Predictors for pathological bone fractures in children undergoing liver transplantation: A retrospective cohort study.

BACKGROUND: Hepatic osteodystrophy refers to bone disorders associated with chronic liver disease, including children undergoing liver transplantation (LT). The aim of this study was to quantify the prevalence of pathological fractures (PF) in children before and after LT and to identify associated factors for their occurrence. METHODS: Children aged 0-18 years who underwent LT from 1/2005 to 12/2020 were included in this retrospective study. Data on patient demographics, types and anatomical locations of fracture and biological workups were extracted. Variables were assessed at 3 time points: T - 1 at the moment of listing for LT; T0 at the moment of LT and T + 1 at 1-year post-LT. RESULTS: A total of 105 children (49 [47%] females) were included in this study. Median age at LT was 19 months (range 0-203). Twenty-two patients (21%) experienced 65 PF, 11 children before LT, 10 after LT, and 1 before and after LT. The following variables were observed as associated with PF: At T - 1, low weight and height z-scores, and delayed bone age; at T0, low weight and height z-scores, high total and conjugated bilirubin; at T + 1, persistent low height z-score. Patients in the PF-group were significantly more under calcium supplementation and/or nutritional support at T - 1, T0 and T + 1. CONCLUSION: More than one in five children needing LT sustain a PF before or after LT. Patients with low weight and height z-scores and delayed bone age are at increased risk for PF. Nutritional support remains important, even if to date it cannot fully counteract the risks of PF.

Benefits of diffusion-weighted imaging in pediatric acute osteoarticular infections.

BACKGROUND: Contrast-enhanced magnetic resonance imaging (MRI) is recommended for the diagnosis of acute osteoarticular infections in children. Diffusion-weighted imaging (DWI) may be an alternative to the injection of gadolinium. OBJECTIVE: To evaluate unenhanced MRI with DWI in comparison to contrast-enhanced MRI for the diagnostic work-up of acute osteoarticular infections in children. MATERIALS AND METHODS: This retrospective study included 36 children (age range: 7 months-12 years) with extra-spinal osteoarticular infections and MRI performed within 24 h of admission. MRI protocol included short tau inversion recovery (STIR), water-only T2 Dixon, T1, DWI, and gadolinium-enhanced T1 sequences. Two readers reviewed three sets of images: 1) unenhanced sequences, 2) unenhanced sequences with DWI and 3) unenhanced followed by contrast-enhanced sequences (reference standard). Sensitivity and specificity of sets 1 and 2 were compared to set 3 and assessed to identify osteoarticular infections: osteomyelitis (long bones, metaphyseal equivalents), septic arthritis and abscess (soft tissues, bone). RESULTS: All 14 cases of osteomyelitis in the metaphyses and diaphyses of long bones and all 27 cases of septic arthritis were identified by unenhanced sequences, but 4/16 abscesses were missed. For the diagnosis of abscess, DWI increased sensitivity to 100%. Among the 18 osteomyelitis in metaphyseal equivalents, 4 femoral head chondroepiphyses were identified by contrast-enhanced sequences only. CONCLUSION: MRI for suspected pediatric acute osteoarticular infections is the best diagnostic modality to guide patient management. An unenhanced protocol with DWI may be an alternative to a contrast-based protocol, even in the presence of an abscess. However, gadolinium remains necessary to assess for chondroepiphyseal involvement of the femoral head.

Epidemiological Study of Equestrian Trauma in Geneva.

