The Influence of the Q-Angle and Muscle Strength on Idiopathic Anterior Knee Pain in Adolescents.

Background and Objectives: Idiopathic anterior knee pain is a common condition in adolescents and is mostly of unknown cause. The aim of this study was to examine the influence of the Q-angle and muscle strength on idiopathic anterior knee pain. Materials and Methods: Seventy-one adolescents (41 females and 30 males) diagnosed with anterior knee pain were included in this prospective study. The extensor strength in the knee joint and the Q-angle were monitored. The healthy extremity was used as a control. The Student's paired sample t-test was applied for testing the difference. Statistical significance was set at 0.05. Results: There was no statistically significant difference in the Q-angle value between the idiopathic AKP and the healthy extremity (p > 0.05) within the entire sample. A statistically significant higher Q-angle of the idiopathic AKP knee (p < 0.05) was obtained in the female subgroup. No statistically significant difference (p > 0.05) was found in the male subgroup. Within the male subgroup, the strength of the extensors within the knee joint of the healthy extremity had statistically significant higher values than the strength of these muscles in the affected extremity (p < 0.05). Conclusion: A greater Q-angle is a risk factor linked to anterior knee pain within the female population. Decreased muscle strength of knee joint extensors is a risk factor linked to anterior knee pain in both sex subgroups.

The Magnetic Resonance Imaging Pattern of the Lesions Caused by Knee Overuse in the Pediatric Population.

Background and Objectives: Excessive use of the knee in patients with immature locomotor systems leads to a whole spectrum of morphological changes with possible consequences in adulthood. This study aimed to examine the morphological pattern in magnetic resonance imaging (MRI) that is associated with recurrent pain due to increased physical activity in children. Materials and Methods: This was a retrospective study conducted among pediatric patients treated at the University Children's Hospital in Belgrade in 2018 and 2019. MRI findings of patients who reported recurrent pain in the knee joint during physical activity and who were without any pathological findings on both clinical examination and knee radiographs were included in the study. Results: MRI findings of 168 patients (73 boys and 95 girls, mean age 14.07 ± 3.34 years) were assessed. Meniscus and cartilage lesions were the most commonly detected morphological findings: meniscus lesions in 49.4%, cartilage ruptures in 44.6%, and cartilage edema in 26.2% of patients. The medial meniscus was more often injured in girls (p = 0.030), while boys were more prone to other joint injuries (p = 0.016), re-injury of the same joint (p = 0.036), bone bruises (p < 0.001), and ligament injuries (p = 0.001). In children older than 15 years, tibial plateau cartilage edema (p = 0.016), chondromalacia patellae (p = 0.005), and retropatellar effusion (p = 0.011) were detected more frequently compared to younger children. Conclusions: Children reporting recurrent knee pain due to increased physical activity, without any detected pathological findings on clinical examination and knee radiography, may have morphological changes that can be detected on MRI. Timely diagnosis of joint lesions should play a significant role in preventing permanent joint dysfunction in the pediatric population as well as in preventing the development of musculoskeletal diseases in adulthood.

T-condylar humerus fracture in children: treatment options and outcomes.

Intracondylar T-type fractures of distal humerus represent a rare condition in paediatric population with unknown incidence since the literature is limited to case reports or case series. The main purpose of this article is to provide a comprehensive review of the current literature about the incidence and diagnostic modalities, as well as to evaluate all treatment options with results and complications. Review of the literature identified nine institutional reports in the period between 1984 and 2015, involving a total of 135 children and adolescents. Treatment options were open reduction with internal fixation and closed reduction in 118 and 17 cases, respectively. Open reduction was performed by different surgical approaches: triceps-sliding, triceps-splitting and olecranon osteotomy. Reported follow-up ranged from ten to 49 months. Outcomes were estimated by various tests, which are mainly based on range of motion. Patients younger than ten years generally had a better range of motion then older patients. Transient neuropathy and elbow stiffness were the most common complications, reported in 16.3% and 9.6% of cases, respectively. Despite the small number of reported clinical series, it is widely accepted that this fracture should be treated by open reduction with internal fixation to reduce and stabilise the displaced intra-articular fragments and to achieve anatomical congruity of the joint and integrity of medial and lateral columns.

