Epidemiological analysis of burn injuries in children during the first COVID-19 lockdown, and a comparison with the previous five years.

BACKGROUND: Child burns rank among the most frequent domestic accidents in France. COVID-19 lockdown between March 16th and May 11th of 2020 increased time spent at home by children. MATERIAL: This retrospective, observational study described the epidemiological impact of COVID-19 lockdown on child burns in a pediatric surgery department compared with previous five years. Child burns in the previous five years constituted the "before COVID-19 group" as the reference group. Child burns during the first lockdown formed the "COVID-19 group". Demographics characteristics, the delay before first attendance at the surgery department, burns characteristics, the place of the incident, need of skin graft, and child reactions to trauma or isolation were recorded for these two groups. RESULTS: A total of thirty-seven children were included, 16 of them in the COVID-19 group. In the COVID-19 group, burned children were mainly boys, with a median age of 18 months. The median time before first attendance was four days. Main burns characteristics were to be deep partial thickness burns, involved lower limbs, caused by scalding. All burns occurred at home. Half parents reported child reactions to trauma or isolation among their children before burn injury. CONCLUSION: The incidence of child burn injuries in the COVID-19 group was higher compared to the before COVID-19 group, but no increased delay to attendance recorded. Time spent at home and psychosocial impact of lockdown might partially explain this high incidence rate of child burns. LEVEL OF EVIDENCE: IV.

[Evaluation of a teaching tool for learning the surgical technique of inguinal orchidopexy]. / Évaluation d'un outil pédagogique pour l'apprentissage de la technique chirurgicale d'abaissement testiculaire.

INTRODUCTION: Practical training of the surgery resident is based on the companionship currently hampered in particular by the increase of the number of residents in training. We created a teaching tool to promote learning and validation of a technique of classic urologic surgery, inguinal orchidopexy. The objective is to evaluate the applicability and the relevance of this tool. MATERIAL AND METHODS: The tool is a technical evaluation sheet made from reference documentation. The trainers evaluated the residents at 3 times of the semester (hetero-evaluation at 0, 3 and 6 months). Residents evaluated themselves monthly on the same items. RESULTS: Three trainers and 6 residents in surgery participated in the study between May and November 2013. The initial evaluation confirmed that the theoretical knowledge was acquired prior to the practical learning. The level of residents was very uneven at the beginning of the study but not at the end of the semester. The monthly evaluations gave a progressive and significant increase of notes. The notes of the intermediate and final hetero-evaluations rose gradually and they were always superior to those previous self-assessments (P<0.05). The tool was considered simple and useful for the participants. CONCLUSION: This tool is applicable and relevant to the technical teaching of inguinal orchidopexy in this population. A larger study would be helpful to confirm it. This type of tool could be applied to the simple and common surgery techniques to enrich the educational tools used in the training. LEVEL OF EVIDENCE: 4.

Successful early surgical treatment in neonatal compartment syndrome: case report.

Neonatal compartment syndrome is rare, and the diagnosis is often missed or delayed because other ischemic diseases can mimic clinical signs observed on the skin. A premature newborn infant presented with skin lesions during the first hours of life that were recognized as the sentinel finding in compartment syndrome of the newborn. We restored normal function by emergency surgery. The authors highlight the importance of effective collaboration between pediatricians and surgeons to improve the management of this neonatal condition.

Use of an iliac crest growth plate for the development of a neo-articulation for congenital transverse deficiencies at the wrist.

PURPOSE: Terminal congenital transverse deficiencies of the wrist and hand are rare malformations. They are usually treated with prosthetic devices. We describe here a surgical technique to create a neo-articulation that could provide mobility distal to the forearm and help children with terminal transverse deficiencies use orthotic devices. METHODS: This procedure involved an autologous, nonvascularized graft from the immature iliac crest. The graft was placed with its cartilaginous side facing the radial and ulnar articular surfaces. We studied the clinical, radiological, and functional outcomes of this technique in 2 pediatric cases 5 and 14 years after this procedure. RESULTS: The x-rays showed a mobile graft distally in the forearm. Magnetic resonance imaging showed a space between the graft and the radius and an intermediate signal on either side of the space highly suggestive of articular cartilage. These various elements were organized into a neo-articulation between the forearm and the graft. The functional ability at follow-up was greater compared with the absence of a graft. CONCLUSIONS: The results of basic research work on cartilage and chondrocytes may help explain the presence of persistent cartilaginous tissue on the articulated part of the graft. The good functional outcome provided by our surgical procedure may translate into reduced need for prosthesis acceptance. Our surgical procedure does not restore limb length, but does add a new functional ability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Management of an outbreak of invasive Kingella kingae skeletal infections in a day care center.

