Diagnostic algorithm for a validated displacement grading of pediatric supracondylar fractures.

BACKGROUND: The first AO comprehensive pediatric long bone fracture classification system has been established following a structured path of development and validation with experienced pediatric surgeons. METHODS: A follow-up series of agreement studies was applied to specify and evaluate a grading system for displacement of pediatric supracondylar fractures. An iterative process comprising an international group of 5 experienced pediatric surgeons (Phase 1) followed by a pragmatic multicenter agreement study involving 26 raters (Phase 2) was used. The last evaluations were conducted on a consecutive collection of 154 supracondylar fractures documented by standard anteroposterior and lateral radiographs. RESULTS: Fractures were classified according to 1 of 4 grades: I=incomplete fracture with no or minimal displacement; II=Incomplete fracture with continuity of the posterior (extension fracture) or anterior cortex (flexion fracture); III=lack of bone continuity (broken cortex), but still some contact between the fracture planes; IV=complete fracture with no bone continuity (broken cortex), and no contact between the fracture planes. A diagnostic algorithm to support the practical application of the grading system in a clinical setting, as well as an aid using a circle placed over the capitellum was proposed. The overall κ coefficients were 0.68 and 0.61 in the Phase 1 and Phase 2 studies, respectively. In the Phase 1 study, fracture grades I, II, III, and IV were classified with median accuracies of 91%, 82%, 83%, and 99.5%, respectively. Similar median accuracies of 86% (Grade I), 73% (Grade II), 83% (Grade III), and 92% were reported for the Phase 2 study. Reliability was high in distinguishing complete, unstable fractures from stable injuries [ie, κ coefficients of 0.84 (Phase 1) and 0.83 (Phase 2) were calculated]; in Phase 2, surgeons' accuracies in classifying complete fractures were all above 85%. CONCLUSIONS: With clear and unambiguous definition, this new grading system for supracondylar fracture displacement has proved to be sufficiently reliable and accurate when applied by pediatric surgeons in the framework of clinical routine as well as research. LEVEL OF EVIDENCE: Diagnostic study, Level II.

Solitary bone cyst of the jaws: a review of the etiopathogenic hypotheses.

Solitary bone cysts (SBCs) of the jaws are often polymorphic, show scalloped borders when located between the teeth roots, are devoid of an epithelial lining, and are usually empty or contain blood or a straw-colored fluid. The numerous synonyms referring to these lesions reflect their uncertain nature (eg, traumatic bone cyst, simple bone cyst). SBC, also found in other skeletal locations, is often suspected after epidemiologic and radiologic test results and confirmed at surgery. Histology usually shows fibrous connective tissue or only bone. The various etiologic elements responsible for SBC include tumor degeneration, trauma, or abnormalities during bone growth. The pathogenesis of the SBC is unknown, but it is widely accepted that it could be the result of a vascular dysfunction leading to a local posthemorrhagic ischemia, inducing an osseous aseptic necrosis. This article reviews likely but still-debated etiopathogenic hypotheses of lesions of the jaws and other, more frequent bony locations, such as the humeral and femoral metaphysis.

[The limping child with a painful hip]. / Boiterie et douleur de la hanche chez l'enfant.

Hip pain is a frequent cause for limping in children. Etiology work out is oriented by the age of the child, the existence of a traumatic or infectious background, the child's morphology and ethnic origin, and most of the diagnoses will require only a standard X-ray and an ultrasound to be confirmed. In this way, the three main causes to be considered in children of less than 10 years of age are septic arthritis, transient synovitis and Perthes disease. Septic arthritis will require an urgent treatment, whereas Perthes disease will need a long care and follow up in order to watch for a poor outcome that will necessitate a surgical treatment to restore containment of the femoral head. In the adolescent, especially in case of overweight, the first etiology to be considered is slipped femoral capital epiphysis, a condition that requires an early and adequate surgical treatment (in situ screw fixation), in order to avoid further displacement and femoral head deformity of poor prognosis.

Treatment of epiphyseo-metaphyseal fractures in children with an original implant. The threaded pin with an adjustable lock (Fixano).