TREATMENT OF UNICAMERAL BONE CYSTS IN CHILDREN: A COMPARATIVE STUDY.

Unicameral bone cysts (UBC) are benign bone tumor-like lesions. Mostly they are located in the metaphyseal-diaphyseal region of long bones in children and adolescents. The etiology of UBC is still unclear. There is no consensus about the protocol of UBC treatment. The aim of this study was to evaluate the effectiveness of three different techniques for the treatment of UBC. This study included 129 pediatric patients with UBC treated at University Children's Hospital in Belgrade during the 8-year period. The mean follow up was 7.14 years. The following parameters were observed: gender, age, site, length of cyst, cyst index, cortical thickness, presentation of pathologic fracture, healing of cyst, treatment complications and length of hospitalization. These parameters were correlated to three treatment modalities, i.e. intracystic methylprednisolone acetate injection (group 1), curettage with bone grafting (group 2) and osteoinductive procedure using demineralized bone matrix (group 3). We found statistically significant differences in healing of the cysts and length of hospital treatment between groups 1 and 2, and between groups 2 and 3. In conclusion, complete healing of UBC can be achieved only using open surgery procedure. Intracystic methylprednisolone acetate instillation can be considered a good option for initial treatment of UBC.

(Un)importance of physical therapy in treatment of displaced supracondylar humerus fractures in children.

Elbow joint stiffness is a common complication following supracondylar humerus fractures. In prospective study, dynamics of establishing a full range of motion in the elbow joint following the treatment of supracondylar humerus fractures were assessed, together with the effects of physical therapy on improvement in the range of motion. Two groups of patients were observed. Physical therapy was administered to the first group, comprised of 25 patients. The second group, comprised of 28 patients, underwent no physical therapy. In the first few months following treatment, the range of motion was significantly greater in the patients who had undergone physical therapy, but after 12 months, the range of motion was almost equal in the two groups. This study has shown that it takes about 12 months to establish a full range of motion after the injury, and that it is not necessary to apply physical therapy in patients with elbow fractures.

Treatment of congenital leg length discrepancies in children using an Ilizarov external fixator: a comparative study.

The purpose of this study was to evaluate the influence of intramedullary (IM) alignment used in combination with an Ilizarov external fixation on the healing index (HI) and lengthening index (LI) in the treatment of congenital leg length discrepancies (LLD). This study included 35patients aged from 3.5 to 19 (average age 10.73) who underwent thl egalisation procedure using an Ilizarov external fixator. We compared the duration of the external fixator application, LLD, HI and LI between two groups of children: children in Group I underwent limb lengthening by the conventional llizarov technique using an Ilizarov external fixator alone, and children in Group II underwent a combination of Ilizarov technique and intramedullary alignment with two Kirschner wires, introduced through two mini-incisions. We found significant differences between the two groups of patients for duration of external fixator application and HI. Patients with congeni- tal LLD treated with combined method of treatment had benefit from intramedullary alignment due to its better outcome.

Combined external fixation and intramedullary alignment in correction of limb length discrepancies.

The aim of this study was to evaluate the influence of intramedullary (IM) alignment used in combination with external fixation on the healing index (HI) and lengthening index (LI) in the treatment of congenital and acquired leg length discrepancies (LLD). We compared duration of the external fixator application, LLD, HI and LI between two groups of children: children in Group I underwent limb lengthening by the conventional llizarov technique, and children in Group II underwent a combination of Ilizarov technique and intramedullary alignment with Kirschner wires. Two types of LLDs were treated: congenital and acquired. We found significant differences between the two groups for duration of external fixator application and HI. Significant differences were also noted in the duration of the external fixator application, HI and LI, between patients with congenital and acquired LLDs. We also noted significant differences between Group I and Group II regarding duration of external fixator application for patients with congenital LLD and also regarding HI for both congenital and acquired types of LLD.

Correlation of ABO and Rh blood groups with transfusion administration and fever onset after hip surgery in children.

