Acute compartment syndrome and fasciotomy after a viper bite in Italy: a case report.

BACKGROUND: Bites caused by European vipers are rare medical emergencies but can occasionally cause life-threatening complications. Viper venom causes local symptoms, which can be accompanied by systemic manifestations in severe cases. The local effects of snakebites include edema and, more rarely, necrosis and compartment syndrome. The consequences of envenomation are often more pronounced in children due to their smaller body size. CASE PRESENTATION: We present the case of a 6-year-old girl who experienced multiple viper bites in the lower limb in northwest Italy. The girl received supportive care but progressed to develop compartment syndrome that required emergency fasciotomy. The patient's condition improved promptly after surgical decompression and administration of antivenom, but full recovery required prolonged hospitalization and rehabilitation. CONCLUSIONS: This case highlights the importance of obtaining a timely assessment of the severity of viper envenomation without delaying the administration of antivenom in most serious cases. The presence of multiple bite marks on the patient is one factor that may help to predict the clinical severity of snakebites and anticipate symptom progression.

Synthetic Cast Material Versus Plaster of Paris for the Treatment of Idiopathic Clubfoot by the Ponseti Protocol: A Comparative Analysis of 136 Feet.

BACKGROUND: Synthetic casting materials have been used as alternatives to plaster of Paris (POP) in the treatment of clubfoot using the Ponseti method. The aim of this study was to evaluate the clinical outcome of children with idiopathic clubfoot managed by the Ponseti method using POP versus semirigid fiberglass (SRF). METHODS: Medical records were retrospectively reviewed for all newborns with idiopathic clubfoot who underwent manipulation and casting by the Ponseti technique between January 2013 and December 2016 at 2 different institutions. In all, 136 consecutive clubfeet were included, of which 68 underwent casting with POP (Group A), and 68 were casted using SRF (Group B). Statistical analysis was performed using the Fisher exact test for categorical variables, and the unpaired t test for quantitative parameters. RESULTS: Mean age at time of first cast was 10 days (range, 3 to 21 d). Mean Pirani score at start of treatment was 4.6 and 4.5 in Groups A and B, respectively. Mean number of casts for each patient in Group A was 5.2 against 4.2 in patients in Group B. Mean follow-up was 63.8 months (range, 42 to 88 mo). In each group, 4 cases of relapse were reported (2.9%). No complications related to cast phase or brace phase were recorded. Shorter duration of cast treatment was recorded in Group B. CONCLUSIONS: Despite its higher cost and slightly lower moldability, the use of SRF in experienced hands showed comparable results in idiopathic clubfeet treated by the Ponseti technique. LEVEL OF EVIDENCE: Level III.

Evolution over Time of Leg Length Discrepancy in Patients with Syndromic and Isolated Lateralized Overgrowth.

OBJECTIVE: To provide information on evolution over time of leg length discrepancy in patients with syndromic and isolated lateralized overgrowth. STUDY DESIGN: This retrospective study investigates leg length discrepancy longitudinally in 105 patients with lateralized overgrowth either isolated (n = 37) or associated with Beckwith-Wiedemann spectrum (n = 56) or PIK3CA-related overgrowth spectrum (n = 12). Discrepancy was measured by standard methods and categorized as minor, mild, severe, and critical, based on the thresholds of 1, 2 and 5, respectively. RESULTS: The period of observation from diagnosis was 1.7 ± 2.6 to 9.0 ± 6.0 years. Leg length discrepancy was 11.0 ± 7.2 mm at diagnosis and 17.1 ± 14.4 mm at last visit. Both final leg length discrepancy and change over time were correlated with discrepancy at diagnosis (r2 = 0.45, P < .001 and r2 = 0.05, P = .019, respectively). Among minor leg length discrepancy at diagnosis, 47.5% remained minor, 40.0% become mild, and 12.5% severe. Among patients with discrepancy classified as severe at diagnosis, 84.6% remained severe and 15.4% evolved to critical. The isolated lateralized overgrowth group showed a milder evolution over time compared with Beckwith-Wiedemann spectrum and PIK3CA-related overgrowth spectrum groups. Among patients with Beckwith-Wiedemann, those with paternal chromosome 11 uniparental disomy had more severe leg length discrepancy at diagnosis and evolution over time. CONCLUSIONS: Leg length discrepancy associated with isolated or syndromic lateralized overgrowth tends to worsen with growth and correlates with discrepancy at first observation. Among the genotypic groups, isolated lateralized overgrowth tends to have a milder evolution, whereas Beckwith-Wiedemann spectrum predisposes to a more severe outcome, especially if associated with paternal chromosome 11 uniparental disomy genotype.

