Isolated Bilateral Upper Limb Amelia - A Rare Case Report.

Introduction: Congenital upper limb amelia is one of the extremely rare conditions. It is defined as a complete absence of upper limbs. It may present as isolated or with other associated anomalies. Case Report: We present a case of a 2-year-old male child with congenital complete absence of bilateral upper limb. This male child was born after four female children. With the advancement in modern-era prenatal diagnostic facilities and a better understanding of fetal-maternal drug pharmacology, such cases are rare entity. Conclusion: Amelia is a very rare and challenging situation for clinicians. Regular prenatal checkup and knowledge of maternal and fetal drug interactions during pregnancy are key factors for prevention.

A Rare Case of Fungal Osteomyelitis of the Distal Tibia in a Pediatric Patient.

Staphylococcus aureus infection is the most common cause of osteomyelitis. Over 100,000 fungal species have been described; only 150 are pathogenic to humans. These opportunistic infections frequently enter the body due to a decrease in host defense or through an invasive gateway, such as a dental extraction or skin discontinuity due to trauma. Symptoms and radiological examination often mimic those of other etiologies, which can lead to substantial delays in treatment. Our case is a 13-year-old healthy boy with no history of immune incompetency who presented to us with complaints of pain and swelling over his left ankle and leg with an on-and-off history of fever for 15 days. Based on his history and examination, he is diagnosed as having sub-acute osteomyelitis of the distal tibia with septic arthritis. The bacterial culture has no growth; however, the potassium hydroxide mount came positive for fungal elements having hyphae and pseudohyphae, and the fungal culture came positive for Candida. Management of fungal infections is challenging as they have infrequent involvement in bones. Fungal osteomyelitis is considered a rare entity in the literature, and the current case is studied for the management and diagnosis of a rare variant of osteomyelitis in the pediatric population. The treatment guidelines vary based on the identified organism and the duration of treatment. Debridement of fungal osteomyelitis or septic arthritis includes removing sinus tracts, evaluation for squamous cell carcinoma, bony and soft-tissue debridement, and antibiotic or antifungal bead placement. The spectrum of osteomyelitis ranges from Staphylococcus aureus organisms to tumors; therefore, it is necessary to investigate every spectrum of the disease, and fungal infections should be considered differential even though they are a rare entity. Early diagnosis, surgical debridement, and proper antifungal treatment based on fungal species lead to better clinical outcomes and results.

Bilateral Van Neck-Odelberg Disease: A Case Report.

Van Neck-Odelberg disease, also known as ischiopubic osteochondritis, is a rare cause of buttock or groin pain in the pediatric age group. The challenge in its diagnosis is due to its radiologic similarity. Ischiopubic synchondrosis occurs in childhood and is seen before the fusion of the pubis and ischium. With the advancement of age toward skeletal maturity, ischiopubic synchondrosis reduces in size and gradually vanishes due to synostosis or bony union. Here, we report the case of a 13-year-old girl who came to our outpatient department with complaints of bilateral groin pain for one year. After a thorough evaluation, she was diagnosed with a case of bilateral Van Neck-Odelberg disease, or ischiopubic osteochondritis, and conservative management was planned. Closure of ischiopubic synchondrosis varies with age and is usually finished before puberty. In a typical scenario, such fusion of the pubis and ischium does not lead to any clinical symptoms. However, in a few instances, children may experience some pain in the groin, hip, or gluteal region, which results in restricted movements at the hip joint and can lead to limping while walking. Van Neck-Odelberg disease is rare in children, causing pain in the groin region. As it is a rare condition, diagnosis is often missed. The radiological appearance suggests many differential diagnoses, such as a stress fracture, neoplasm, or infection. Prompt diagnosis and treatment can relieve the symptoms.

Prevalence and Associations of Depression in Parents of Children With Congenital Talipes Equinovarus: A Single-Centre Study.