BACKGROUND: Horse-related activities are increasingly popular among young people but are frequently associated with severe injuries requiring hospital treatment. There are few data on the incidence of equestrian injuries, especially in child populations, or on means of prevention. Thus, this study's purpose was to highlight the epidemiological data on specific injuries due to equestrianism and serve as the groundwork for future studies on the prevention of equestrian accidents. METHODS: A retrospective study collected data on all children younger than 16 years old who attended our regional emergency department after involvement in an equestrian accident. The study covered the periods from 1990 to 2003 and 2011 to 2018. Twenty-two years of data on trauma circumstances, injury patterns (mechanism, anatomic site, and severity), treatment protocols, and hospital lengths of stay were analyzed. RESULTS: This study confirmed that more young females participating in equestrian sports attended our emergency department than males. The leading cause of equestrian injury was falling from a horse (80.2%). Orthopaedic injuries represented around 60% of all reported lesions, far ahead of head injuries (30%). More than half of the injured children required hospitalization for inpatient medical care, and almost 50% of these underwent a surgical procedure, especially for upper extremity fractures (72% of all fractures). One patient died due to severe cerebral injury. CONCLUSIONS: Horse riding injuries occur more frequently and are more serious than in many other sporting activities. There is an urgent need to reassess preventive measures to reduce the incidence and severity of equestrian injuries. LEVEL OF EVIDENCE: Level IV.

Proximal Interphalangeal Hyperextension Injuries in Children: The Development of a Clinical Decision Guide.

OBJECTIVE: To develop a clinical decision guide for the diagnosis and treatment of hyperextension injuries of long fingers. STUDY DESIGN: Consecutive patients age <16 years (n = 300) with an acute proximal interphalangeal (PIP) joint hyperextension injury were included. High-risk and low-risk measures for severe injury were established with a standardized clinical examination and anteroposterior and lateral radiographs of the injured finger. Four clinical variables were assessed: location of pain; swelling and bruising, stability, and mobility. Pathological radiographic findings were compiled, and the risk of late complications was analyzed. The predictive value of the clinical examination in the identification of low-risk injuries was assessed. RESULTS: The majority (67%) of children consulting for a hyperextension finger trauma did not have a fracture. No child with a low-risk clinical examination had a subsequent high-risk diagnosis (eg, relevant intra-articular fracture, dislocation). Among 64 clinical high-risk diagnoses only 12 significant fractures were found. CONCLUSION: Treatment decisions after PIP hyperextension injuries can be based on a clinical examination using a standardized evaluation protocol. Application of the clinical decision guide presented here has a sensitivity of 100% to rule out a significant injury. Present results showed that the majority of radiographs currently performed are avoidable. Once the decision rule is validated, its clinical application will improve patient care, reduce waiting times in emergency departments, avoid unnecessary radiation exposure, and possibly reduce costs.

Recovery of Bone Mineral Mass After Upper Limb Fractures in Children and Teenagers.

BACKGROUND: Loss of bone mineral mass and muscle atrophy are predictable consequences of cast-mediated immobilization following wrist and forearm fractures. This study aimed to prospectively determine whether previously reported lower bone mineral mass following immobilization for wrist and forearm fractures in children and teenagers had recovered at 6- and 18-month follow-up. METHODS: We recruited 50 children and teenagers who underwent a cast-mediated immobilization for a forearm or wrist fracture. Dual-energy x-ray absorptiometry scans of different skeletal sites were performed at the time of fracture, at cast removal, at 6 and at 18-month follow-up. Injured patients were paired with healthy controls according to sex and age. Dual-energy x-ray absorptiometry values were compared between groups and the injured and uninjured forearms of the patients. RESULTS: At the time of fracture, injured and healthy subjects showed no differences between their bone mineral density (BMD) and bone mineral content (BMC) z-scores at the lumbar spine, or between their BMDs at the peripheral wrist. At cast removal, upper limb bone mineral variables were significantly lower in the injured group (except for the ultradistal radius) than in the uninjured group, with differences ranging from 3.8% to 10.2%. No residual decrease in bone mineral variables was observed at any upper limb site at 6- and 18-month follow-up (28 injured patients). Significant residual increases in the BMDs and BMCs were observed for the injured group's ultradistal radius and whole wrists (+4.8% to +5.2%). CONCLUSIONS: A rapid bone mass reversal occurs by resumption of mobilization, with full bone recovery 6 months after a forearm or wrist fracture. Finally, healing bone callus could introduce a bias into the interpretation of BMD and BMC data at the fracture site, not only at cast removal but also 18 months after the fracture.

Mechanism and predisposing factors for proximal tibial epiphysiolysis in adolescents during sports activities.