Intraoperative Issues and Clinical and Radiographic Outcomes of Femur Fractures Treated With Flexible Nails: A Comparison of Cases Utilizing Skeletal Traction and a Traction Table to Cases Using Manual Traction Only.

INTRODUCTION: The use of the orthopaedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal femur fractures (DFFs) is still debated. In most centers, children with displaced DFF are treated using an OTT. In some other institutions, however, fracture reduction and stabilization by ESIN are performed on a radiolucent table without an OTT. The aim of this study was to evaluate the clinical and radiologic outcome of children with displaced DFF managed by ESIN with and without the use of an OTT. METHODS: Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining DFF managed by ESIN from 2011 to 2017 at 2 different institutions. In all, 69 consecutive children with displaced DFF were recorded, of whom 35 underwent operative treatment by ESIN with the use of an OTT with skeletal traction (Group A), and 34 by ESIN without OTT (Group B). The titanium elastic nails outcome measure scale score and Beaty radiologic criteria were used to evaluate the results. RESULTS: Average patient age at time of injury was 9 years (range, 5 to 13) and 10 years (range, 4 to 15) in Groups A and B, respectively. The mean follow-up was 54 months (range, 24 to 96). Overall, complications were observed in 6 patients (8.6%). Complication rate was higher among children managed without OTT (11.8%) than among children treated with OTT (2.5%); no complication related to pin insertion for skeletal traction was recorded. However, the number of patients with a poor outcome according to the titanium elastic nails outcome score was higher in Group A (20%) than in Group B (5.8%). Beaty radiologic criteria were comparable between the 2 groups. Mean length of surgery and mean cumulative time of radiation exposure during surgery were similar between the 2 groups. CONCLUSIONS: Overall, both techniques work equally well although patients treated by ESIN with the use of an OTT and skeletal traction tended to have a lower rate of complications and radiologic outcome was worse than for patients treated without using an OTT; however, no statistically significant difference was found.Despite their limitations, the results of this study suggest that displaced DFF can be safely managed by ESIN with or without the use of intraoperative OTT and skeletal traction, according to the surgeon's preference. Further studies are now needed to consolidate these conclusions and clarify the role of the OTT. LEVEL OF EVIDENCE: Level III.

Functional and radiographic outcomes of Gartland type II supracondylar humerus fractures managed by closed reduction under nitrous oxide as conscious sedation.

The management of Gartland type II supracondylar fractures remains controversial. This study aimed to evaluate the clinical, functional, and radiographic outcomes of Gartland type II supracondylar fractures treated by immediate closed reduction and casting in the emergency department using equimolar nitrous oxide as conscious sedation. All patients were treated non-operatively using equimolar nitrous oxide as conscious sedation during closed reduction and cast immobilization. Three out of 34 patients (three elbows; 8.8%) were lost during follow-up. The mean follow-up time was 26.4 months (range: 6-48). The mean Quick DASH score at cast removal was 22.4 (range: 19-40) and 2.3 (range: 0-9) at the last follow-up visit in patients without secondary displacement (n = 26; 76.5%). The mean Quick-DASH score of patients (n = 5; 16.1%) requiring closed reduction and percutaneous pinning under general anesthesia because of secondary displacement was 21.4 (range: 19-25) at cast removal and 0.9 (range: 0-2.3) at the last follow-up visit. No significant differences between the two groups were found at any time (P = 0.38 and P = 0.48, respectively). The two groups also showed a comparable radiographic outcome and similar Flynn's criteria. The mean Numeric Pain Intensity was three (range: 0-6). No complications related to the administration of equimolar nitrous oxide were recorded. The use of equimolar nitrous oxide as conscious sedation for closed reduction and casting appears to be a safe, inexpensive, and appropriate conservative method of treatment for displaced Gartland type II supracondylar fractures in children. A regular follow-up is mandatory to detect early secondary displacement, as 16.1% of fractures required additional closed reduction and percutaneous pinning under general anesthesia. Level IV, retrospective study.

