Sinus pericranii with facial involvement-A great mimicker.

Sinus pericranii is a rare vascular anomaly characterized by an abnormal communication between the intra- and extracranial venous systems through a calvarial defect(s). We present three cases of congenital sinus pericranii with facial involvement, emphasizing its cutaneous presentation with diagnostic pitfalls and discuss the multidisciplinary management of this vascular anomaly.

Inclusion Cysts after Fetal Spina Bifida Repair: A Third Hit?

INTRODUCTION: Fetal spina bifida repair (fSBR) has proven effective in the reversibility of hindbrain herniation, lower rate of shunt-dependent hydrocephalus, and independent ambulation. Besides distinct advantages, there are also concerns related to fSBR. One of these is the postnatal occurrence of inclusion cysts (IC). METHODS: In a prospective study, 48 children who underwent fSBR were followed up. Postnatal assessment included clinical examination, cystometry, and spinal MRI. Indication for IC resection was the evidence of a spinal mass on MRI in the presence of deteriorating motor or bladder function, pain, or considerable growth of the IC. RESULTS: Fourteen children (30%) developed IC, all within the first 2 years of life. Six children underwent IC resection; 4 children due to deteriorating function, 2 children due to doubling of the mass on MRI within 1 year. Following IC resection, 4/6 children (67%) demonstrated altered motor function and 6 children (100%) were diagnosed with neurogenic bladder dysfunction. CONCLUSIONS: Systematic follow-up of patients with a history of fSBR revealed a high incidence of IC. Whether these are of dysembryogenic or iatrogenic origin, remains unclear. Since both IC per se and IC resection may lead to loss of neurologic function, IC can be considered a "third hit".

Hydroxyapatite ceramic implants for cranioplasty in children: a single-center experience.

PURPOSE: The use of hydroxyapatite ceramic (HAC) implants for the treatment of skull defects in pediatric patients started 2010 at our institution. Ceramic implants facilitate osteoblast migration and therefore optimize osteointegration with the host bone. The purpose of this study is to report a single-center experience with this treatment modality. METHODS: A retrospective review of all patients from July 2010 through June 2014 undergoing a cranioplasty using hydroxyapatite ceramic implant and managed at a single institution was performed. Indication for cranioplasty, the hospital course, and follow-up were reviewed. Bone density was measured in Hounsfield Units (HU) and osteointegration was calculated using Mimics Software® (Mimics Innovation Suite v17.0 Medical, Materialize, Leuven, Belgium). RESULTS: Over the 4-year period, six patients met criteria for the study. Five patients had an osteointegration of nearly 100%. One patient had an incomplete osteointegration with a total bone-implant contact area of 69%. The mean bone density was 2800 HU (2300-3000 HU). Bone density alone is estimated to have a Hounsfield value between 400 and 2000 HU depending on the body region and bone quality. There were no major complications, and the patients were highly satisfied with the esthetical result. CONCLUSION: Hydroxyapatite ceramic implants for cranioplasty in pediatric patients are a good choice for different indications. The implants show excellent osteointegration and esthetical results.

Diagnostic performance of S100B protein serum measurement in detecting intracranial injury in children with mild head trauma.

OBJECTIVE: To assess the accuracy of S100B serum level to detect intracranial injury in children with mild traumatic brain injury. METHODS: A multicenter prospective cohort study was carried out in the paediatric emergency departments of three tertiary hospitals in Switzerland between January 2009 and December 2011. Participants included children aged <16 years with a mild traumatic brain injury (GCS ≥13) for whom a head CT was requested by the attending physician. Venous blood was obtained within 6 h of the trauma in all children for S100B measurement before a head CT was performed. As the S100B value was not available during the acute care period, the patient's management was not altered. The main measures were protein S100B value and the CT result. RESULTS: 20/73 (27.4%) included children had an intracranial injury detected on CT. S100B receiver operating characteristics area under the curve was 0.73 (95% CI 0.60 to 0.86). With a 0.14 µg/L cut-off point, S100B reached an excellent sensitivity of 95% (95% CI 77% to 100%) and 100% (95% CI 81% to 100%) in all children and in children aged >2 years, respectively. The specificity, however, was 34% (95% CI 27% to 36%) and 37% (95% CI 30% to 37%), respectively. CONCLUSIONS: S100B has an excellent sensitivity but poor specificity. It is therefore an accurate tool to help rule out an intracranial injury but cannot be used as the sole marker owing to its specificity. Used with clinical decision rules, S100B may help to reduce the number of unnecessary CT scans.

Intrathecal baclofen therapy in children with acquired brain injuries after drowning: A case series.

