Paediatric trigger thumb: Diagnostic pearls.

AIM: The purpose of this study is to report diagnostic pearls and review the clinical presentation and outcomes of surgical treatment of paediatric trigger thumbs. METHODS: A retrospective review of medical records and imaging studies was performed on children with trigger thumbs from January 2009 to December 2019. RESULTS: Sixty-four trigger thumbs in 52 consecutive patients were treated. The average age at referral was 2.5 years. Symptoms include pain (4), triggering (14) and fixed contracture (38). The average symptom duration was 8 months. Forty patients had been evaluated and referred by a paediatrician or primary care doctor. Twenty-four of the 52 (46%) patients received hand x-rays and were initially misdiagnosed as a fracture or dislocation. Physical exam demonstrated a volar nodule in 64 thumbs (100%), fixed flexion deformities in 38 (73%) thumbs and triggering with active extension of the interphalangeal joint in 14 (27%) thumbs. The average age at surgery was 3.2 years. Follow-up averaged 12 months. Surgery resulted in complete relief of symptoms and correction of deformity. There was no reported loss of function or complication. CONCLUSIONS: Children with trigger thumbs who ultimately undergo surgery present with distinct physical exam findings, including a volar nodule and a fixed flexion contracture. Understanding these pearls can minimise misdiagnosis of the condition as a fracture or dislocation. Highlighting trigger thumbs during musculoskeletal education for paediatric and primary care physicians is recommended. Surgical outcomes were excellent in patients aged 2-8 years old.

Occipitocervical Dissociation in Three Siblings: A Pediatric Case Report and Review of the Literature.

This report includes three cases of occipitocervical (OC) dissociation in three siblings involved in a single, head-on, motor vehicle accident. The oldest sibling, a 9-year-old girl, required surgical fixation. The second sibling, a 6-year-old boy, was treated nonsurgically with a neck brace. The youngest sibling, a 5-year-old boy, sustained a fatal OC dissociation. CT and MRI findings are used to assess the reliability of the currently recommended diagnostic modalities for OC dissociation. The literature review focuses on the diagnosis of OC dissociation via CT measurements and proposed treatment recommendations using CT and MRI classification systems. In the 9-year-old girl, the mean atlanto-occipital joint width, the interspinous ratio, and space available for cord measurements indicated OC dissociation. However, on MRI evaluation, OC dissociation was observed in both living siblings and severe ligamentous injury was noted in the girl. The proposed CT measuring techniques for the diagnosis of OC dissociation were inconsistent in our cases. In the setting of clinically suspected OC dissociation with normal CT measurements, we recommend obtaining a cervical spine MRI to properly assess the extent of ligamentous injury.

Comparison of Pain Scores in Postoperative Patients: Intravenous Morphine Patient-Controlled Analgesia vs Iontophoretic Transdermal Fentanyl.

Postoperative management of pain has traditionally utilized intravenous (IV) morphine for pain control. An alternative approach to the invasive patient-controlled analgesia (PCA) system is the administration of transdermal analgesics, such as fentanyl. In 2006 the Food and Drug Administration (FDA) approved the fentanyl hydrochloride (fentanyl HCl) iontophoretic transdermal system (ITS), which utilizes iontophoretic technology to produce a controlled electrical current that propels ionized fentanyl molecules into the systemic vasculature. Transdermal fentanyl has been shown to be equivalent or superior to IV morphine PCA in a variety of postoperative settings with patients experiencing decreased pain scores and a favorable side effect profile.