BACKGROUND: Proximal tibial epiphysiolysis (PTE) can have debilitating consequences for young athletes. The mechanism and predisposing factors for this lesion have yet to be determined. To find a common denominator and a biomechanical explanation for PTE, we were using a retrospective analysis of 15 cases in combination with a systematic review of literature. METHODS: A retrospective review of medical charts was performed to identify all PTE between 2003 and 2012. Records were screened for patient age and gender, sports activity, mechanism of injury, and treatment protocols. Additionally, a literature review (MEDLINE/PubMed database, the Cochrane Library, online search engines) was conducted. RESULTS: Medical charts of 14 adolescents (15 Salter-Harris I and II fractures) were analyzed. The literature review revealed additional 75 fractures. The predominant mechanisms were landing from a jump, takeoff for a jump, stop and go movements, and eccentric muscle contraction with the knee in flexion. The main sports-activities implicated in these injuries were basketball. CONCLUSIONS: Landing from a jump with a decreased knee and hip flexion movement increases tensile forces on the proximal tibia epiphysis. During physiological epiphysiodesis, the growth plate displays an increased vulnerability and such increased tensile forces can lead to a growth plate failure. Neuromuscular fatigue can alter coordination and proprioceptive accuracy during landing from a vertical jump and thus perturbs sagittal shock absorption. In our opinion, trainers should instruct young athletes in techniques that help avoiding uncontrolled high impact landings. LEVEL OF EVIDENCE: Level IV.

The Contemporary Bacteriologic Epidemiology of Osteoarticular Infections in Children in Switzerland.

OBJECTIVES: To assess the contemporary bacteriologic epidemiology of pediatric osteoarticular infection with particular regard to children's ages, because Kingella kingae has gained increasing recognition as the predominant pathogen for osteoarticular infection in young children. STUDY DESIGN: Retrospective file review of enrolled children from 0 to 15 years of age, admitted to our institution from 2007 to 2015 for suspected osteoarticular infection (217 cases). Information on age, sex, the bone or joint infected, imaging studies, and laboratory data (including bacterial investigations) were collected for analysis. RESULTS: Microorganism identification was possible for 138 infected children (63.6%), through blood (cultures or polymerase chain reaction [PCR]) and/or operative samples (cultures or PCR). Thirty-one patients (14.3%) were found to both have positive blood cultures and operative samples. The results of positive bacteriology specimens identified the most common causative pathogen for osteoarticular infection as K kingae (47.8% of microbiologically confirmed osteoarticular infections of all ages, and 87.7% in children between the ages of 6 and 48 months), significantly more common than Staphylococcus aureus (35.5% of microbiologically confirmed osteoarticular infections of all ages, and 78.2% in children >4 years of age). CONCLUSIONS: Use of the appropriate PCR assays demonstrated that K kingae currently is the major bacterial cause of pediatric osteoarticular infection, especially in children <4 years of age in whom K kingae is more common than S aureus. PCR assays should be used in routine microbiologic laboratory evaluation to improve diagnostic performance. However, despite the use of molecular methods, there are many osteoarticular infections in which no microorganism is detected, which suggests that these infections may be caused by other as yet unrecognized fastidious microorganisms.

A modified multilocus sequence typing protocol to genotype Kingella kingae from oropharyngeal swabs without bacterial isolation.

BACKGROUND: Outbreaks of Kingella kingae infection are an emerging public health concern among daycare attendees carrying epidemic clones in the oropharynx. However, genotyping of such epidemic clones from affected cases is limited by the low performance of current methods to detect K. kingae from blood samples and lack of specimens available from infected sites. We aimed at developing a modified multilocus sequence typing (MLST) method to genotype K. kingae strains from oropharyngeal samples without prior culture. We designed in silico MLST primers specific for K. kingae by aligning whole nucleotide sequences of abcZ, adk, aroE, cpn60, recA, and gdh/zwf genes from closely related species belonging to the Kingella and Neisseria genera. We tested our modified MLST protocol on all Kingella species and N. meningitidis, as well as 11 oropharyngeal samples from young children with sporadic (n = 10) or epidemic (n = 1) K. kingae infection. RESULTS: We detected K. kingae-specific amplicons in the 11 oropharyngeal samples, corresponding to sequence-type 6 (ST-6) in 6 children including the epidemic cases, ST-25 in 2 children, and 3 possible novel STs (ST-67, ST-68, and ST-69). No amplicon was obtained from other Kingella species and N. meningitidis. CONCLUSIONS: We herein developed a specific MLST protocol that enables genotyping of K. kingae by MLST directly from oropharyngeal samples. This discriminatory tool, with which we identified the first K. kingae outbreak caused by ST-6 in Europe, may be used in further epidemiological investigations.