OBJECTIVE: Aim of our study was to evaluate distribution of ABO and Rh blood type groups in children after hip surgery regarding transfusion administration and fever presence. METHODS: Four types of ABO blood groups (A; B; AB; O) and 2 types of Rh blood groups (Rh+; Rh-) were evaluated in group with administered transfusion (tr+) and without given transfusion (tr-); and in group with fever (fev+) and without fever (fev-), in 146 children after hip surgery. Tr+ and fev+ groups were divided into 3 groups (0-24h; 25-48h; 49-72h): for tr+ group (Group 1, Group 2, Group 3), and for fev+ group (Group A, Group B, Group C). RESULTS: AB blood group significantly decreased in Group 1 (χ2= 6.44; p<0.05) and A blood group in Group 3 in tr+ group (χ2= 7.68; p<0.01). O blood group significantly increased in Group 3 in tr+ group (χ2= 9.96; p<0.01). AB blood group significantly decreased in Groups B (χ2= 12.2; p<0.01) and C (χ2= 4.2; p<0.05) in fev+ versus fevgroup. B blood group significantly increased in Group C (χ2= 34.4; p<0.01) in fev+group. CONCLUSION: Administration of transfusion and fever onset in pediatric patients undergoing surgical correction of the hip is not influenced by the ABO and Rh blood groups system in humans. There is correlation between distribution of ABO blood groups with the time of transfusion administration and fever onset in children after hip surgery.

Vitamin D and Forearm Fractures in Children Preliminary Findings: Risk Factors and Correlation between Low-Energy and High-Energy Fractures.

Background: The forearm is the most common fracture site in childhood, accounting for every fourth pediatric fracture. It is well described that vitamin D is involved in the regulation of bone mineralization and skeletal homeostasis by the regulation of calcium absorption. The aim of our study was to determine the influence of 25-hydroxyvitamin D levels on forearm fracture falls in a pediatric population, depending on level of energy impact. Additionally, we also aimed to evaluate the correlation between 25-hydroxyvitamin D levels and other tested risk factors for pediatric fractures. Methods: We evaluated 50 eligible children aged 3 to 12 years with a forearm fracture. According to energy impact, patients were grouped into low-energy fractures (LEF) and high-energy fractures (HEF) groups. The general characteristics of the patients included age, gender, sport participation, and fractured bone and its localization. We analyzed 25-hydroxyvitamin D, parathyroid hormone (PTH), calcium, magnesium, phosphate, C-reactive protein (CRP) levels, and body mass index (BMI). Results: There is a significant difference in the 25-hydroxyvitamin D levels distribution between LEF and HEF (p < 0.001) and PTH levels (p = 0.002). For magnesium levels, calcium levels, phosphate levels, and CRP levels, there were no significant differences in their frequency distribution. For the group of patients with LEF, there is a significantly positive correlation between 25-hydroxyvitamin D and calcium levels (p = 0.019) and a borderline significantly positive correlation between 25-hydroxyvitamin D and magnesium levels (p = 0.050). For the group of patients with HEF, there was only a significantly positive correlation between 25-hydroxyvitamin D and PTH levels (p < 0.001). Conclusions: Children with LEF were more frequently insufficient in 25-hydroxyvitamin D levels but had normal calcium levels, compared to the ones with HEF. These findings suggest that LEF and HEF in children might to a certain degree have different pathophysiological mechanisms.

Brachial plexopathy as a consequence of nerve root swelling after shoulder trauma in a patient following an acute seizure.

BACKGROUND: Epileptic seizures might be associated with an increased risk of fractures, either as a result of trauma after a fall or as a result of excessive muscle contraction. In the pediatric population, excessive muscle contraction is a more significant risk factor for fractures, due to the lack of maturity in the musculoskeletal system, while antiepileptic therapy itself can lead to a reduction of bone density. Proximal humeral fractures in the pediatric population are not frequent but both proximal humeral fractures and shoulder dislocation increase the chance of brachial plexus injuries and peripheral nerve lesions. CASE: In this case report, we present a patient who suffered both avulsive greater tuberosity humeral fracture and anterior shoulder dislocation, initially diagnosed by radiography, with consequent brachial plexus injury of the left arm after an epileptic seizure followed by excessive muscle contraction. Electromyoneurography initially showed amplitudes` reduction in tested nerves along with signs of muscle denervation as well as clinical examination signs of the left arm muscular hypotrophy and hypoesthesia, especially in the left humero-scapular region. Electrotherapy and kinesitherapy as well as intramuscular dexamethasone injections administered three weeks after the injury finally improved the clinical examination findings in the patient. CONCLUSION: The early detection of swelling compression, accompanied with appropriate therapy may prevent the progression of axonal damage and preserve the functional status of the affected limb.

