Primary closure of fasciotomies has a reduced complication rate following compartment syndrome in the paediatric population.

PURPOSE: Currently no guidance exists within the literature regarding diagnostic criteria or the long-term outcomes for paediatric patients with acute compartment syndrome (ACS). We conducted a retrospective cohort study reviewing all cases of paediatric ACS managed at a single tertiary referral centre with the aim of characterising the factors responsible for the eventual outcomes. METHODS: The patient cohort was identified retrospectively by interrogating the hospital coding system for all paediatric patients between January 2014 and November 2022. The electronic emergency department, inpatient and operative notes as well as clinic letters for each patient were reviewed and data collected regarding presentation, associated injuries, management and subsequent complications plus length of follow-up. The data was analysed to determine if differences in presentation or management affected long term outcome. RESULTS: The final cohort consisted of 34 patients with a mean age of ten years at the time of presentation. The mean time from presentation to fasciotomy was 27.6 h (range 3.0 - 66.6). There was an overall complication rate of 37.5% with a mean follow-up period of 21 months. Patients who had direct closure of their fasciotomy wounds had a significantly lower complications rate and fewer operations compared to those who healed via other wound coverage methods or secondary intention (p < 0.05). CONCLUSIONS: Significantly higher complication rates were observed in patients who were unable to have direct wound closure following emergency fasciotomy. This information may be utilised to rationalise long term treatment plans and in counselling of patients and parents.

Spinal dysraphism in congenital scoliosis and kyphosis: a retrospective analysis in an Indian population.

PURPOSE: Early recognition is crucial for occult spinal dysraphism associated with congenital spinal deformities. There is limited literature available on its occurrence in congenital scoliosis and kyphosis in the Indian population. METHODS: Our study involved a retrospective review of 247 children who presented at a single centre. We analyzed their demographics and clinical and radiological findings, which included the type of deformity, its location, vertebral anomaly, Cobb angle, and MRI findings. The deformities were categorized as congenital scoliosis or congenital kyphosis with failure of formation, failure of segmentation, or both. RESULTS: A total of 247 cases were examined (congenital scoliosis-229, congenital kyphosis-18). The average age was seven years (range 0.8 to 19 years, SD 4.6). The mean Cobb angle at presentation in the congenital scoliosis group was 49.4° (range 8 to 145°, SD 23.77) for those with abnormal MRI and 42.45° (range 5 to 97°, SD 20.09) for those with normal MRI. For the congenital kyphosis group, the mean K angle at presentation was 47.7° (range 14 to 110°, SD 33.33) for those with abnormal MRI and 47.36° (range 15 to 70°, SD 16.63) for those with normal MRI. Abnormal MRI results were observed in 130 of the patients (congenital scoliosis-53.7%, congenital kyphosis-38.8%). The highest incidence of abnormal MRI findings was observed in the failure of segmentation (66.6%) and mixed (65%) types. Deformities in the dorsal region had the highest incidence (61.9%). The most common dysraphism instances were diastematomyelia and tethered cord. There was a significant correlation between type of deformity and presence of dysraphism. CONCLUSION: This is the largest case series of congenital scoliosis and kyphosis reported from India. We found a high incidence of occult spinal dysraphism as compared to other published series. Occult spinal dysraphism is more common in the thoracic region. Diastematomyelia followed by tethered cord was the most common anomaly observed. We recommend MRI screening of whole spine and craniovertebral junction.

Obturator Internus Bursitis Mimicking Groin Pain in a Football Player: A Case Report.

Introduction: Traumatic groin pain (GP) is frequently the result of acute trauma, often an indirect muscle injury. The most affected muscles in traumatic GP are the rectus abdominis, adductors, and iliopsoas. The obturator internus bursitis as a cause of GP is very rare. Case Presentation: The present case describes a rare indirect injury of obturator internus bursitis in a 22-year-old male football player who reported GP that used to worsen with sprinting and change in directions. The pain was relieved with rest and sprinting at 80% capacity. The patient had been diagnosed clinically and on magnetic resonance imaging (MRI) as a case of obturator internus insertional tendinopathy with bursitis. His symptoms resolved after ultrasound-guided injection in the inflamed tendon sheath at its insertion point. After 2 years, the patient was followed up with a triumphant return to professional football with no recurrence and a good prognosis in a relatively short recovery time. Conclusion: Clinical diagnosis of obturator injuries is often tricky. GP not responding to conservative management presents a unique challenge to the physician and the rehabilitation team. MRI must follow the radiological investigations and ultrasound if the reports were inconclusive of the diagnosis. In the present case study, the usual causes of such pain (osteitis pubis, and adductor muscle strains/tendinosis) were ruled out, and a specific unique condition was diagnosed with the help of the MRI.