Association between oropharyngeal carriage of Kingella kingae and osteoarticular infection in young children: a case-control study.

BACKGROUND: Kingella kingae has been increasingly identified in patients with osteoarticular infections. Our main objective was to evaluate the association between carriage of K. kingae in the oropharynx of preschool children and osteoarticular infections. METHODS: We conducted this prospective case-control study in 2 tertiary care pediatric hospitals (Canada and Switzerland) between 2014 and 2016. Potential cases were children aged 6 to 48 months with a presumptive diagnosis of osteoarticular infection according to the treating emergency physician. Confirmed cases were those with diagnosis of osteomyelitis or septic arthritis proven by positive findings on technetium-labelled bone scan or magnetic resonance imaging or identification of a microorganism in joint aspirate or blood. For each case, we recruited 4 age-matched controls from among children presenting to the same emergency department for trauma. The independent variable was presence of oropharyngeal K. kingae DNA identified by a specific polymerase chain reaction assay. We determined the association between oropharyngeal carriage of K. kingae and definitive osteoarticular infection. RESULTS: The parents of 77 children admitted for suspected osteoarticular infection and 286 controls were invited to participate and provided informed consent. We identified K. kingae in the oropharynx of 46 (71%) of 65 confirmed cases and 17 (6%) of 286 controls; these results yielded an odds ratio of 38.3 (95% confidence interval 18.5-79.1). INTERPRETATION: Detection of oropharyngeal K. kingae was strongly associated with osteoarticular infection among children presenting with symptoms suggestive of such infection.

[Corrective surgery for lower limb length discrepancy and malalignment in paediatric orthopaedics]. / Corrections d'axes et allongements des membres inférieurs en orthopédie pédiatrique.

Lower limb length discrepancy and malalignment in paediatric orthopaedics constitute a set of acquired or malformative structural pathologies. These anomalies, which may alter statics of lower limbs, are susceptible to engender an asymmetry of mechanical constraints' distribution across joints, and thus to promote the onset of arthritic phenomenons. The purpose of this review's article is to define the limits of tolerance of the various malformations and describe the innovative techniques available in order to correct them.

Les inégalités de longueur et les troubles d'axe des membres inférieurs constituent un ensemble de pathologies structurelles acquises ou malformatives. Ces anomalies, qui altèrent la statique des membres inférieurs, vont engendrer une asymétrie de répartition des contraintes mécaniques sur les différentes pièces osseuses et sur les articulations et, de ce fait, faciliter la survenue de phénomènes dégénératifs arthrosiques. Le but de cet article de synthèse est de définir les limites de tolérance des différentes malformations et de décrire les différentes techniques novatrices pour les corriger.

The Seatbelt Syndrome-Do We Have a Chance?: A Report of 3 Cases With Review of Literature.

The seatbelt syndrome represents an injury pattern seen after motor vehicle accidents. It is secondary to either the misplacement of seatbelts over the abdomen or the misuse of the restraint systems. This syndrome is infrequent in the pediatric population and occurs mostly in school-aged children because recommended lap-shoulder belts and booster seats are often not used in this age group, so that the seatbelt lies over the abdomen. Sudden deceleration bends the child around the lap belt causing injuries to the viscera, head, and spine (Chance fracture), often associated with paraplegia. Because not all patients have an abdominal seatbelt sign, this syndrome can easily not be recognized with potentially life-threatening consequences.We report on 3 patients with the seatbelt syndrome and review the literature regarding prevalence, diagnosis, treatment, and prognosis of the different injuries and discuss the diagnostic challenges of intestinal lesions and their management.Following this accident pattern, in hemodynamically stable patients with a normal abdominal computed tomography scan, close surveillance is warranted to rule out intestinal lesions manifesting with progressive peritoneal irritation. In hemodynamically unstable patients, or if there is evidence of free air on the computed tomography scan, emergency abdominal exploration is required.

