Irreducible Dislocation of the Great Toe Interphalangeal Joint, Dorsal, and Plantar. Management and Long-term Evolution.

Introduction: Irreducible dislocation of the great toe interphalangeal (IP) joint is a rare injury that has scarcely been reported in dorsal direction, but no reported in plantar direction. Closed reduction usually leads to sesamoid incarceration, making the reduction impossible. The purpose of this article is to review the management of irreducible IP dislocation of the great toe presenting three new patients who cover several forms: Open and closed dorsal Miki Type 2 dislocation and one chronic neglected plantar dislocation. Case Report: These three new cases demonstrate different presentations of IP (adolescents or young adults, open or closed, acute or chronic, dorsal, and plantar). Usually, Miki's Type I is the result of a failed IP dorsal Miki's 2 dislocation reduction. Closed reduction without traction is not usually sufficient, thus percutaneous reduction with K-wire fixation or open reduction should be employed. Open reduction was required in these cases. A Kirschner wire was used to for temporal immobilization in two of the cases and a buddy strapping securing to the second toe for 3 weeks in the three cases. Conclusion: In dorsal dislocations the reduction must be performed without axial traction and only by pressure in the base of the phalanx. Secondary to the trial of orthopedic reduction or spontaneously, incarceration of the sesamoids bones is the rule (Miki 1). In this situation, percutaneous or open reduction must be performed. Plantar dislocation does not provoque intra-articular sesamoid interposition. This article describes the first reported case of neglected plantar dislocation that required open reduction, similar management adding that the long-term functional prognosis is good.

Avascular necrosis of the proximal epiphysis of the first metatarsal bone in childhood. Long-term outcome.

Ten-year old boy with an 8-month history of limping for pain in the dorsomedial region of the right midfoot. At examination, there were signs of local swelling and tenderness to palpation, as well as antalgic gait with internal rotation. X-ray results showed widening of the proximal epiphysis of the first metatarsal. One month later, local fragmentation with hypodense and sclerotic areas was observed. MRI showed fragmentation, sclerosis, and collapse in the proximal epiphysis consistent with avascular necrosis of the proximal epiphysis of the first metatarsal bone. Patient was only recommended to avoid any physical activity that could increase the load on the foot, without pharmacological treatment. Symptoms spontaneously subsided over the course of six weeks and local pain disappeared after four months. Four years later, the patient remains asymptomatic, playing sports. A high index of suspicion is needed to avoid superfluous diagnostic tests, as it is a self-resolving lesion.

Prospective study of pediatric medial humeral epicondyle fractures nonoperatively treated. Clinical, radiologic, and functional evaluation at long term.

The objective of the study is to evaluate the natural history of the medial epicondyle avulsion in children with nonoperative treatment (NOPT) on different magnitude of displacement and long-term follow-up. A prospective study of 34 patients with medial epicondyle avulsion with (NOPT) was performed. Clinical test (stability, strength, atrophy, tenderness, Tinel test, and range of motion), subjective scores [Visual Analog Scale (VAS), Likert scale, side-to-side valgus test], and objective four scores were performed. Age at the time of injury was 8.9 ± 2.81 years. Follow-up was 7 ± 2.81 years. Four of the patients had anterior displacement. Displacement varied between 3 and 26 mm (10.49 ± 6.16 mm). Subjective: VAS and ordinal three-point Likert scale were excellent. Objective results were also excellent Mayo Elbow Score: 98.67 ± 4.31 (85-100), Oxford Elbow Score: 59.35 ± 1.68 (51-100), Elbow Assessment Score System: 96.27 ± 9.77 (57-100), Disabilities of the Arm, Shoulder, and Hand (DASH) score 0.64 ± 1.001 (0-4.16). We did not find any differences in strength or forearm diameter. There was an extension deficit in seven cases with a significant association with the magnitude of displacement (P = 0.02) and with the presence of concomitant lesions or anterior displacement of the medial epicondyle >5 mm. All except one were stable clinically on valgus stress. There is a significant association between the objective outcomes (scores) and concomitant lesions but not with regards to the DASH score P = 0.102). There is no association between the magnitude of medial epicondyle displacement or the follow-up and the objective outcomes. Instability was associated with valgus stress activities. There is no association between the magnitude of displacement of the medial epicondyle or the follow-up and the objective outcomes. NOPT produces excellent subjective and objective outcomes that worsened when there were associated lesions, anterior medial epicondyle displacement, or in patients who performed activities with repeated valgus stress. Based on our study, NOPT is suitable except for Open Reduction Internal Fixation indications: absolute indications, high energy injury with associated lesions, medial humeral epicondyle fracture in the dominant elbow in patients subject to activities with chronic valgus stress, and anterior displacement.