OBJECTIVE: Improvement of stability of internal fixation of epiphyseo-metaphyseal fractures in children with an implant characterized by its small diameter, easy utilization and its versatility. It avoids the drawbacks of screw fixation particularly in respect to the growth plate. INDICATIONS: Potentially all epiphyseo-metaphyseal fractures in children. CONTRAINDICATIONS: None. Crossing of the growth cartilage by small pins (< 2 mm) is without consequences under the condition that no compression is applied and that correction of a faulty pin position is limited to one. SURGICAL TECHNIQUE: In general, two threaded pins are used. They are inserted in a divergent fashion after the fracture has been reduced. Percutaneous insertion is possible. An adjustable lock screwed on a special key is slid over the end of the pin and put in contact with bone. It is squeezed until the key breaks off. The pins are then shortened. RESULTS: Since November 1999 these pins have been used for six olecranon fractures. In January 2002 we extended the indication to other fracture sites. Between January 2002 and July 2003 this system has been used 37 times (six olecranon fractures, eleven lateral condylar fractures and 13 medial epicondylar fractures of the elbow, and seven fractures of the ankle). A total of 43 fractures were treated (20 girls, 23 boys, average age 9.8 +/- 3.6 years) Average duration of follow-up 16.8 +/- 4.7 months. The assessment of results was based on technical, radiographic, and functional aspects. The overall results were good, in particular in respect to the stability of implants and the functional results. No secondary displacement, nor nonunion were observed; the pins were removed in all children at 6 weeks. The ease of handling the implants and the good clinical and radiologic results led us to propose these pins for routine use in epiphyseal and epiphyseo-metaphyseal fractures in children. Some improvements, however, are indicated principally, in particular in respect to the control of compression achieved by the adjustable lock.

Long term follow up of two independent patients with Schinzel-Giedion carrying SETBP1 mutations.

Schinzel-Giedion syndrome (SGS, MIM #269150) is a rare syndrome characterized by severe intellectual disability, typical facial gestalt, hypertrichosis and multiple congenital malformations including skeletal, genitourinary, renal and cardiac abnormalities. The prognosis of SGS is very severe and death occurs generally within a few years after birth. In 2002, we reported 2 children with SGS with a follow-up of 3 years. They presented a very similar and particular phenotype associating distinctive facial gestalt, severe developmental delay, megacalycosis, progressive neurodegeneration, alacrimi, corneal hypoesthesia and deafness. Furthermore, temporal bone imaging revealed a tuning-fork malformation of the stapes. In 2010, Hoischen et al. identified in SGS patients pathogenic heterozygous de novo mutations in SETBP1. We sequenced SETBP1 in our patients and found the previously reported c.2608G>A (p.Gly870Ser) mutation in both children. Since 2002, one of our patients died at 6 years old and the other patient is still alive at 15 years old. Such a life expectancy has never been reported so far. We describe herein the follow up of the 2 children during 6 and 15 years respectively. This article gives further evidence of the implication of SETBP1 as the major gene of SGS, and reports the previously unseen natural evolution of the disease in a 15 years old patient.

Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results.

PURPOSE: A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN. METHODS: Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10-17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients. RESULTS: Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications. CONCLUSIONS: Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.

Treatment of congenital pseudarthrosis of the fibula by periosteal flap.

Pseudarthroses of the fibula are frequently associated with a pseudarthrosis of the tibia, but they can be isolated. To treat them it is usually necessary to have ankle alignment at skeletal maturity. We report six cases of fibular pseudarthrosis treated with periosteal flap, all having Recklinghausen's neurofibromatosis type 1. The mean age at the time of treatment was 4 years. Four children were diagnosed with isolated congenital pseudarthrosis of the fibula, with a simple curvature of the tibia, and two children had an associated pseudarthrosis of the tibia that was treated earlier. Treatment of the pseudarthrosis of the fibula was indicated to prevent a fracture of a curved tibia or to prevent ankle valgus. The technique of periosteal flap was different: in one case, the periosteum was taken from the fibular diaphysis as a free pedicled flap; in two cases, the flap was taken with its proximal pedicle; and in three cases, the flap was taken from the fibular diaphysis with its distal pedicle and returned to the pseudarthrosis. We analyzed the different operative techniques used for each patient, the complications and the functional result to follow-up. We did not use any osteosynthesis in two cases; a centro-medullary wire and a screwed plate were used in two cases. The pseudarthrosis healed in four cases in a mean period of 10 months. Healing was faster in the cases treated with distal pedicled returned periosteal flaps, a relatively simple technique not requiring vascular sutures. The distal pedicled returned periosteal flap permits good mobility of the periosteum and gives the best healing times. This treatment is indicated for young children to prevent a fracture and a pseudarthrosis of a dysplastic or congenital curvature of the tibia, or after treatment of congenital pseudarthrosis of the leg after healing of the tibia to prevent ankle instability and severe ankle valgus formation.

