally stable SCF (type 1/2 according to Havránek) only from the radial column (and thus eliminate the risk of iatrogenic ulnar nerve injury), provided the fracture characteristics allows so. Nonetheless, the CRLPP has its own specific rules for implant entry which have to be adhered to. Key words: supracondylar fracture of the humerus, paediatric fractures, closed reduction, percutaneous pinning, lateral percutaneous pinning, iatrogenic ulnar nerve injury, osteosynthesis failure.

Monteggia lesion and its equivalents in children.

PURPOSE: The aim of the study is to evaluate our group of paediatric patients with Monteggia lesion and its equivalents and to compare the characteristics of basic types of these lesions concerning therapeutic approach and results of the treatment. METHODS: Retrospective study of 111 children treated in the Department of Pediatric and Trauma Surgery of the Thomayer Hospital in Prague between 2001 and 2013 (13 years). When evaluating the outcome of the therapy, Bruce's criteria modified by Letts that assesses range of movement, pain and deformity of the elbow joint were applied. Regarding the therapeutic approach, four groups were compared: nonoperative treatment, reduction and casting, closed reduction and internal fixation (CRIF) and opened reduction and internal fixation (ORIF). Results were compared between three groups of patients (Monteggia lesions, displaced equivalents and non-displaced equivalents) using Fisher´s exact test with α set to 0.05. RESULTS: In all, 46 patients were treated for (true) Monteggia lesion, 27 for non-displaced Monteggia equivalent and 38 for displaced equivalent. There is a statistically significant difference in therapeutic approach between all three groups of patients. There is no significant difference in outcome between Monteggia lesions and both types of Monteggia equivalents, but there is a statistically significant difference between displaced and non-displaced equivalents. CONCLUSION: There are only two lesions that meet the criteria of Monteggia - (true) Monteggia lesion and displaced Monteggia equivalent. The non-displaced equivalent does not meet the criteria of Monteggia and, therefore, should not be termed a Monteggia equivalent. LEVEL OF EVIDENCE: Level III - Retrospective comparative study.

[Diagnostics of the retrocalcaneal bursitis: possibilities of the use of new anatomical data]. / Diagnostika retrokalkaneárních burzitíd: moznosti vyuzití nových anatomických poznatku.

The anatomy and histology of the normal retrocalcaneal bursa (RB) was studied on both embalmed and fresh cadaverous material. The bursa is a constant structure, its upper and posterior walls are completely covered with the unilayered synovial membrane. Its anterior wall represents the superior facet of the calcaneal tuberosity, the posterior one corresponds to the anterior surface of the insertional part of the Achilles tendon. The superior wall is formed by the adipose tissue of the inferior part of Kager's triangle, extending into the cavity of the bursa in a form of constant large and irregularly shaped synovial fold. The normal anatomical features as well as some pathological changes of the bursa and its neighbourhood were demonstrated on examples of some case reports, by use of the ultrasonography and magnetic resonance investigations. In healthy individuals the space of the bursa was not figured in the ultrasonographic investigations, but was well apparent in the MR images. The pathological changes of the bursa are detectable by using of both methods, but the MR images present substantially precise quality of depiction. The authors recommend the use of presented new anatomical data for the improvement in differential diagnostic of the wide spectrum of achillar enthesopathies.

Clinical anatomy of the retrocalcaneal bursa.

The goal of the study was to perform a detailed anatomical description of the retrocalcaneal bursa (RB). Its morphological arrangement was studied on 10 fresh and 30 embalmed lower extremities by microdissection and light microscopy. The RB was present constantly and in all the cases contained 1-2 cm long synovial fold, beginning on the upper wall of RB and distally interposed between the anterior surface of the Achilles tendon and the posterior surface of the calcaneal tuberosity. The volume of RB was 1-1.5 ml. The histological analysis confirmed that the inner surface of the superior and posterior wall of RB have been covered by unilayered synovial membrane, projecting into synovial villi of different shapes and sizes. In the ceiling of RB, delicate fascicle of skeletal muscle fibers was discovered, radiating distally into the regularly present synovial fold. The whole bottom of RB has been covered by 200-500 microm layer of fibrous cartilage into which the calcaneal tendon attached. The cartilagineous layer continued anteroproximally to cover the whole bursal surface of the calcaneal tuberosity, where the thickness of the cortical bone was reduced on mere 50 microm. The obtained results can be used in the improvement of the differential diagnostics and therapy of diagnostics and therapy of the retrocalcaneal bursitis as well as of other kinds of achillar enthesopathies and heel pain.