UNLABELLED: Objective: To investigate clinical efficacy as well as the incidence and extent of complications regarding intrathecal baclofen (ITB) therapy in children. METHODS: This is a retrospective medical chart review of three paediatric patients with acquired brain injuries (ABI) resulting from drowning who underwent ITB pump implantation for treatment of severe spasticity. RESULTS: Compared to the pre-operative state, ITB therapy reduced spasticity with a corresponding decrease of modified Ashworth scale in upper (3.2 ± 1.4 to 1.3 ± 0.6) and lower extremities (3.5 ± 0.9 to 2.0 ± 1.0). Overall, six complications, five device-related and one accidental, were found in two out of three patients. CONCLUSION: Intrathecal baclofen is an effective therapy option for paediatric patients with ABI after drowning to significantly reduce spasticity of upper and lower extremities. A word of caution must be addressed to the incidence and extent of complications related to ITB therapy.

Third ventriculostomy in a single pediatric surgical unit.

PURPOSE: Endoscopic third ventriculostomy (ETV) is a successful method of treatment for obstructive hydrocephalus that has become popular over the last 20 years. The purpose of this paper is to study the outcome of infants with obstructive hydrocephalus treated by ETV by a single surgeon and to evaluate the safety, reliability, and efficacy of this treatment. METHODS: All data were collected retrospectively. Between July 1999 and June 2005, 14 children underwent an ETV. In one child, a second ETV was performed. The age of the eight female and six male patients at the time of ETV ranged from less than 1 month up to 13 years and 11 months. The indication for an ETV was an obstructive hydrocephalus. Median follow-up period was 5 years and 9 months. The need of a further operation after ETV was defined as a failure of ETV. RESULTS: In six patients, the first ETV was successful. In the remaining eight patients, there was a need for further treatment (ventriculoperitoneal shunt). Although the follow-up shunt failed in one patient, he was successfully treated by a second ETV. CONCLUSION: Our study suggests that ETV can be successfully done in a small pediatric unit, but with a lower success rate because of small caseload, and therefore, lower experience and routine of the surgeon. Therefore, we propose a centralization of patients to obtain a higher number of cases. We confirm that ETV is a safe, reliable, and efficient method with a better outcome in children than infants.

Comparison of lower extremity fasciotomy wound closure techniques in children: vacuum-assisted closure device versus temporary synthetic skin replacement.

PURPOSE: No clear consensus on the optimal treatment of fasciotomy wounds due to acute compartment syndrome of the lower leg in children exists. We therefore compared two commonly used methods to close fasciotomy wounds, Epigard, a temporary synthetic skin replacement (SSR) and the vacuum-assisted closure (V.A.C.) device, in respect of treatment duration and complication rates. METHODS: We studied the cases of 27 patients who were treated at our institution for acute compartment syndrome of the lower leg with a fasciotomy over a 10-year period. The fasciotomy wound was either treated with SSR or V.A.C. device. We recorded the number of procedures to definitive wound closure, days to wound closure, hospitalization days and sequelae rate. RESULTS: In the V.A.C. device group (18 patients) the mean number of procedures until definitive wound closure was 3.1, mean days until wound closure was 9.4 and mean days of hospitalization was 16.2. One patient suffered from a wound infection and one patient required a full thickness skin graft. In the SSR group (9 patients), the mean number of procedures was 1.8, mean days until definitive wound closure was 4.9 and mean days of hospitalization was 9.9. No sequelae were recorded. There was a statistically significant smaller number of procedures (p value 0.018), fewer days to definitive wound closure (p value 0.002) and fewer hospitalization days (p value 0.005) in the SSR group. CONCLUSIONS: Both SSR and V.A.C. device are safe and reliable for closure of fasciotomy wounds in children, whereas SSR seems to lead to shorter time until definitive wound closure.

Intrathecal baclofen therapy in children with severe spasticity: Outcome and complications.

OBJECTIVE: To investigate clinical efficacy and incidence of complications regarding intrathecal baclofen (ITB) therapy in children. METHODS: Retrospective medical chart review of 15 paediatric patients with congenital brain injuries who underwent ITB implantation for treatment of severe spasticity between 2003 and 2009. RESULTS: Compared to the preoperative state, ITB therapy significantly reduced spasticity of lower limbs with corresponding decrease of the modified Ashworth scale (p < 0.05), while baclofen dosage increased (p = 0.001). Cobb angle of patients with scoliosis prior to ITB therapy (n = 8) increased significantly (p < 0.05) during follow-up. Overall, 10 complications (nine device related and one accidental) were found in six patients (40%), mostly emerging within the first three years after implantation. CONCLUSION: Intrathecal baclofen is an effective therapy option for paediatric patients to significantly reduce spasticity of lower limbs. The high incidence of complications implicates the need for a close monitoring of the patients especially in the early post-operative period.