Image-guided laser ablation of osteoid osteoma in pediatric patients.

BACKGROUND: We aimed to evaluate the effectiveness of image-guided laser ablation for the treatment of osteoid osteomas in pediatric patients. METHODS: From June 1994 to June 2006, 68 patients aged 3 to 18 years (mean age, 12.1 +/- 4.2 years) with a diagnosis of osteoid osteoma underwent laser ablation in our department. Among them, 3 patients had prior unsuccessful attempt of surgical resection. Procedures were performed under spinal or general anesthesia with combined computed tomographic and fluoroscopic guidance. An 18-gauge needle was placed in the nidus after bone drilling when required, and an optical fiber was inserted through it. An average energy of 1200 J was delivered using an infrared diode laser generator. Patients were discharged the next day and followed up with assessment of pain, medication intakes, and potential complications. Clinical success was defined by complete pain relief without need for medication intake. RESULTS: Technical success was achieved in all but 1 of our first patients, which was subsequently treated by percutaneous resection. Overall clinical success was 98%. Primary clinical success was obtained in 60 patients (88%). In 7 patients, recurrence of symptoms at 4 to 27 months from the initial procedure was managed by repeat laser ablation, resulting in secondary success (10%). No complications related to the procedure were observed. Follow-up ranged 16 to 146 months (mean, 83 months). CONCLUSIONS: Currently, image-guided laser ablation is a safe and effective procedure that can be proposed as the mainstay treatment of osteoid osteomas in pediatrics. LEVEL OF EVIDENCE: Therapeutic case series study level IV.

The AO comprehensive classification of pediatric long-bone fractures: a web-based multicenter agreement study.

The first AO comprehensive pediatric long-bone fracture classification system has been proposed following a structured path of development and validation with experienced pediatric surgeons. A Web-based multicenter agreement study involving 70 surgeons in 15 clinics and 5 countries was conducted to assess the reliability and accuracy of this classification when used by a wide range of surgeons with various levels of experience. Training was provided at each clinic before the session. Using the Internet, participants could log in at any time and classify 275 supracondylar, radius, and tibia fractures at their own pace. The fracture diagnosis was made following the hierarchy of the classification system using both clinical terminology and codes. kappa coefficients for the single-surgeon diagnosis of epiphyseal, metaphyseal, or diaphyseal fracture type were 0.66, 0.80, and 0.91, respectively. Median accuracy estimates for each bone and type were all greater than 80%. Depending on their experience and specialization, surgeons greatly varied in their ability to classify fractures. Pediatric training and at least 2 years of experience were associated with significant improvement in reliability and accuracy. Kappa coefficients for diagnosis of specific child patterns were 0.51, 0.63, and 0.48 for epiphyseal, metaphyseal, and diaphyseal fractures, respectively. Identified reasons for coding discrepancies were related to different understandings of terminology and definitions, as well as poor quality radiographic images. Results supported some minor adjustments in the coding of fracture type and child patterns. This classification system received wide acceptance and support among the surgeons involved. As long as appropriate training could be performed, the system classification was reliable, especially among surgeons with a minimum of 2 years of clinical experience. We encourage broad-based consultation between surgeons' international societies and the use of this classification system in the context of clinical practice as well as prospectively for clinical studies.

Documentation of fracture severity with the AO classification of pediatric long-bone fractures.

BACKGROUND: The AO comprehensive pediatric longbone fracture classification system describes the localization and morphology of fractures, and considers severity in 3 categories: (1) simple, (2) wedge, and (3) complex. We evaluated the reliability and accuracy of surgeons in using this rating system. MATERIAL AND METHODS: In a first validation phase, 5 experienced pediatric (orthopedic) surgeons reviewed radiographs of 267 prospectively collected pediatric fractures (agreement study A). In a second study (B), 70 surgeons of various levels of experience in 15 clinics classified 275 fractures via internet. Simple fractures comprised about 90%, 99% and 100% of diaphyseal (D), metaphyseal (M), and epiphyseal (E) fractures, respectively. RESULTS: Kappa coefficients for severity coding in D fractures were 0.82 and 0.51 in studies A and B, respectively. The median accuracy of surgeons in classifying simple fractures was above 97% in both studies but was lower, 85% (46-100), for wedge or complex D fractures. INTERPRETATION: While reliability and accuracy estimates were satisfactory as a whole, the ratings of some individual surgeons were inadequate. Our findings suggest that the classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures.