Management of Neglected Developmental Dysplasia of the Left Hip in a 14-Year-Old Child with Staged Osteotomies Planned with 3D-Printed Model - A Case Report.

Introduction: Developmental dysplasia of hip (DDH) is abnormal development of hip joint causing mild subluxation to complete dislocation of femoral head from acetabulum. Incidence in India is 1-9.2/1000 . Typical risk factors for DDH are said to be female child, first born, breech position, positive family history, left hip, and unilateral involvement. Femoral head and acetabular compressive forces are mutually important stimulators for normal growth (both shape and depth). Deviation from above normal process due to subluxated or dislocated head since birth can lead to abnormal development of both acetabulum and femoral head. Diagnosis of the DDH is made at birth using clinical test and radiologically using ultrasound of hip joint. Management is based on the age of presentation and severity of the instability. Most hips are managed conservatively management depends on the age and symptoms of the patient. Case Report: A 14-year-old female child presented with the complaints of pain in the left hip and difficulty in walking. On clinical and radiological examination, she was diagnosed to have developmental dysplasia of the left hip with partial subluxation of the left hip. Thorough investigation and planning were done using CT PBH and 3D reconstruction of the pelvis to plan the osteotomy. Stages surgery was planned, first, triple innominate osteotomy was performed and later femoral varus derotation osteotomy 6 weeks later. At 3-year follow-up, the patient is pain free and is having no difficulty in doing day-to-day activities. X-ray showing complete coverage of the femoral head with no changes of arthritis in hip. Conclusion: Late presentations of neglected developmental dysplasia poses difficult challenges in management. It can be addressed with osteotomies for improving range of motion and preventing future early arthritis. In our case, good functional range of motion was restored at 3 years follow-up.

Parosteal Lipoma of the Proximal Phalanx of Hand.

Parosteal lipomas are rare benign tumors accounting for less than 0.1% of all primary bone tumors. Only 3 cases of parosteal lipoma have been previously described affecting the distal and middle phalanges. We describe a case of parosteal lipoma in a 45-year-old man involving the proximal phalanx of the right middle finger. The tumor was marginally excised with the osseous attachment. There was no clinical or radiological recurrence at a follow-up of 2 years, with full range of movement at the proximal interphalangeal joint.

Bilateral Severe Genu Varum in Dyggve-Melchior-Clausen Syndrome - A Case Report.

INTRODUCTION: Dyggve-Melchior-Clausen (DMC) syndrome was described in 1962 as an autosomal recessive type of spondyloepimetaphyseal dysplasia associated with mental retardation. Dymeclin (DYM) gene on chromosome 18q12.1 that encodes for DYM protein which is expressed in cartilage, bone, and brain is mutated in DMC. CASE REPORT: A 6 year -old male child presented with bilateral gradually progressive genu varum deformity of 4 years' duration. There was no significant past medical and family history. A plain radiograph of his knee, pelvis, and spine shows some classical signs of skeletal dysplasia. A plain radiograph of the pelvis with both hips shows a classical semilunar, irregular lacy appearance around the iliac crest which is a pathognomonic radiological sign of this syndrome. CONCLUSION: The radiographic lacy appearance of iliac crests and generalized platyspondyly with double-humped end plates are pathognomonic of DMC.

Primary Hypothyroidism Presenting as Slipped Capital Femoral Epiphysis in an Adult Patient : A Case Report and Review of Literature.

Introduction: Slipped capital femoral epiphysis (SCFE) is rare in adults and is often associated with endocrine pathology. Case Report: We report a case of a 21-year-old male presenting with an acute on chronic left hip SCFE who was diagnosed with primary hypothyroidism on the investigation. The patient was treated for hypothyroidism and positional reduction with in-situ fixation was carried out with two cannulated cancellous screws for the SCFE. At the latest follow-up of 30 months, patient remains asymptomatic, euthyroid, with a nearly full range of motion in the hips, significant functional improvement, fused physis on radiographs, and no signs of avascular necrosis. Conclusion: SCFE is a potentially devastating but avoidable complication in children/adults with the endocrine disorder and there may be a possible role for a screening pelvic radiograph in detecting this condition earlier.

Segmental Fibulectomy to Excise the Adherent Distal Tibia Osteochondroma in a Case of Hereditary Multiple Exostosis - A Rare Case Report.