Oropharyngeal Kingella kingae carriage in children: characteristics and correlation with osteoarticular infections.

BACKGROUND: The aim of this study was to investigate changes in oropharyngeal K. kingae carriage during the first 4 y of life, including seasonal variation and comparison of asymptomatic carriage with cases of invasive osteoarticular infections (OAI). METHODS: Oropharyngeal bacterial K. kingae carriage was screened in 744 healthy children aged 7-48 mo between January 2009 and December 2012. Oropharyngeal swabs were analyzed by rt-PCR targeting the DNA of K. kingae RTX toxin, epidemiological characteristics of asymptomatic carriers and OAI case patients were recorded. RESULTS: The carriage prevalence showed no significant difference between age groups or seasons. Compared with asymptomatic carriers, OAI cases were more likely to be aged from 7 to 12 mo (OR = 2.5; 95% CI (1.2-5.0)) and 13-24 mo (OR = 2.2; 95% CI (1.2-3.9)), and less likely over 36 mo (OR = 0.2; 95% CI (0.1-0.7)). Fewer OAI cases were identified in spring compared to asymptomatic carriers (OR = 0.3; 95% CI (0.1-0.7)), while more were detected in autumn (OR = 2.5; 95% CI (1.4-4.4)). CONCLUSION: Although oropharyngeal K. kingae colonization is a prerequisite for further invasive infection, this epidemiological study emphasizes that the carriage rate variations do not correlate with the variations of OAI incidence by gender, season, or age group.

Concomitant septic arthritis and osteomyelitis of the hip in young children; a new pathophysiological hypothesis suggested by MRI enhancement pattern.

BACKGROUND: In children, septic arthritis (SA) of the hip is either primary or concomitant with acute haematogenous osteomyelitis (AHO). However, seldom, patients with isolated SA at presentation, may later show osteomyelitis in the metaphysis. The aim of this study was to elaborate a physiopathological hypothesis based on the peculiar MRI findings to explain the onset of AHO after SA. METHODS: Cases of acute infection of the hip admitted between January 2010 and December 2013 were retrospectively reviewed to assess radiographic and MRI features, as well as bacteriological findings. Only children with isolated SA were included in this study, whereas cases of concomitant SA and AHO at presentation were excluded. RESULTS: Ten patients met the inclusion criteria. Six (1-11 months) demonstrated, on the initial MRI, decreased perfusion on gadolinium enhanced fat-suppressed T1-weighted sequence of the femoral epiphysis and developed one month later metaphyseal AHO. Four (5-14 years) did not show decreased perfusion and did not develop AHO on follow-up. The type of germ involved influenced neither the type of enhancement pattern nor the outcome. CONCLUSIONS: Age under one year and decreased perfusion of the affected femoral epiphysis increases the risk of secondary AHO. Our study is the first report in human medicine supporting the physiopathological hypothesis described by Alderson et al. in an animal model: primary infection can originally affect the joint, then penetrate the epiphyseal cartilage, and finally spread into the metaphyseal region through transphyseal vessels present only in the first 12/18 months of life.

Factors affecting bone mineral mass loss after lower-limb fractures in a pediatric population.