Correlation between hypermobility score and injury rate in artistic gymnastics.

BACKGROUND: Generalized joint hypermobility (GJH) is suggested as a contributing factor for injuries in young athletes and adults. It is presumed that GJH causes decreased joint stability, thereby increasing the risk of joint and soft tissue injuries during sports activities. The aim of this study was to determine the correlation between the hypermobility score (using the Beighton`s modification of the Carter-Wilkinson criteria of hypermobility) in gymnasts and injury rate, during the period of one year. METHODS: This study observed 24 artistic gymnasts (11-26 years old), members of Qatar National Team in artistic gymnastics. We examined the Beighton joint hypermobility screen and a seasonal injury survey. The gymnasts characteristics (age, gender) and gymnastics characteristics (training per day and number of years in training artistic gymnastics) and their relations to injury rate were also included. RESULTS: The most common injury was the lower back pain injury, followed by knee, shoulder, hip and ankle injuries. We found strong correlation of number of years gymnastics training and injury rate (P<0.001). There is no significant correlation in the numbers of training hours during one week and hypermobility score to numbers of injuries (P>0.05). CONCLUSIONS: According to this study there is no correlation between GJH and injury rate in artistic gymnasts in Qatar. Total training period in gymnastics have greater contribution in injury rate.

A prospective randomised non-blinded comparison of conventional and Dorgan's crossed pins for paediatric supracondylar humeral fractures.

BACKGROUND: Closed reduction and percutaneous pinning are the preferred treatment of displaced supracondylar humeral fractures in children. The purpose of this study is to evaluate the non-standard Dorgan's method and compare its results with those of the standard percutaneous cross pinning method in treatment of unstable or irreducible Gartland type II and III supracondylar humeral fractures in children. PATIENTS AND METHODS: This was a prospective evaluation of 138 consecutive patients with Gartland type II or III extension supracondylar humeral fractures referred to University Children's Hospital during a four-year period. The patients were randomized into two groups: the first group, comprised of 71 patients, was treated with standard pin configuration and the second group, comprised of 67 patients, underwent Dorgan's method. The study included 88 boys and 50 girls aged 1.5-11.4 years (mean 6.5±2). At initial presentation 8.7% (n-12) fractures were classified as Gartland type IIa, 25.4% (n-35) as Gartland type IIb and 65.9% (n-91) as Gartland type III. RESULTS: Flynn's criteria were used to evaluate the results. An excellent clinical outcome was reported in about 90% of patients (n-90) treated with standard pin configuration and 89.5% (n-60) of patients treated with Dorgan's method. There were no statistically significant differences in outcomes between the groups in terms of their gender, age, fracture types, function and cosmetics. Neurological lesions were observed in 9.9% of patients (n=7) who were treated using the standard configuration Kirschner pins, while in those treated by Dorgan's method neurological complications were not observed. However, the procedure time was longer (mean 36.54±5.65min) and radiation exposure significantly higher (mean 10.19±2.70 exposures) in the group that was treated using Dorgan's method, compared to the conventional method (mean 28.66±3.76min and 7.54±1.63 exposures). CONCLUSION: Two laterally inserted crossed pins provide adequate stability with good functional and cosmetic outcome for most unstable paediatric supracondylar humeral fractures with no risk of iatrogenic ulnar nerve injury.

Displaced supracondylar humeral fractures in children: Comparison of three treatment approaches.