Dupuytren's disease in a child: a long-term evolution after surgery.

We report the case of a 13-year-old girl who presented with a fibrous nodular lesion on the palm of her hand. After ultrasonographic examination, surgical resection of the skin (dermofasciectomy) was performed, and a nodular phase mass was recovered, characterized as fusocellular fibroblast proliferation in a dense collagenous stroma with a cell population consisting of parallel fascicles of densely packed fusiform cells of a fibroblast strain. No signs of encapsulation or malignant changes were observed, all of which was consistent with Dupuytren's disease. This lesion is exceptional in childhood. Sixteen years later, the patient has not relapsed, and retains full active and passive mobility. Dupuytren's disease in childhood must be considered in the differential diagnosis of any hard palmar lesion. Diagnostic uncertainty and the fact that a hard palmar lesion in children may be clinically indistinguishable from a malignant process mean that resection of the lesion and histological examination are required.

Study of fall risk-increasing drugs in elderly patients before and after a bone fracture.

BACKGROUND: Accidental falls have a significant economic and human impact. The use of certain drugs is one of the modifiable risk factors associated with these events. OBJECTIVE: The aim of this study was to determine the prevalence of use and to explore changes in treatment with fall-related drugs in patients over 65 years of age admitted as a result of a fall-related fracture. METHODS: Observational and prospective study performed in a tertiary level hospital. A list of fall risk-increasing drugs (FRIDs) was drawn up. The main study variables were number and type of FRIDs prescribed at admission and 1 month after the fracture and number, type, treating physician and place where changes in FRIDs were implemented. RESULTS: In total, 252 patients were included. At admission, 91.3% were receiving at least one FRID, mean daily use was 3.1 FRIDs and the most frequently prescribed FRIDs were diuretics (18%), renin-angiotensin system-acting agents (15.8%) and antidepressants (15%). One month later, mean daily use was 3.4 FRIDs (p=0.099) and a significant increase was detected in the use of hypnotics (p=0.003) and antidepressants (p=0.042). A total of 327 changes in treatment were recorded (1.3 changes/patient). Of the changes, 52.6% were new prescriptions, 72.2% occurred at discharge and 56.6% were ordered by a geriatrician. CONCLUSIONS: The use of FRIDs among patients with a fall-related fracture is very high. This use rises 1 month after the fracture, significantly in the case of hypnotics and antidepressants.

Partial double-layered patella in a nondysplasic adolescent.

Double-layered patella (DLP) is a rare patella-formation abnormality reported in association with multiple epiphyseal dysplasia. DLP is one of the five types of bipartite patella, caused by a coronal septum that divides the patella into anterior and posterior segments. Although the double layer of bone has been reported as complete, it may also manifest as partial, as in our case. A 13-year-old male patient attended A&E after accidentally falling and sustaining a direct injury to his left knee, with pain in the anterior surface of the right patella. He was diagnosed with an incomplete vertical fracture of the left patella. An axial view radiography indicated an external partial DLP. No bone dysplasia was found. Computed tomographic scan and MRI showed partial DLP and bone marrow oedema because of the injury in the femoral condyle, but no fracture. The reason for highlighting this type of patella abnormality is to present the case of a patient without bone dysplasia, either partial or incomplete, that has not been reported previously. We also wish to emphasize the importance of not confusing it with a fracture in standard radiographies.

WITHDRAWN: Symptomatic Os Vesalianum Pedis: Long-Term Follow-Up of a Rare Entity in Childhood.

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Efficacy of reduction maneuvers for "pulled elbow" in children: a prospective study of 115 cases.

BACKGROUND: The objective of our study is to determine the relative efficacy of the 2 reduction maneuvers, hyperpronation (HP) and supination-flexion (SF), in pulled elbow (PE). METHODS: We conducted a randomized, prospective study of 2 reduction maneuvers in 115 patients with PE and a mean age of 2 years and 3 months. Patients were randomly divided into 2 groups: group A, with 65 children (56.52%) who underwent HP; and group B, with 50 children (43.47%) who underwent SF. RESULTS: In 97.39% of the children, reduction was achieved by manipulation. Reduction was achieved at first attempt (using either maneuver) in 101 of 115 patients (87.82%), with 93.84% success for HP and 80% for SF (P=0.0243). Most patients in whom our first attempts failed (85.71%) had undergone prior manipulation: 100% of treatment failures from group A; and 80% of failures from group B. Most (95.04%) patients in whom our first attempts succeeded had not undergone prior manipulation: 93.44% from group A; and 97.5% from group B. A significant relationship was found when comparing those who had undergone prior manipulation from group A (P=0.0001) and group B (P=0.000000072). CONCLUSIONS: Although both SF and HP are effective for reduction of PE, a higher first-attempt success rate was achieved by HP, and this should therefore be the first maneuver used. In recurring cases, it would seem appropriate to teach the child's parents the HP maneuver as the most effective and easiest to do.