BACKGROUND: Kingella kingae (Kk) is frequently responsible for invasive skeletal infections in children aged 3-36months. However, few outbreaks of invasive Kk infections in day care centers have been reported. The objective of the present study was to describe (a) the clinical and laboratory data recorded during an outbreak of invasive Kk skeletal infections, and (b) the management of the outbreak. METHOD: Four children from the same day care center were included in the study May and June 2019. We retrospectively analyzed the children's clinical presentation and their radiological and laboratory data. We also identified all the disease control measures taken in the day care center. RESULTS: We observed cases of septic arthritis of the wrist (case #1), shoulder arthritis (case #2), knee arthritis (case #3) ans cervical spondylodiscitis (case #4). All cases presented with an oropharyngeal infection and concomitant fever prior to diagnosis of the skeletal infection. All cases were misdiagnosed at the initial presentation. The mean (range) age at diagnosis was 10.75months (9-12). The three patients with arthritis received surgical treatment. All patients received intravenous and then oral antibiotics. In cases 1 and 2, Kk was detected using real-time PCR and a ST25-rtxA1 clone was identified. The outcome was good in all four cases. Four other children in the day care center presented with scabies during this period and were treated with systemic ivermectin. The Regional Health Agency was informed, and all the parents of children attending the day care center received an information letter. The day care center was cleaned extensively. CONCLUSION: Our results highlight the variety of features of invasive skeletal Kk infections in children and (given the high risk of transmission in day care centers) the importance of diagnosing cases as soon as possible.

Clinical features and outcomes in children with bone and joint infections of the ankle or foot.

BACKGROUND: The foot and ankle are uncommon sites of bone and joint infections (BJIs) in children. The objectives of the present study were to determine the clinical and bacteriologic features of BJIs and to assess any associated complications and orthopedic sequelae. METHODS: We performed a retrospective, single-center study of children treated for foot or ankle BJIs between 2008 and 2018 in a French university medical center. A total of 23 children were included. The median age at diagnosis was 9.1 years. Osteomyelitis was noted in 14 cases; it involved the calcaneus in seven cases, the distal fibula in four cases, the first metatarsal in two cases, and the distal tibia in one case. Arthritis affected the ankle in six cases and the cuneiform-cuboidal joint in one case. In two cases, osteoarthritis of the ankle was associated with distal osteomyelitis of the tibia. Clinical, radiological, and bacteriological parameters, surgical procedures, complications, and sequelae were recorded and analyzed. RESULTS: The median (range) time to diagnosis was 3.18 days (0-10), and trauma was reported in four cases. Fever was present on admission in 18 cases, and the serum C-reactive protein level was elevated in 22 cases. Standard X-rays showed osteolysis in one case and bone sequestration in another. Staphylococcusaureus was identified in 10 cases. Surgery was performed in 17 cases. A subperiosteal abscess that required surgical drainage complicated 10 cases of osteomyelitis. No recurrence was observed. At the last follow-up, the median (range) age was 11.9 years (1.5-19). Sequelae (spontaneous tibia-talus fusion, first metatarsal epiphysis fusion, and varus deformity of the hindfoot) were observed in three cases, all of which were initially complicated by an abscess. CONCLUSION: Physicians should be aware that pediatric BJIs of the lower limb may involve the foot and ankle. S. aureus is frequently involved. In cases of osteomyelitis, complications are closely associated with subperiosteal abscesses justifying an early diagnosis. These BJIs must be treated rapidly, and the risk of sequelae justifies long-term follow-up.

Aplasia cutis congenita of both knees: A new therapeutic strategy.

Aplasia cutis congenita is defined as the absence of all layers of the skin. The condition involves mainly the scalp but it can affect any area of skin on the body. A clear therapeutic strategy is not available. Here, we describe the 6-year clinical outcome of a patient with aplasia cutis congenita of both knees following treatment with an artificial dermis and a thin skin graft.

Development of a cadaveric training model for pollicization of the index finger.

There are currently no surgical models for learning index finger pollicization. This led us to develop and evaluate a cadaveric model for index finger pollicization. Ten hands from fresh cadavers were used. In each case, we evaluated all the surgical steps, the appearance of the web space, the new thumb's position, and the model's advantages and disadvantages. Flap coverage was insufficient due to poor skin condition in 3 cases and the commissure was too short in 3 cases. The dissection and tendon transfer steps were performed correctly in 9 cases. In one case, the interosseous transfer was too proximal. The new thumb was positioned correctly in 6 cases, too proximally in 3 cases, and was insufficiently rotated in one case. Our model reproduces the haptic characteristics of the surgical procedure and is valuable for dissection and flap coverage training.

Extravasation of calcium solution in the child: Value of negative-pressure wound therapy.

