Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control.

PURPOSE: The management of overriding distal forearm fractures is still controversial. This study aimed to evaluate the efficacy of immediate closed reduction and cast immobilization (CRCI) at the emergency department (ED) using equimolar nitrous oxide (eN2O2) as conscious sedation, and without the use fluoroscopic assistance. METHODS: Sixty patients with overriding distal forearm fracture were included in the study. All procedures were performed in the ED without fluoroscopic assistance. Antero-posterior and lateral wrist radiographs were taken after CRCI. Follow-up radiographs were taken 7 and 15 days post-reduction, and at cast removal to evaluate callus formation. Depending on the radiological outcome, two groups of patients could be identified: Group 1 (satisfactory reduction and maintenance of alignment) and Group 2 (poor reduction or secondary displacement requiring further manipulation and surgical fixation). Group 2 was additionally divided into Group 2A (poor reduction) and Group 2B (secondary displacement). Pain was assessed using Numeric Pain Intensity (NPI) score, while functional outcome was measured according to Quick DASH questionnaire. RESULTS: Mean age at the time of injury was 9.2 ± 2.4 years (range, 5-14). Twenty-three (38%) patients were aged between 4 and 9 years old, 20 (33%) patients between 9 and 11, 11 (18%) patients between 11 and 13, and 6 (10%) patients between 13 and 14. The mean follow-up time was 45.6 ± 12 months (range, 24-63). Satisfactory reduction with maintenance of alignment was achieved in 30 (50%) patients (Group 1). Re-reduction was performed in the remaining 30 (50%) patients (Group 2) due to poor reduction (Group 2A) or secondary displacement (Group 2B). No complications related to the administration of eN2O were recorded. No statistically significant difference could be identified between the three groups for any clinical variable (Quick DASH and NPI). CONCLUSION: Overriding distal forearm fractures may be safely treated with CRCI at ED using eN2O2 as conscious sedation. However, fluoroscopic assistance during CRCI might significantly improve the quality of reduction thus avoiding further treatment as the lack of relaxed muscle can restrain reduction.

Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients.

INTRODUCTION: Femoral shaft fractures are the commonest major pediatric fractures. For generations, traction and casting were the standard method of treatment for children. However, over the past two decades there has been growing recognition of the advantages of fixation and rapid mobilization. METHODS: A prospective multicenter study was conducted at four Italian centers of reference for pediatric fractures (January 2005 to December 2014). The study involved 62 patients of both sexes, between 6 and 14 years of age, with closed femoral shaft fractures. The aim was to find out more about the short-term complications of titanium elastic nailing in diaphyseal femur fractures in children in order to reduce them. RESULTS: The commonest complication observed in our study was pain at the nail entry point (24.19%) due to a local inflammatory reaction. After 1 year, 3.22% had limbs of different lengths. Proximal migration occurred in 1.61% of cases. DISCUSSION: Over the last two decades, the treatment of femoral shaft fractures in pediatric patients has developed to include internal fixation using Titanium Elastic Nails (TEN). We only observed a few complications in our study, most of which were minor and associated with the surgical technique employed, particularly during the initial phase of the surgeon's learning curve. CONCLUSIONS: TEN are an excellent internal fixation system if used by an expert surgeon and have a very low rate of complications. None of them produced permanent damage in the patients. In older children weighing more than 50 kg, alternative techniques such as subtrochanteric nailing, plates, or external fixation are advisable.

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome.

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.

Outcomes of the calcaneo-stop procedure for the treatment of juvenile flatfoot in young athletes.

PURPOSE: Flexible flatfoot (FFF) is a widespread condition in juvenile patients. If symptomatic, FFF can require surgical treatment. The calcaneo-stop procedure has shown excellent clinical and radiographic outcomes and low rates of complications. The aim of the present study was to assess the sport practice of young athletes affected by FFF having undergone the calcaneo-stop procedure. METHODS: Between 2008 and 2016, 68 sport practitioners were bilaterally treated by the calcaneo-stop procedure, for a total of 136 FFF cases. Clinical evaluation, including the American Orthopedic Foot and Ankle Score (AOFAS), the Yoo et al score and The Foot & Ankle Disability Index (FADI) and FADI Sport scores were assessed. Radiographic evaluation was based on measurement of talar declination, Costa-Bertani's angle and calcaneal pitch. RESULTS: Mean follow-up was 57.6 months (sd 16.8). The AOFAS score mean increased from 79.3 (sd 5.7) to 97.3 (sd 4.5) three years after surgery. The Yoo score improved from 3.1 (sd 1.0) preoperatively to 11.7 (sd 0.6) three years after surgery. The FADI Sport subscale mean improved from 74.1 (sd 10.4) preoperatively to 95.9 (sd 4.9) three years after surgery.Costa-Bertani's angle decreased from 156.1° (sd 4.2°) to 135.8° (sd 7.3°) at three years postoperatively; mean talar declination angle decreased from 44.2° (sd 6.3°) to 30.6° (sd 3.2°) at three years postoperatively and mean calcaneal pitch increased from 12.6° (sd 2.3°) to 16.3° (sd 1.3°) at three years postoperatively. CONCLUSION: Adolescent patients who underwent the calcaneo-stop procedure reported satisfactory outcomes in terms of clinical and radiological evaluations. Moreover, our results showed an improvement of sport activity levels, with patients recovering sports activity within three months of surgery and without limitation in the execution of preferred activities. LEVEL OF EVIDENCE: IV.