Forearm fractures in children: split opinions about splitting the cast.

BACKGROUND: Fractures of the forearm are the most common fractures in children. Various methods of cast immobilization have been recommended. Currently, there is still controversy regarding the optimal method of treatment, especially regarding the need for cast splitting. METHODS: We conducted a single-center randomized and controlled trial between June 2008 and September 2009. Children younger than 16 years presenting to the emergency department with a closed fracture of the forearm needing reduction were eligible for random assignment to immobilization in a closed or split circumferential semirigid cast. The primary outcome was the incidence of cast-related soft-tissue problems such as compartment syndrome, neurovascular compromise, saw burns, or skin breakdown. The secondary outcome was fracture stability. RESULTS: During this period, 100 patients were randomly assigned to one of the two procedures and analyzed. Follow-up was completed in 99 patients. No compartment syndrome was observed in either group. Moderate skin breakdown (< 2 cm(2)) occurred in two patients, one in the closed cast and one in the split cast group. Secondary splitting was necessary in one patient because of a reversible lymphedema. Significant secondary displacement of the fracture was slightly more common in the split group (5 of 50 patients [10%] vs. 4 of 49 patients [8%] in the closed cast group) without reaching statistical significance. CONCLUSIONS: No significant difference in the incidence of cast-related problems was observed between the groups. Fracture stability was comparable in both groups. We suggest that closed circumferential semirigid casts are a safe and effective immobilization technique for fractures of the forearm in children and splitting can be omitted.

Intraventricular catheter placement by electromagnetic navigation safely applied in a paediatric major head injury patient.

INTRODUCTION: In the management of severe head injuries, the use of intraventricular catheters for intracranial pressure (ICP) monitoring and the option of cerebrospinal fluid drainage is gold standard. In children and adolescents, the insertion of a cannula in a compressed ventricle in case of elevated intracranial pressure is difficult; therefore, a pressure sensor is placed more often intraparenchymal as an alternative option. DISCUSSION: In cases of persistent elevated ICP despite maximal brain pressure management, the use of an intraventricular monitoring device with the possibility of cerebrospinal fluid drainage is favourable. We present the method of intracranial catheter placement by means of an electromagnetic navigation technique.

Treating Displaced Distal Forearm Fractures in Children.

PURPOSE: Distal forearm fractures are among the most common fractures in children. In the past few years the option of percutaneous pinning has gained more attention in the treatment of unstable fractures. However, it remains unclear in which cases a fracture or its reduction should be considered unstable. STUDY DESIGN: In order to evaluate which type of fractures profit most from additional pinning after closed reduction, we performed a retrospective analysis of 225 consecutive cases using the recently published AO pediatric classification of long bone fractures. RESULTS: After closed reduction, position in the cast was lost in 23% of the cases. The proportion of unstable reductions was much higher in completely displaced fractures. The amount of dislocation was more important than the type of fracture according to the AO classification proposal. CONCLUSIONS: Fully displaced fractures should always be reduced in a setting with pins immediately available. If anatomical reduction cannot be achieved, pinning is advocated. The AO proposal for pediatric long bone fracture classification could be a useful tool to render the diverse studies more comparable. However, the important feature of complete versus subtotal displacement is lacking.

Pelvic osteomyelitis: a diagnostic challenge in children.

BACKGROUND: Acute hematogenous osteomyelitis (AHOM) in children usually occurs in tubular bones. Acute hematogenous osteomyelitis of the pelvis is rare and is often not recognized primarily. METHODS: To review the experience with pelvic AHOM at our institution, we analyzed records from children diagnosed with pelvic AHOM (1984-2003) and compared with those reported in the literature. RESULTS: Among 220 children with AHOM (median age, 6.4 years), those 19 (9%) with pelvic AHOM were significantly older (median age, 9.0 years; range, 0.04-15.6). All children presented with limping or refused to walk. Twelve of 19 patients were febrile, 16 of 18 had elevated C-reactive protein (>20 mg/L), and 6 of 19 had leukocytes greater than 12 G/L. Staphylococcus aureus was isolated from blood or bone aspirates in 9 of 17 patients, and Streptococcus pneumoniae was isolated in 1. Scintigraphy was diagnostic in 15 of 15 children, and magnetic resonance imaging in 7 of 7 children. The mean time between initial symptoms and diagnosis was 3 days (range, 1-8 days). Infection resolved completely in all children after antibiotic therapy. CONCLUSION: Pelvic AHOM should be considered in children with limping and pain referred to the hip, thigh, or abdomen. Diagnosis by scintigraphy or magnetic resonance imaging followed by local puncture and microbiological workup allows for specific antibiotic treatment and results in an excellent outcome of pelvic AHOM.