The extravasation of a calcium solution into soft tissue constitutes a medical emergency, and a lack of adequate management can lead to significant functional and cosmetic sequelae. Here, we report on the management of and long-term outcome in two children who experienced calcium infusion leakage. We also describe the emergency procedures used in cases of extravasation and discuss the role of negative pressure wound therapy as an appropriate adjunct to conventional techniques for dealing with serious extravasation-related injuries.

Forearm lengthening and prosthetic management in children with transverse congenital forearm deficiency.

In cases of transverse congenital forearm deficiency, achieving a good prosthesis fit during childhood remains a challenge. Ulnar lengthening is a treatment option for improving the prosthesis fit. The objective of this study was to evaluate surgical ulnar lengthening and the subsequent prosthesis fit. We reviewed four cases of ulnar lengthening in children with transverse congenital forearm deficiency. The procedure was evaluated in terms of the duration of lengthening, increase in ulnar length and healing index. The elbow range of motion, functional outcome (Prosthetic Upper Extremity Functional Index, PUFI) and time spent using the prosthesis per day were evaluated. The mean age at the time of the lengthening procedure was 3.5 years, the mean duration of lengthening was 58.3 days, the mean length gain was 21 mm, and the mean healing index was 70.1 days/cm. Elbow range of motion was restricted in one patient (100°-140°) and full in the other three patients. Based on the PUFI, 88.4% of activities were performed without the prosthesis. Children only used their prosthesis to perform specific tasks. Given the high complication rate and the lack of prosthesis use during daily activities, the main indication for forearm lengthening is a very short forearm that prevents prosthesis fitting. This procedure should be performed later in life - in adolescence.

Lawnmower accidents involving children: Characteristics and suggested preventive measures.

Although the absolute frequency of lawnmower accidents is low, children account for a relatively high proportion of the victims. We describe 16 children who were victims of lawnmower accidents between 2004 and 2016. Most of the accidents involved lower limb injuries, which were responsible for amputation and significant socioeconomic costs. We also propose preventative measures.

Late recurrence of an osteoarticular infection caused by Klebsiella pneumoniae in a child.

Klebsiella pneumoniae is an opportunistic pathogen in neonates. A 23-day-old newborn developed septic arthritis of the right hip due to an ESBL-producing strain. A recurrence on the knee was observed at 4 years of age. A molecular investigation confirmed the clonal link of the strains responsible for the two infections and allowed us to identify virulence factors.

[Slipped capital femoral epiphysis]. / Épiphysiolyse fémorale supérieure.

Slipped capital femoral epiphysis (SFCE) is a disorder of the hip, characterized by a displacement of the capital femoral epiphysis from the metaphysic through the femoral growth plate. The epiphysis slips posteriorly and inferiorly. SCFE occurs during puberty and metabolic and epidemiologic risk factors, such as obesity are frequently found. Most chronic slips are diagnosed late. Sagittal hip X-rays show epiphysis slip. In case of untreated SCFE, a slip progression arises with an acute slip risk. Treatment is indicated to prevent slip worsening. The clinical and radiological classification is useful to guide treatment and it is predictive of the prognosis. In situ fixation of stable and moderately displaced SCFE with cannulated screws gives excellent results. Major complications are chondrolysis and osteonecrosis and the major sequelae are femoroacetabular impingement and early arthritis.

[Congenital mesenteric band simulating a small-bowel volvulus in a mesenteric rotation anomaly]. / Bride mésentérique congénitale simulant un volvulus de l'intestin grêle sur anomalie de rotation mésentérique.

A congenital mesenteric band is a rare cause of intestinal obstruction. We describe a case of upper gastrointestinal obstruction on a jejunal congenital band in a 2-year-old child. The challenge is to make the diagnosis in a patient with no history of previous surgery.

Surgical technique and indications of the induced membrane procedure in children.

The induced membrane technique is now quite adaptable to segmental bone reconstruction in children. This technique is much the same as the technique used in adults. A cement spacer is interposed, and in a second operating phase, occurring 6 weeks after the interposition of the spacer, the cement is removed and a morselized corticocancellous graft is installed in the induced membrane that had formed around the cement. Graft expansion using allograft chips should not exceed 30% of the total volume. An additional autograft strut is useful in the reconstruction of long femoral or metaphyseal-diaphyseal tibial defects. Despite the apparent simplicity of this technique, it requires rigorous technique during cement sleeving and to stabilize the defect to prevent nonunion, stabilization device loosening, or resorption of the graft, the main complications. This technique is now becoming the gold standard for bone reconstruction in trauma and septic bone surgery. In pediatrics, the Masquelet technique is now mainly used in the context of cancer surgery reconstructions. Constraints related to chemotherapy have led to deferral of the graft, which is therefore empirically performed 8 weeks after the last course of chemotherapy. Congenital anomalies, including congenital pseudarthrosis, may now be treated using this technique, replacing long and difficult conventional treatment. A longer follow-up would be necessary to assess and confirm the superiority of this pediatric reconstruction technique.