Development and validation of the AO pediatric comprehensive classification of long bone fractures by the Pediatric Expert Group of the AO Foundation in collaboration with AO Clinical Investigation and Documentation and the International Association for Pediatric Traumatology.

A series of four agreement studies (classification sessions) were conducted to support the development and validation of a comprehensive pediatric long bone fracture classification system. This system follows the principle of the Müller-AO classification for long bones in adults and integrates most relevant existing pediatric classification systems. The diagnosis includes the distinction between epiphyseal (E), metaphyseal (M), or diaphyseal (D) fractures, as well as identification of child-specific features. This article describes the proposed system in some detail. Digital standard preoperative anteroposterior and lateral radiographs from 267 consecutive pediatric patients (<16 years old and open physis) with single fractures of the distal humerus, radius, or tibia were collected at a single university children's hospital. Fractures were classified independently by five experienced pediatric surgeons. The classification process was assessed for reliability using the kappa coefficient and accuracy using latent class modeling separately for each bone for bone type, and separately for each bone type for child codes. At the last classification session, kappa values for E-M-D and child code classifications were mostly above 0.90, and accuracy estimates were between 75% and 100% for different surgeons, types, and bones. Disagreement and misclassification of fractures were overall very low; hence, experienced and trained surgeons can classify pediatric long bone fractures using the proposed system with high accuracy based on standard radiographic views. The authors encourage wide consultation and further evaluation of this proposed pediatric long bone classification system with a larger number of future users with different training before being used for documentation and clinical studies.

Problems of operative and non-operative treatment and healing in tibial fractures.

Based on the experience of the department of pediatric surgery at the Strasbourg University Hospital, the authors present indications and limitations of various treatment techniques for tibial shaft fractures in children. Two retrospective series are reported on: one group of patients treated with the Sarmiento technique and one group of patients treated with Elastic Stable Intramedullary Nailing (ESIN or Métaizeau technique). The main problem in treatment is restoration of the mechanical axis of the tibia, especially in isolated fractures treated conservatively. Residual varus deformity is frequent, although it is usually within an acceptable range. ESIN has given better results than conservative treatment in this specific case, but valgus malunion shave been noticed when both bones were fractured, due to insufficient bending of the medial nail. ESIN is perfectly suited for treating polytrauma patients,especially those with multi level or open fractures (Gustilo 1 or 2), as it makes monitoring and nursing easier. Treatment of tibia fractures in children remains principally conservative. ESIN is indicated in cases of failure of conservative treatment, especially in isolated tibia fractures or polytrauma patients. For high grade open fractures (Gustilo 3)or extended comminuted fractures, external fixation remains the gold standard.

Surgical technique and preliminary results of a new fixation concept for olecranon fractures in children.

The authors report preliminary results of an original fixation technique used for the treatment of olecranon fractures in six children. This technique uses two threaded pins fitted with an adjustable lock, introduced through a minimal skin incision. With a mean follow-up of 14 months, clinical results are excellent in five cases and good in one case. Radiologic results are satisfying, with five anatomic reductions and without any secondary displacement. No growth impairment has been observed, but the follow-up period is still too short to conclude that this technique is superior, as far as this factor is concerned. However, the simplicity of the technique and its efficiency have led the authors to use it routinely for this fracture type.

Biomechanical analysis of olecranon fracture fixation in children.

The authors present an original fixation technique for olecranon fractures in children, achievable without opening the fracture site. The standard method of Kirschner wire fixation with tension band wiring is replaced by a threaded pin stabilization with adjustable lock effect. An olecranon fracture model was used to compare the mechanical properties of this new system with the tension band wiring technique, and with a simple pin fixation. No significant difference was found between the two first techniques, whereas the simple pin fixation had much poorer mechanical properties.