INTRODUCTION: Hereditary multiple exostosis (HME) is an autosomal dominant disorder affecting the skeletal system, which is characterized by multiple osteochondromas in bones arising from osteochondral ossification and leading to skeletal deformities, short stature, soft tissue, and neurovascular compressive symptoms. CASE REPORT: A 10-year-old female a case of HME presented with painless multiple swelling around knees, wrist, and painful varus deformity in the lower third of the right leg. The large exostosis of the right distal tibia was symptomatic and indenting the fibula which required excision along with the segment of the fibula of about 2.5 cm above the syndesmosis adjacent to the exostosis as the mass was adherent to the fibula. CONCLUSION: Although distal tibia osteochondromas are rare, they can lead to deformity of the ankle and loss of function if not managed early and properly. Hence, early detection, proper planning, and management of periarticular distal tibia osteochondromas are essential to prevent the development or progression of the deformity. Segmental fibulectomy is required to remove the adherent osteochondromas completely and to prevent the recurrence and secondary surgical procedures. It is very essential to follow up the patient till the skeletal maturity to identify the delayed presentation and late progression of the ankle deformities.

Neuroblastoma: a rare cause of a limping child. How to avoid a delayed diagnosis?

UNLABELLED: Neuroblastoma is the most common solid extracranial tumor of childhood. Even though >25% of presentations are orthopaedic in nature, ranging from a limp to lower limb paralysis, neuroblastoma is a rare cause of limping in childhood and can therefore be easily missed by the admitting orthopaedic surgeon. Four cases of metastatic neuroblastoma are reported who all presented with hip pain within the last 3 years at Royal Manchester Children's Hospital. They all posed a diagnostic dilemma and an alternative diagnosis was initially made. A simple screening examination of the abdomen after ultrasonographic hip examination for sepsis would have led to an earlier diagnosis in all 4 cases. We suggest that including the abdomen in children undergoing a hip sonographic examination in those who are slightly atypical in nature or have indications of malignancy may lead to an early diagnosis of this rare cause of hip pain. LEVEL OF EVIDENCE: IV.

Hypertension as a complication of circular external fixators.

Hypertension is not a recognized complication of circular external fixation. The aim of this study was to determine the incidence of hypertension following this procedure. A retrospective review of 57 patients was carried out between January 2006 and May 2010. At least three blood pressure readings were used to define hypertension. Five of the 41 qualifying patients (12.2%) developed hypertension. Three of these were found to have a sustained hypertension throughout the frame period, two requiring treatment for visual symptoms and left ventricular hypertrophy. A limb reconstruction surgeon needs to be alert to this potential complication to initiate prompt investigations and treatment.

Vitamin D: a poor screening tool for biochemical and radiological rickets.

This retrospective study aims to determine if a relationship exists between serum 25-hydroxyvitamin D level and the diagnosis of biochemical or radiological rickets in children with bone and joint pain, muscle fatigue or varus/valgus knees. A retrospective biochemistry database and case note study was undertaken on 115 new patients referred to the senior authors' elective Paediatric Orthopaedic Clinic in 2010. Their mean age was 10.95 years (95% CI 10.24-11.68). Mean serum vitamin D was 18.27 mcg/l (95% CI 16.13-20.41), while 30 mcg/l is the normal threshold. One hundred and three children (88%) had vitamin D levels below normal. Winter/springtime blood samples were more likely to be deficient and this was statistically significant. Three Asian females (2.61%) were diagnosed with radiological rickets. Vitamin D levels below normal are common in children presenting with vague limb or back pain, but this rarely presents with biochemical or radiological rickets. Serum vitamin D level is not a suitable screening tool for biochemical or radiological rickets. Vitamin D requirement in children is unclear and requires further study.

Radiographic measurements of normal elbows: clinical relevance to olecranon fractures.

This study aims to calculate a clinically relevant and intra-operatively accessible measure of olecranon length that could be reliably applied by the operating surgeon to optimise fixation of comminuted olecranon fractures. One hundred normal adult antero-posterior and lateral radiographs of the elbow were studied with respect to the proximal olecranon height (OH), trochlear notch width (TW) on lateral views, and trans-epicondylar distance (TED) and trochlear width distance (TWD) on AP views. Three mean ratios were then derived: TWD/TW, TED/TW and OH/TW. The average OH was 26.2 mm (range 21-29), TW was 24.7 mm (range 21-32), TED was 58.7 mm (range 49-74), and the TWD was 27.0 mm (range 22-32). The average ratio of TWD: TW was 1.08 (SD = 0.08), that of TED: TW was 2.38 (SD = 0.18) and OH/TW was 1.06 (SD = 0.08). Comminuted fractures of the olecranon are a surgical challenge since it is often impossible to gauge the correct length to achieve in reconstruction of the olecranon process. Our data can be easily applied to the clinical situation, by taking intra-operative radiographs, and calculating the ratios as demonstrated above. These will guide the surgeon to obtain a more reliable length of the olecranon intra-operatively.