BACKGROUND: The purpose of this study was to assess the effects of the durations of cast immobilization and non-weight-bearing periods, and decreases in vigorous physical activity (VPA) on bone mineral parameters in a pediatric population treated for a lower-limb fracture. METHODS: Fifty children and teenagers who had undergone a cast-mediated immobilization for a leg or ankle fracture were prospectively recruited. The durations of cast immobilization and non-weight-bearing periods were recorded for each participant. Dual-energy x-ray absorptiometry scans were performed at the time of fracture treatment (baseline) and at cast removal. Physical activity during cast immobilization was assessed using accelerometers. RESULTS: A strong negative correlation was found between the total duration of cast immobilization and decreases in both calcaneal bone mineral density (BMD) (r=-0.497) and total lower-limb bone mineral content (BMC) (r=-0.405). A strong negative correlation was also noted between the durations of the non-weight-bearing periods and alterations in calcaneal BMD (r=-0.420). No apparent correlations were found between lower BMD and BMC and decreased VPA. CONCLUSIONS: Bone mineral loss was correlated to the total duration of cast immobilization for all measurement sites on the affected leg, whereas it was only correlated to the durations of non-weight-bearing periods for calcaneal BMD and total lower-limb BMC. However, no correlations were noted between bone mineral loss and decreased VPA.

Treatment of congenital thoracic scoliosis with associated rib fusions using VEPTR expansion thoracostomy: a surgical technique.

INTRODUCTION: Untreated growing patients with congenital scoliosis and fused ribs will develop finally thoracic insufficiency syndrome. The technique of expansion thoracoplasty with implantation of a vertical expandable prosthetic titanium rib (VEPTR) was introduced initially to treat these children. METHODS: This article attempts to provide an overview of the surgical technique of opening-wedge thoracostomy and VEPTR instrumentation in children with congenital thoracic scoliosis and fused ribs. RESULTS: Our modification of the surgical approach using a posterior midline incision rather than the modified thoracotomy incision initially described could potentially help to diminish wound dehiscence and secondary infection, while preserving a more acceptable esthetic appearance of the back. CONCLUSIONS: Vertical expandable prosthetic titanium rib-based treatments should be undertaken only with a good knowledge of its numerous specific complications. Every aspect of the treatment should be oriented to minimize these complications. At the same time it should be kept in mind that the ultimate step of this long-term fusionless treatment strategy will be a technically demanding spine fusion.

[Severe osteoarticular infections with Staphylococcus aureus producer of Panton-Valentine Leukocidine in children]. / Infections ostéo-articulaires sévères d staphylocoque doré producteur de leucocidine de Panton-Valentine chez l'enfant.

Emerging strain of Stapylococcus aureus (S. aureus) producer of the Panton-Valentine Leukocidine (PVL+) are becoming a new issue in public health. Those bacteria are accountable for serious cutaneous infection with a necrotic evolution, necrotizing pneumonia and severe osteoarticular infection. These last infections can be life-threatening and are at high risk of complications. Therefore, a multidisciplinary approach is necessary, in addition with an aggressive chirurgical treatment. We are here reporting 3 cases of osteoarticular infections by S. aureus PVL+ sensitive to methicilline, which illustrate the difficulties encountered in the management and treatment, as well as the potential for serious orthopedics complications.

The Kocher-Caird Criteria for Pediatric Septic Arthritis of the Hip: Time for a Change in the Kingella Era?

Pediatric septic arthritis of the hip (SAH) in children is a severe pathology, requiring prompt diagnosis and treatment to avoid destructive sequelae of the joint. Its diagnosis can be challenging, however, due to its spectrum of manifestations and differential diagnosis. Last century, multiple research teams studied the curves of systemic inflammation markers to aid the differential diagnosis. Kocher showed that a history of fever >38.5 °C, non-weight bearing, an erythrocyte sedimentation rate >40 mm/h, and serum white blood cells >12,000/mm3 were highly suggestive of SAH, with a predicted probability of 99.6% when all these predictors manifested in pediatric patients. Caird validated these criteria, also adding a C-reactive protein >20 mg/L, reaching a 98% probability of SAH when these five criteria were present. The Kocher and the Caird criteria were then applied in multiple settings, but were never clearly validated. Moreover, they were studied and validated in the years when Kingella kingae was just emerging, and this was probably responsible for false-negative cases in multiple centers. For this reason, the Kocher and the Caird criteria are still at the center of a debate on the diagnostic tools for pediatric SAH. We provide a historical overview of the development of clinical and laboratory test algorithms for pediatric SAH. Further, new perspectives for future research on the prediction rules of pediatric SAH are here proposed.