Chronic exertional compartment syndrome of the forearm in adolescents.

PURPOSE: Chronic exertional compartment syndrome (CECS) is a well-known process, although rare in the forearm. The diagnosis is based on history, clinical examination, and compartment pressure readings. My objective is to present the largest series of CECS of the forearm in adolescents and describe my experience in its management and evolution. METHODS: I reviewed 5 patients, 4 male (competing in motorcycling or motocross) and 1 female (CECS in both the legs and forearms), aged between 15 and 18 years. Volar and dorsal compartments were affected in 3 patients and isolated volar in 2 cases. The clinical diagnosis was objectively confirmed by measuring ICP with a low-pressure digital transducer (Stryker). RESULTS: Open fasciotomy was carried out in 4 patients. They resumed their athletic activities 6 weeks after surgery without complications, increasing their athletic performance level in line with their preoperative status. All these patients remained asymptomatic, recovering their previous competitive levels. The results were objectively classified as excellent in all 4 cases. After a mean follow-up of 6 years, the condition has not relapsed in any of the patients. Two of the patients agreed to a new ICP measurement 1 year after the surgery, showing normal values. CONCLUSIONS: CECS in the forearm in adolescents is a rare condition that occurs after puberty. A high index of suspicion is necessary to diagnose it. It is based on symptoms and ICP measurements. Most patients are competing motorcyclists. Surgical treatment, involving isolated decompression of the superficial volar compartment, is safe and effective (restoring normal ICP).

Avascular necrosis of the intermediate cuneiform bone in a child: a very rare cause of limp in a child. A variant of the normality?

Only four cases of avascular necrosis in the intermediate cuneiform bone have been described. A new case of avascular necrosis of the intermediate cuneiform bone as a very rare cause of limp is presented. A boy aged 4 years and 4 months came to the clinic with a 1-month history of pain in the left foot and on palpation of the base of the third metatarsal of the left foot. There were no signs of inflammation, bruising, erythema or fever. In the radiograph, a clear increase in the radiological density of the second cuneiform bone was seen. No treatment was prescribed. The symptoms remitted spontaneously after 2 weeks. The pain did not return and the patient was asymptomatic after 3 months. Five months later he presented a normal radiograph, continuing to be completely asymptomatic. One year later, he remained asymptomatic and carried out normal sports activities. A high index of suspicion is necessary with the aim of avoiding the performance of superfluous diagnostic tests (laboratory tests, MRIs or technetium-99 bone scans). The indication of treatments should be avoided, including conservative treatments such as shoe inserts or casts. Given its benign nature as well as the possibility of it presenting with no symptoms, we believe that it may be considered as a variant of normality.

Primary obturator-muscle pyomyositis in immunocompetent children.

PURPOSE: Primary pyomyositis in immunocompetent children in non-tropical regions (countries with temperate climates) is very uncommon. It is rarely found in the intrapelvic muscles, and even more rarely in the obturator muscles. We try to draw attention to the potential occurrence in these conditions. METHODS: Five new cases of primary obturator-muscle pyomyositis in immunocompetent children aged between 6 and 11 years in a temperate climate are presented. They present with symptoms as follows: fever, pain (thigh, abdominal, inguinal, and/or hip pain), and limp. Three of them had no hip movement limitation. All of them had tenderness in the perineum zone. RESULTS: Laboratory tests may reveal high erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) counts, but depend on the length of diagnostic delay. The evolution time oscillated from 1 to 5 days. Fever and limp disappearance depends on the evolution time previous to the onset of the antibiotics administration. In 4 out of 5 patients, Staphylococcus aureus was present in the blood cultures. In all cases of obturator-muscle pyomyositis, diagnosis was confirmed using computed tomography (CT) scan (one) and/or magnetic resonance imaging (MRI) (four). CONCLUSIONS: Obturator-muscle pyomyositis is aimed at emphasizing the diagnostic difficulties associated with the condition, due to its deep location and to the fact that the disease presents with multiple manifestations that may initially cause confusion, since they mimic other conditions occurring in the abdomen, hip (septic arthritis, osteomyelitis), spine, etc. The diagnosis is only confirmed using CT scan and/or MRI. In the five patients with antibiotics treatment, the condition resolves without sequelae, even at long-term follow-up.