INTRODUCTION: Congenital talipes equinovarus (CTEV) is a congenital deformity that requires weekly visits to the hospital for manipulation and corrective cast application, followed by an intensive bracing regimen requiring multiple visits to the hospital spread over the years. Parents of children with clubfoot are known to undergo a range of negative emotions. The objective of this study was to identify the prevalence of depression and the factors associated with depression in parents of children with idiopathic CTEV. METHODS: This cross-sectional study consecutively enrolled 190 parents of children with idiopathic CTEV undergoing treatment at King George Medical University. Parents with conditions that preclude the assessment of mental status were not included. These conditions include a history of head injury or psychiatric illness, parents with ongoing treatment of psychiatric illness, ongoing chronic illness, chronic neurological disease, and parents with clinically established intellectual disability. Information was recorded on certain parent-related characteristics and certain child-related characteristics. Parent-related information included age and sex of the parent, religion, area of residence, number of children in the family, degree of perceived social support (using the Multidimensional Scale of Perceived Social Support, MSPSS), level of education, socio-economic status, depression subscale score of DASS 21 (Depression, Depression Anxiety, and Stress Scale -21), chronic pain (visual analogue scale, VAS), family history of clubfoot or depression, and level of stress caused by a major life event during the past year using the Presumptive Stressful Life Event Scale (PSLES). Child-related information included the sex of the child, phase of treatment (casting or bracing), limb involvement (unilateral or bilateral), relapse of the deformity, and Pirani score of the deformity. Bivariate analysis and logistic regression were used to identify factors associated with a score ≥10 on the depression subscale of DASS 21. RESULTS: One hundred forty-five subjects were males (76.3%). The mean age of the enrolled parents was 28.47±4.89 years. The mean score on the depression subscale of DASS-21 was 4.87±6.3. Thirty-two parents (16.8%) had a score of ≥10 on the depression subscale of the DASS-21. On bivariate analysis, female sex, being Hindu, having studied up to class 12th, relapse, MSPSS score, and PSLES score were found to be associated with a score ≥10 on the depression subscale of the DASS-21. On logistic regression, female sex, lack of graduate education and above, and MSPSS scores were found to be significantly associated with a score of ≥10 on the depression subscale of the DASS 21 score. CONCLUSION: The prevalence of depression in parents of children with idiopathic clubfoot was 16.8%. Female gender, lack of college education, and the level of perceived social support (MSPSS) are independently associated with a score ≥10 on the depression subscale of DASS 21. We recommend screening parents of children with clubfoot and referring those with abnormal scores to a psychiatrist for a confirmed diagnosis.

The Effect of Vitamin D Deficiency as a Risk Factor of Early Fragmentation in Legg-Calve-Perthes Disease: A Prospective Study.

INTRODUCTION: Legg-Calve-Perthes disease (LCPD) is a disorder involving the hips in young children of preschool and school-going age groups, more common in 4-8 years. The insufficient blood supply to the femoral head is the main reason behind various etiologic theories. Multiple factors affect the natural progression of the disease. The natural progression of the disease involves early avascular necrosis, fragmentation, reconstitution, and healed stages. In the fragmentation stage, the bony epiphysis begins to fragment, and the subchondral radiolucent zone (crescent sign) is the result of a subchondral stress fracture, which later on determines the extent of a necrotic fragment of the femoral head. These changes later contribute to changes in the shape of the femur head and the extent of deformity. As vitamin D plays a vital role in the onset of the fragmentation stage, we conducted a study to assess the effect of vitamin D deficiency as a risk factor for early fragmentation in Legg-Calve-Perthes disease. METHODS: In our study, 50 patients aged 4-12 years were examined over three years and classified according to Catterall and Herring's lateral pillar classification; the length of the fragmentation stage and the vitamin D level were considered. A vitamin D level of less than 20 ng/mL was labeled as the deficient group, 20-30 ng/mL as the insufficient group, and more than 30 ng/mL as the sufficient (normal) group. RESULTS: The critical fragmentation stage was significantly longer (more than 12 months) in vitamin D deficiency (34%), leading to a higher risk of deformity and extrusion of the femoral head, which led to higher rates of surgical intervention and containment procedures. CONCLUSION: The fragmentation stage is critical in the course of LCPD. Vitamin D levels play a vital role in predicting the prognostic of LCPD, and it should be measured in all patients of LCPD. Patients with normal vitamin D levels have a comparatively shorter fragmentation stage duration than patients with insufficient or deficient levels, leading to a lesser duration of femoral head damage.

Transient inferior over-reduction after open reduction in walking-age DDH: A retrospective analysis of 42 Hips.