Shear fractures of the capitellum in children: a case report and narrative review.

The shear fractures of the capitellum are rare fractures in the pediatric population. Their diagnosis is challenging because of the high cartilaginous component of the growing elbow, requiring a high level of clinical suspicion especially in the case of small osteochondral or chondral fragments. The literature on capitellar shear fractures is mainly represented by case reports, which provides a patchy view of the topic. For this reason, we aimed to draw a narrative review presenting the available management strategies and their outcomes, and present two cases treated in our institution.

A retrospective epidemiological cohort study of ankle fractures in children and teenagers.

Background: Ankle fracture is one of the most frequent pediatric lower-limb fractures and may result in serious complications. Objective: This study aimed to determine the epidemiology of ankle fractures, defining fracture types, treatments, and complications in a pediatric population below 16 years old. Methods: Medical records of all the ankle fracture patients treated in our hospital during 2004-2020 were retrospectively reviewed. Data regarding age, sex, mechanism of injury, fracture type, treatment modalities, and complications were collected. Results: We examined records involving 328 children with 331 ankle fractures, with a ratio of 1:2 male per female. Mean annual prevalence was 24.3 per 100,000 children. Mean patient age was 11.2 ± 4.2 years, with 75.3% of them aged over 10 years. Sports activities accounted for the largest percentage of fractures (162 cases; 49.4%), followed by falls (67; 20.4%) and road traffic accidents (37; 11.3%). Physeal fractures were the most frequent type of lesion (223 cases). Most ankle fractures (60%) were managed using closed reduction and casting; for the remaining 40% of cases, fracture fixation was performed after closed or open reduction to correct the articular step-off and ensure the anatomical restoration of the physis. The main ankle fracture complication was premature growth arrest (12.1% of all physeal fractures). Conclusion: Pediatric ankle fractures primarily affect children older than 10 years. Most of these fractures were caused by sports injuries or low-energy trauma. The majority of these fractures are physeal, and the distal tibial physis is affected 10 times more frequently than the distal fibular physis. Level of evidence: Level III.

Clinical and Biologic Characteristics of Kingella kingae -Induced Septic Arthritis of the Knee in Young Children.

BACKGROUND AND OBJECTIVES: Septic arthritis of the knee is presumed to be the most frequent form of Kingella kingae -induced osteoarticular infection. This study aimed to report on the clinical course, biological parameters, and results of microbiological investigations among children with K. kingae -induced septic arthritis of the knee. It also assessed the modified Kocher-Caird criteria's ability to predict K. kingae -induced septic arthritis of the knee. METHODS: The medical charts of 51 children below 4 years old with confirmed or highly probable K. kingae -induced arthritis of the knee were reviewed. Data were gathered on the five variables in the commonly-used Kocher-Caird prediction algorithm (body temperature, refusal to bear weight, leukocytosis, erythrocyte sedimentation rate, and C-reactive protein level). RESULTS: Patients with K. kingae -induced arthritis of the knee usually presented with a mildly abnormal clinical picture and normal or near-normal serum levels of acute-phase reactants. Data on all five variables were available for all the children: 7 children had zero predictors; 8, 20, 12, and 4 children had 1, 2, 3, and 4 predictors, respectively; no children had 5 predictors. This gave an average of 1.96 predictive factors and a subsequent probability of ≤ 62.4% of infectious arthritis in this pediatric cohort. CONCLUSIONS: Because the clinical features of K. kingae -induced arthritis of the knee overlap with many other conditions affecting this joint, the Kocher-Caird prediction algorithm is not sensitive enough to effectively detect K. kingae -induced septic arthritis of the knee. Excluding K. kingae -induced arthritis of the knee requires performing nucleic acid amplification assays on oropharyngeal swabs and joint fluid from those young children presenting with effusion of the knee, even in the absence of fever, leukocytosis, or a high Kocher-Caird score.