Gait analysis in children with haemophilia: first Italian experience at the Turin Haemophilia Centre.

AIM: To investigate the functional status in haemophilia patients referred to an Italian paediatric haemophilia centre using gait analysis, verifying any differences between mild, moderate or severe haemophilia at a functional level. METHODS: Forty-two patients (age 4-18) presenting to the Turin Paediatric Haemophilia Centre who could walk independently were included. Therapy included prophylaxis (n = 21), on-demand (n = 17) or immune tolerance induction + inhibitor (n = 4). Patients performed a test of gait analysis. Temporal, spatial and kinematic parameters were calculated for patient subgroups by disease severity and background treatment, and compared with normal values. RESULTS: Moderate (35.7%) or severe (64.3%) haemophilia patients showed obvious variations from normal across a variety of temporal and spatial gait analysis parameters, including step speed and length, double support, swing phase, load asymmetry, stance phase, swing phase and speed. Kinematic parameters were characterized by frequent foot external rotation with deficient plantar flexion during the stance phase, retropelvic tilt, impaired power generation distally and reduced ground reaction forces. Both Gait Deviation Index and Gait Profile Score values for severe haemophilia patients indicated abnormal gait parameters, which were worst in patients with a history of past or current use of inhibitors and those receiving on-demand therapy. CONCLUSION: Functional evaluation identified changes in gait pattern in patients with severe and moderate haemophilia, compared with normal values. Gait analysis may be a useful tool to facilitate early diagnosis of joint damage, prevent haemophilic arthropathy, design a personalized rehabilitative treatment and monitor functional status over time.

Alimentación enteral: vías de infusión / Enteral feeding: routes of food intake

The study of digestive pathophysiology and scientific advnces showed a better knowledge related to the invaluable usefulness of the nutritional stage and the importance of the intestinal route for feeding purposes. In this consideration, the enteral feeding is elective considered not only in patients with an adquate digestive function but further more with some difficulties or swallowing disturbances, but also in those patients that because of their underlying pathology can not feed tremselves by mouth in a temporary way. The caloric support by the intestinal route con be performed by nasoenteral tubes or osteomas as gastrostomies, gastrojejunostomy, jejunostomies and hepato-jejunostomies. The aim of this report eas to show our results with the different ways of enteral feeding. These results are presented and discussed.

Factors leading to hip subluxation and dislocation in femoral lengthening of unilateral congenital short femur.

Congenital short femur is a rare and complex deformity. For it to be treated in the most accurate way, we must know of every possible complication. The purpose of this study was to determine the factors leading to hip subluxation or dislocation in patients with an unilateral congenital short femur who underwent a femoral lengthening procedure. Forty-four patients with congenital unilateral short femora types I, II, and IIIA were seen between 1981 and 1993 at Alfred I. duPont Hospital for Children. Seventeen patients had type I, 9 patients had type II, and 18 patients had type IIIA. Twenty patients underwent simultaneous lengthening of the femur and tibia, and 24 patients had primary lengthening of the femur. Eleven patients had an epiphysiodesis of the contralateral femur for residual leg length discrepancies of <6 cm. We observed that in patients with type IIIA, the acetabular dysplasia is severe, as well as the coxa vara deformity, and is associated with progressive subluxation and dislocation of the hip with lengthening. We believe that the combined abnormality of coxa vara and bow of the femoral shaft contributes to hip subluxation and dislocation in congenital short femur in association with an acetabular dysplasia prior to the lengthening. We recommend correction of the varus bow of the femur and the neck-shaft angle to 120 degrees and the acetabular index to <25 degrees prior to lengthening of type IIIA femora.

Lateral column lengthening as treatment for planovalgus foot deformity in ambulatory children with spastic cerebral palsy.

The purpose of this study was to investigate the effectiveness of lateral column lengthening in the treatment of flexible, planovalgus foot deformity of ambulatory children with spastic cerebral palsy (CP). Fifteen ambulatory children (23 feet) with spastic CP and flexible planovalgus foot deformities received lateral column lengthenings through the calcaneus or calcaneocuboid joint. At an average of 4.1 years of follow-up (minimum, 2.3 years), 17 (74%) feet had good, two (9%) had fair, and four (17%) had poor outcomes. Poor outcomes resulted from recurrence of deformity. Improvements in preoperative, postoperative, and follow-up radiographic measurements were found. However, these improvements are not related to the clinical outcomes. Calcaneal lengthening is a successful treatment for flexible planovalgus foot deformity in ambulatory children with spastic CP. The high failure rate is a significant limitation to the procedure. Further investigation of the objective measurement of planovalgus foot deformity is needed.