Developmental anterior dislocation of the radial head resulting from a congenital solitary osteochondroma of the proximal ulna in an infant.

A 4-month-old female infant was brought to our office by her parents, who had noticed a lump on the child's right elbow. Examination revealed a hard, painless lump in the antero-external region that was not reducible in flexion-extension or in pronation-supination. Neither palpation nor passive motion produced pain. Preoperative radiographs revealed a bony mass in the anteroexternal region of the proximal ulnar metaphysic (solitary osteochondroma), which was displacing the radial head into anteroexternal dislocation. No physiological bowing of the proximal metaphysis of the ulna was present. The infant underwent surgery at 6 months of age. No remains of the annular ligament were found. A complete resection of the tumour mass was performed, after which it was possible to reduce the radial head, together with the humeral condyle. Trans-radiocapitellar fixation was applied, with immobilization for 6 weeks. Subsequent radiological study revealed a congruent reduction of the radial head, with a progressive periosteal reaction of the posterior cortex of the ulna that evolved towards remodeling of the physiological bowing. Eight years after the surgery, the child remains asymptomatic, with complete range of motion and symmetric carrying angles. There were no relapses of osteochondroma, the deformity, or radioulnar synostosis.

L3-L4 dislocation without neurological lesions.

Vertebral dislocations are high energy injuries that rarely occur in the low back, but are found more frequently at the level of the thoracolumbar and sacrolumbar junctions. Dislocations of the mid-lumbar vertebrae are exceptional, with only 16 cases found in the literature. All previously reported cases were treated surgically. In four of these cases, the patients had no initial neurological lesions, and most of those who did have a neurological defcit exhibited some degree of recovery. We present the case report of an L3-L4 dislocation, without neurological lesions, resulting from an airplane crash. The anatomopathological mechanism of injury is discussed, together with treatment, which consisted of an initial closed reduction using a halo-bifemoral system, followed by pedicle instrumentation and arthrodesis from L2 to L5.

Anteromedial plantar nodules of the heel in childhood: a variant of the normality?

Localized, bilateral, painless, nonpruritic and symmetric papuloid lesions in the posteromedial part of the foot are the clinical features of benign plantar nodules of the heel in children. They are probably congenital; they are asymptomatic and benign. We present 18 children with posteromedial nodules of the heel, 15 bilateral. Mean age was 45.31+/-53.49 months. The reason for the consultation was the lump itself in 10 of the cases. Thirteen were asymptomatic and five presented transient tenderness to pressure. Radiographs were nonspecific in all cases. Sonography showed an accumulation of tissue similar to subcutaneous cell tissue, compatible with fat. MRI was performed in one case, showing an accumulation of fatty tissue similar to subcutaneous cell tissue. Follow-up time was 5.44+/-3.78 years (range 2-16 years). At the end of follow-up, all the patients are asymptomatic with normal functional outcome and with the lump persisting in all but one. In conclusion, a sonographic study is sufficient to diagnose this type of mass, without the need for biopsy and/or surgical exeresis to distinguish fatty tissue from another type of consistency. Subsequent studies should aim at showing piezogenic, hamartomatous or congenital fat herniation aetiology of these typical lumps, probably normal variant of normality.

Hair tourniquet syndrome of the toe: report of 2 new cases.

This report describes 2 new cases of toe tourniquet syndrome without accompanying signs of irritability. They were an 18-month-old girl and a 5-month-old boy suffering from strangulation of the third toe. The period of evolution was 20 days and 5 weeks. The toe worsened, with more extensive reddening and swelling, and deepening of the circular groove. Since a hair tourniquet was suspected, attempts were made to grasp the fiber with small-sized, blunt, and hook-shaped instruments, and mosquito clamp, with no success. The strand of hair compressing the toe lay deeper than expected. As improvement was barely noticeable, 2 dorsal paratendinous incisions were made and the hairs were extracted. Our aim is to raise awareness in the pediatric orthopaedic community of the existence of this syndrome, with a view to promoting the earliest possible diagnosis and appropriate management. In case of impossibility of removing the hairs we propose performing 2 dorsal paratendinous incisions, deep to the bone, to release completely the strangulation.