INTRODUCTION: Closed reduction and percutaneous pinning are the most widely used treatment options for displaced supracondylar humerus fractures in children, but there is still no consensus concerning the most preferred technique in injuries of the extension type. OBJECTIVE: The aim of this study was to compare three common orthopaedic procedures in the treatment of displaced extension type supracondylar humerus fractures in children. METHODS: Total of 93 consecutive patients (66 boys and 27 girls) referred to our hospital with Gartland type II or III extension supracondylar humeral fractures were prospectively included in the study over a six-year period. At initial presentation 48 patients were classified as Gartland type II and 45 as Gartland type III fractures. The patients were subdivided into three groups based on the following treatment modality: closed reduction with percutaneous pinning, open reduction with Kirschner wires (K-wires) fixation, and closed reduction with cast immobilisation. The treatment outcome and clinical characteristics were compared among groups, as well as evaluated using Flynn's criteria. RESULTS: Excellent clinical outcome was reported in 70.3% of patients treated with closed reduction with percutaneous pinning and in 64.7% of patients treated with open reduction with K-wire fixation. The outcome was significantly worse in children treated with closed reduction and cast immobilisation alone, as excellent outcome is achieved in just 36.4% of cases (p = 0.011). CONCLUSION: Closed reduction with percutaneous pinning is the method of choice in the treatment of displaced pediatric supracondylar humeral fracture, while open reduction with K-wire fixation is as a good alternative in cases with clear indications.

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period.

BACKGROUND: The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA). PATIENTS AND METHODS: The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed. RESULTS: There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation. CONCLUSION: IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

Femoral neck fractures in children and the role of early hip decompression in final outcome.

BACKGROUND: Femoral neck fractures in children are very rare and account for about 1% of all paediatric fractures. The aim of this retrospective study was to analyse the clinical and radiographic outcome in paediatric femoral neck fracture and to review the role of early decompression of the hip in the final outcome. PATIENTS AND METHODS: The study was performed at the Department of Paediatric Orthopaedics and Traumatology, University Children's Hospital in Belgrade, Serbia from January 1996 to January 2010. The study included 28 patients, 12 female and 16 male, aged 4-14 years. Patients who were aged over 14 years or who had pathological femoral neck fractures or metabolic disturbances were excluded from the study. The type of neck fracture was determined according to the Delbet and Colonna classification. The patients were treated using different surgical procedures: closed reduction and cast immobilisation, closed reduction and percutaneous fixation with Kirschner wires (K-wires), closed reduction and fixation with cannulated screws and open reduction with Wagner plate stabilisation. The final outcome was evaluated using the clinical outcome (based on the Howorth-Ferguson scale), radiographic outcome and occurrence of complications. RESULTS: The median age of patients included in the study was 10.75 years and the average follow up was 9 years. According to the Delbet classification, there was one patient with type I, eight patients with type II, 16 patients with type III and three patients with type IV femoral neck fracture. Based on the Colonna classification, there were 23 displaced and five non-displaced femoral neck fractures. Decompression of the hip was performed in 21 patients. Avascular necrosis (AVN) developed as the main complication in 11 patients. The final outcome was excellent in 14 patients, good in four patients and poor in 14 patients. CONCLUSION: Our study unequivocally confirms the positive effect of urgent treatment on the incidence of AVN as well as on the outcome. We have established a 12-hour interval after injury as an optimal time limit for commencing treatment. Unambiguously positive effects of hip decompression on the incidence of AVN were also noted. We found similar efficiency for open and needle hip decompression.

Evaluation of inflammatory markers after orthopedic surgical intervention in children.

OBJECTIVE: The study aim was to evaluate inflammation markers values (C-reactive protein (CRP), Erythrocite sedimentation (ES), White blood cells count (WBC)) in surgically treated pediatric patients with diagnosed developmental displasia of the hip or Perthes disease before and after operation. METHODS: We have evaluated 43 children (20 patients were with diagnosed unilateral developmental displasia of the hip while 23 had Perthes disease). Blood samples were drown at the admission and 5 days after admission, and further inflammatory parameters were analyzed: ES (mm/hour), CRP (mg/L) and WBC (x1000/mm3) count. RESULTS: Elevated erythrocite sedimentation (ESR) was significantly frequent than elevated CRP (p<0.01) and elevated WBC as well (p<0.01). Values of ESR and WBC do not correlate closely with age (FESR= 1.805; FWBC= 0.130; p>0.05) while CRP values correlate significantly with the age of the patients (FCRP= 4.948; p<0.05). The most frequently isolated marker was ESR (34.88%). The most frequent elevated two markers were ESR and CRP (44.19%). CONCLUSION: Surgical procedure could alter the values of inflammatory markers leading to the increasement even though there is no other clinical signs of infection. For estimation of the possible presence of the infection, clinical signs and patients intensive clinical follow-up after the surgery, should be done along with the evaluation of inflammatory markers.