Extra-articular proximal femur fractures in children and adolescents treated by elastic stable intramedullary nailing.

PURPOSE: Extra-articular proximal femur fractures (EPFF) remain challenging for their intrinsic instability. The aim of this study is to evaluate the results of elastic stable intramedullary nailing (ESIN) of extra-articular proximal femur fractures in children and adolescents. METHODS: A retrospective monocentric study of children treated by ESIN for EPFF between 2012 and 2018 was conducted. We included all patients sustaining a fracture within 10% of the femur length below the lesser trochanter. Studied data were age, sex, femur length, fracture distance below the lesser trochanter, number of days of hospitalization, time to nail removal, and complications. Beaty's criteria and the titanium elastic nailing (TEN) outcome measure scale were used to evaluate radiologic outcome and assess clinical recovery, respectively. RESULTS: A total of 24 cases were reviewed (18 males, 6 females). Mean age was 8.23 years (range 5-13). Mean duration of hospitalization was 3.7 days (range 2-12). Mean time to nail removal was 28 weeks (range 12-53). Malalignment was observed in five patients, but in all cases, angulation did not exceed 10°. No limb length discrepancy was observed. Twenty out of 24 patients had excellent Beaty's radiological and TEN clinical outcome scores. No poor results were observed. CONCLUSIONS: The results of our study show that good outcomes following surgical treatment by ESIN should be expected in children younger than 14 years of age with displaced EPFF. Excellent radiological and clinical outcomes were observed in 83.7% of the cases, with a low rate of complications and short hospital stay.

Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents.

The aim of this work was to evaluate the outcome and efficacy of treatment in a homogeneous group of skeletally immature patients with chronic osteomyelitis of the long bones managed by a combination of radical debridement and insertion of tobramycin-impregnated calcium sulfate pellets to fill the bone defect in a single-stage procedure. Between 2011 and 2016, 12 skeletally immature patients were treated surgically by the reported technique. Single-stage surgery using tobramycin-impregnated calcium sulfate pellets in association with systemic antibiotic therapy yields satisfactory outcomes in skeletally immature children presenting chronic osteomyelitis by reducing the risk of occurrence of comorbidities, hospital stays, and healthcare costs.

Complications of elastic stable intramedullary nailing of femoral shaft fractures in children weighing fifty kilograms (one hundred and ten pounds) and more.

AIM: The purpose of this study was to assess treatment outcomes in children weighing 50 kg (110 pounds) or more with displaced femur shaft fractures treated by elastic stable intramedullary nailing (ESIN) and to identify potential correlations between nail size/medullary canal diameter ratio and outcome. METHODS: Twenty out of 117 consecutive children surgically treated by ESIN for displaced fractures of the femoral shaft with no associated neurovascular injury weighed 50 kg (110 pounds) or more. All patients underwent regular clinical and radiographic follow-up for at least one year after their index surgery. RESULTS: The average patient age at the time of injury was 13.1 years (25th and 75th interquartile range [IQR] = 11.7-14.5). The mean follow-up was 27.4 months (IQR = 18.4-36.8). Overall, nine (45 %) adverse events were observed. The rate of complications was higher among children weighting 55 kg and over (67 %) than in children weighing less than 55 kg (35 %) and among children aged 13 years old or older (72 %) than among children younger than 13 years old (11 %). DISCUSSION: Femoral shaft fractures in children and adolescents weighing 50 kg (110 pounds) and over and older than ten years of age have an increased rate of complications. CONCLUSION: Heavier patients have a greater chance of complications. In particular, patients younger than 13 years old and weighing less than 55 kg can be safely managed with ESIN, but older and heavier patients should preferably be treated with rigid fixation systems due to a greater complication rate. However, further studies are needed to consolidate the conclusions.