Background: Due to various policy and health infrastructure issues, it is not uncommon to present developmental dysplasia of hip(DDH) at walking-age in India. The purpose of this study was retrospective analysis of operated cases of walking-age DDH with "inferior over-reduction". Methods: "Inferior over-reduction" was defined as break in the Shenton's arc inferiorly in an operated hip which otherwise appears reduced. After Ethical Committee approval, we searched children operated for walking-age DDH. Children suggestive of syndromic association were excluded. We collected demographic data, follow-up, procedures performed, inferior over-reduction and complications. The IHDI grade, Acetabular Index(AI), Smith's ratio for superior (h/b) & lateral displacement(c/b) of femur, and clinical outcome (Modified McKay criteria) were evaluated. The outcomes of cases with inferior over-reduction(Group A) were compared with those without(Group B). Results: 42 patients with average follow-up of 23 months were enrolled. 21 hips belonged to Group A. By 6 months follow up, all these cases recovered. On comparison of Smith's ratio, group A had significantly higher c/b for the operated hip at 3-month follow-up(p < 0.05). Patients undergoing acetabuloplasty had significantly lower c/b versus all other groups(p < 0.05). Correlation between h/b or c/b with age did not show any significant finding. 15 cases in group A and 14 cases in group B had excellent outcome as per modified McKay's criteria. None of the patients had inferior over-reduction, inferior or obturator dislocation at final follow-up. Three patients with group B had re-dislocation with poor outcome. we recorded 3 hips with AVN (7%). Conclusions: This study highlights that after OR of walking-age DDH, the inferior over-reduction may be noted in as much as 50% of the cases. However, this is transient, and all cases recover by the 6 months follow up. There is no significant difference between group A & B in functional outcome, AVN rate. Long-term studies are required to see outcome differences between two groups.

Epidemiology of Pediatric Musculoskeletal Trauma Patients Admitted to a Trauma Center in Northern India: A Prospective Cohort Study.

Background Pediatric injuries are the leading cause of death and disability worldwide and place a considerable burden on nations with limited resources. A careful investigation of the epidemiology of pediatric musculoskeletal trauma can provide insight into its causation and the demography of the affected children and help us devise preventive strategies to reduce the burden of pediatric musculoskeletal trauma. Methodology Musculoskeletal trauma patients up to the age of 18 years were included in this prospective cohort study. Information about age, sex, time since the injury to presentation to a trauma center, mode of injury, the site where the injury was suffered, and the exact injury were recorded. Age was further recorded as 0 to 3 years, >3 to 6 years, >6 to 12 years, and >12 to 18 years. A subgroup analysis of the mode of injury was done using age group and sex.  Results A total of 201 patients were enrolled in the study. The age (mean ± standard deviation [SD]) of the enrolled patients was 12.48 ± 4.71 years. Of the 201 patients enrolled, 146 (72.63%) were males. The mean time since the injury to the reception in the emergency department of the King George's Medical University trauma center (a tertiary care center) was 19.13 ± 33.86 hours. The common mechanisms of injury observed were road traffic accidents (RTAs, 55.22%), falls from height (29.35%), and falls at ground level. There was a significant difference in the mode of injury in the age groups (P = 0.0297) and among males and females (P = 0.0034). Injuries to the lower limbs were most common in all age groups. Conclusions Our study presents the baseline epidemiological data on pediatric musculoskeletal injuries distributed by age groups, gender, mode of injury, site of injury, and region-wise distribution of injuries. The data may be used by policymakers in planning a pediatric trauma care system in India.

Late-Presenting Septic Arthritis of the Hip in Children: Variations in Presentation and a Review of 25 Hips After Surgical Debridement.

INTRODUCTION: The septic arthritis of the hip (SAH) is one of the most common musculoskeletal infections occurring in pediatric populations requiring urgent intervention. This study discusses the myriad of clinical and radiological presentations of late-presenting SAH in children and the outcomes of surgical management. METHODS: After ethical approval, we did retrospective reviews of children treated for late-presenting SAH (after five days of symptoms). We excluded late cases with established sequelae. We recorded age, duration of symptoms, clinical evaluation, and radiographs. We evaluated the final results clinically and radiologically. RESULTS: Twenty-four patients with 25 hips were eligible for evaluation. At presentation, all had decreased or painful hip movements, but none had a fever. Radiographs revealed the following changes: hip dislocation (four), capital femoral slip (seven), proximal femur/neck osteomyelitis (six), pathological fractured neck femur (two), iliac osteomyelitis (two), and early arthritic changes (two). Hip arthrotomy was done in all cases. Frank pus was found in 21 (84%) cases. Cases with capital slip and fractured neck femur required fixation with two smooth K-wires. Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in three patients and tuberculosis in two cases. Clinical outcomes showed 14 patients with poor outcomes, eight with fair, and two with good. Avascular necrosis (AVN) of the femoral head was noted in 14 hips and complete femoral head resorption in nine. CONCLUSIONS: The late-presenting SAH in children has a myriad of presentations including dislocation and capital slip with unsatisfactory outcome. However, ongoing local infective processes may necessitate debridement. With limited salvage options available at the sequelae stage, awareness and training for early diagnosis and treatment may be the best way to improve the scenario. We recommend future multicenter randomized studies of predictive factors and indications of arthrotomy in late presenters.

Complex Metacarpophalangeal Joint Dislocation of the Index Finger in Pediatric Age: A Case Report and Review of Literature.

Introduction: Metacarpophalangeal (MCP) joint dislocation is a rare occurrence in the pediatric population. A few case reports are available globally. Understanding of anatomy of the MCP joint is necessary for the surgical approach. We report a case of complex volar MCP joint dislocation in a pediatric patient. Case Report: We report a 13-year-old male child with traumatic dislocation of the MCP joint of the index finger. It was a complex volar dislocation that was surgically treated via a dorsal approach. On 6-month follow-up, child regained an almost normal range of motion at the MCP joint with a good functional outcome. Conclusion: Complex MCP joint dislocation often needs open reduction. Out of the two described surgical approaches, we preferred the dorsal approach which allowed proper visualization of the volar plate and avoided risks to neurovascular bundles. Early management and early mobilization provide good functional outcomes.

Impact of COVID-19 pandemic on clubfoot program at tertiary care institute.

PURPOSE: The COVID-19 pandemic had serious impact on health care sector. During reprioritisation of the services, elective and non-emergency procedures were suspended, with gradual resumption of services after lockdown was over. In this study we assessed the impact of pandemic on our clubfoot program at a tertiary care institute. Also, we discussed the future challenges and strategies to re-start our clubfoot program. METHODS: Data was collected retrospectively regarding registrations, demography and procedures done at our clubfoot centre. Study period was 25 March to 31 December 2020 and it was compared with same duration from previous years 2019 and 2018. After the data analysis, the findings were discussed on departmental committee meeting, future challenges were considered and strategies were charted out for re-establishing the clubfoot program at our Institute. RESULTS: When compared to previous year, we noted 46% decline in paediatric outpatient registrations and 60% decline in new clubfoot registrations at our centre. The clubfoot follow-up visits reduced by 30% in the pandemic year 2020. 80% of clubfoot registrations were local residents during pandemic year, which was 54%, 58% in year 2019 and 2018 respectively. The percentage of neglected cases remained stable, however, share of relapse cases increased during pandemic year. There was 80% decline in number of tenotomies and 90% decline in other clubfoot surgeries performed during pandemic year 2020 compared to year 2019. CONCLUSION: COVID-19 pandemic had definite disruptive impact on our clubfoot program. With decreased new registrations, follow-up visits and increased relapses, we anticipate a significant increase in clubfoot cases in need of casting & treatment. To deal with pent-up demand and an anticipated wave of relapse and neglected clubfoot cases, we have proposed strategies to re-establish clubfoot program in post-pandemic new-normal. We hope these will prepare us for any adversaries we face.

Comparison of clinic-radiological outcome of cross pinning versus lateral pinning for displaced supracondylar fracture of humerus in children: A randomized controlled trial.

INTRODUCTION: Supracondylar fracture of humerus (SFH) is frequently encountered in the immature skeleton, [1] predominantly in the non-dominant extremity. AIM: This study compared the clinic-radiological outcome between cross pinning with lateral pinning for fixation of displaced supracondylar fracture of humerus in children. MATERIALS AND METHODS: All eligible patients were randomized into two groups, group I for lateral pinning and group II for cross pinning. Before passing medial pin in group II a stab incision was given to visualise the medial epicondyle. Patients were followed up on 3 weeks, 6 weeks and 3 months. Final outcome was measured in terms of clinic-radiological union, Baumann angle, loss of reduction, stability of fracture fixation, incidence of iatrogenic nerve injury and Flynn's score. Results: There were 37 patients in group I and 40 in group II. Both groups were comparable in terms of demographic details. At the final outcome there were no difference in between the groups in terms of all radiological and clinical outcome. Two patients of group I developed delay ulnar neuritis, which resolve completely in subsequent follow-up. CONCLUSION: Both techniques provide stable fixation, union and good functional outcome without iatrogenic ulnar nerve injury provided that small incision sufficient enough to identify the medial epicondyle is given with passing of medial pin.