Outcome of isolated olecranon fractures in skeletally immature patients: comparison of open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation.

PURPOSE: The olecranon fracture is an uncommon injury reported to incur many possible complications in children. The aim of this study was to compare the outcome of two different surgical techniques in isolated olecranon fracture. METHODS: We retrospectively evaluated 22 children with isolated olecranon fracture treated by open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation. We compared the dislocation before and after surgery by radiography. The patients were evaluated clinically with Quick DASH(®). RESULTS: Both techniques showed good radiological and clinical outcome (Quick DASH(®) 1.82 vs. 3.42) with no statistically significance difference (p > 0.05). In two cases (16.6 %) of the group treated with cannulated screw, it was necessary to convert into open reduction to obtain optimal reduction of the fracture. All the children returned to previous activity. In four cases, the extension of the elbow was slightly reduced (15°-20°), with no statistically significant difference in the two groups. CONCLUSION: It is not contraindicated to operate skeletally immature patients with displaced olecranon fracture. However, results were essentially the same, and so either method is a satisfactory choice for pediatric displaced olecranon fractures, with equally acceptable radiological results and similar rate of complications and clinical outcome at final follow-up. LEVEL OF EVIDENCE: III.

Displaced humeral shaft fractures in children and adolescents: results and adverse effects in patients treated by elastic stable intramedullary nailing.

PURPOSE: The objectives of this study were to retrospectively investigate the clinical and radiological outcome of humeral shaft fractures treated by ESIN in children <16 years old and to evaluate the functional outcome of these injuries using the short version of the Disabilities of the Arm, Shoulder and Hand Outcome questionnaire (Quick DASH(®)). METHODS: We retrospectively evaluated children with fractures of the humeral shaft, surgically treated by ESIN. All the patients were regularly followed clinically and radiographically for at least 1 year after their index surgery. After hardware removal, the patients were asked to answer the short version of the Disabilities of the Arm, Shoulder and Hand Outcome questionnaire (Quick DASH). RESULTS: Thirty-eight patients met the inclusion criteria. Mean age at the time of trauma was 11.1 years. Mean follow-up was 30 months. All fractures healed, but three patients had a residual valgus of >10°, two a residual varum of >10°, four a residual recurvatum deformity of >10°, and one a residual procurvatum deformity of >10°. Four complications were observed. Functional outcome was nevertheless good in all the patients, with a mean Quick DASH(®) score of 3. CONCLUSION: The study shows good clinical and functional outcomes in children and adolescents with closed isolated fractures of the humeral shaft surgically treated by ESIN, even with ensuing mild residual frontal and sagittal plane deformity. However, conservative treatment has also been advocated in the scientific literature for this type of injuries, and surgical treatment should not be considered as the only option for the management of humeral shaft fractures in older children and adolescents.

Displaced tibia shaft fractures in children treated by elastic stable intramedullary nailing: results and complications in children weighing 50 kg (110 lb) or more.

The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced tibia shaft fractures in children weighing 50 kg (110 lb) or more treated by elastic stable intramedullary nailing (ESIN). Translation, sagittal and coronal angulations were assessed on plain radiographs in all the patients. Twenty-six out of 106 patients met the inclusion criteria. The average patient age at the time of injury was 13.5 ± 1.3 years (range 11.3-16.1). The mean patient weight was 57 ± 8 kg (range 50-80). This study demonstrates that the use of ESIN for displaced tibia shaft fractures in children and adolescents weighing 50 kg (110 lb) or more, or older than 13 years of age, is not contraindicated. In contrast to data in femoral shaft fractures, we did not find poorer outcomes in older or heavier patients. No correlation between nail size/medullary canal diameter ratio and outcome was observed.