Successful hemicondylar femoral allograft for traumatic bone loss: a paediatric case study with ten years of follow-up.

The management of massive traumatic defects of the knee joint is challenging, especially in children. Massive osteoarticular allograft may be an option in this kind of traumatic bone loss. We report on the case of a male patient who (at the age of 15) suffered an open grade III condylar femoral joint fracture, with a massive bone defect and a Schatzker V tibial plateau fracture. Ten years after first-line treatment with massive osteoarticular allograft of the lateral femoral condyle, the patient's knee was capable of full extension and 90° flexion. The patient reached a point of being pain free for nine years before he subsequently developed some pain with lateral arthritis progression.

Risk of sural nerve injury during lateral distal Achilles tendinoscopy: a cadaver study.

BACKGROUND: The risk of damage to cutaneous sensory nerves located near portals has been evaluated for both conventional arthroscopy and extra-articular posterior ankle endoscopy. The objective of the anatomic study reported here was to assess the risk of injury to the sural nerve or lateral calcaneal nerve while using the distal lateral portal for the Achilles tendinoscopy procedure described by Vega et al. in 2008. MATERIALS AND METHODS: We dissected the sural nerve and its branch, the lateral calcaneal nerve, of 13 human cadaver ankles in the prone position. We defined P as the point where the Achilles peritendon was opened during the distal lateral approach used for the study technique. P was adjacent to the lateral edge of the Achilles tendon, 2 cm proximal to the postero-superior edge of the calcaneal tuberosity. T was defined as the attachment site of the most lateral fibres of the Achilles tendon to the postero-superior edge of the calcaneal tuberosity. We evaluated the origin of the lateral calcaneal nerve relative to T and we measured the shortest distances separating P from the sural nerve and lateral calcaneal nerve. RESULTS: A lateral calcaneal nerve was identified in 10 (77%) ankles and originated a mean of 39.1mm (range, 25.0-65.0mm) proximal to T. P was at a mean distance from the sural nerve of 12.3mm (range, 5.0-18.0mm) and from the lateral calcaneal nerve of 6.8mm (range, 4.0-9.0mm). The median difference between these two distances was statistically significant (P=0.002). DISCUSSION: While using the distal lateral portal for Achilles tendinoscopy, the lateral calcaneal nerve is at greater risk for injury than is the sural nerve. LEVEL OF EVIDENCE: Level IV. Anatomic Study.

[Malleolar fractures. Predictive factors for secondary osteoarthritis. Retrospective study of 32 cases]. / Fractures malléolaires. Critères prédictifs de l'arthrose à long terme. Etude rétrospective de 32 cas.

The authors report a series of 32 ankle fractures treated by internal fixation and reviewed with a follow-up of more than 15 years. The series includes 12 fibular, 14 bimalleolar and 6 trimalleolar fractures. Following Weber's classification, there were 4 type A, 18 type B and 10 type C fractures. The postoperative x-ray showed 28 anatomy reductions; shortening of the fibula from 3 to 5 mm was noted in 4 cases. Clinical results were evaluated according to Kitaoka's criteria, and radiological results according to Magnusson's criteria. Statistical analysis was made with a Chi-square test. The retrospective review at an average follow-up of 15 years showed 19 painfree ankles, normal mobility in 22 cases, absence of edema in 18. The shoe-wear was normal in 30 cases. Walking had returned to normal in 23 cases but radiography showed narrowing of the tibiotalar joint line in 12 cases and lengthening of the medial malleolus in 16. Narrowing of the tibiotalar joint space was associated with lengthening of the medial malleolus in 10 cases. The objective results were rated as follows: 23 good, 8 fair, and 1 poor. With a follow-up of 15 years, we noted degenerative changes in the ankle in 37% of cases in spite of an anatomic reconstruction which had been perfect in 28. Shortening of the fibula, observed in 4 cases, was associated with subsequent ossification below the medial malleolus corresponding to avulsion of the non sutured medial collateral ligament. Nevertheless, degenerative changes of the ankle were clinically well-tolerated. The long term result of internal fixation of malleolar fractures was good. This was achieved only through perfect restoration of the joint anatomy. Contrary to other series, non-operative repair of the medial collateral ligament was associated with long team degenerative changes and reduced mobility of the joint. We therefore now advocate surgical repair of the medial collateral ligament.

Bone defect reconstruction in children using the induced membrane technique: a series of 14 cases.

INTRODUCTION: In pediatrics, Masquelet's induced membrane reconstructive technique has mainly been used in the context of cancer surgery reconstruction or congenital pseudarthrosis of the tibia. This retrospective study consisted of a series of pediatric patients where bone defects were reconstructed with this technique. MATERIALS AND METHODS: Between 2006 and 2011, 14 children underwent bone reconstruction using this technique in the context of trauma, tumor resection or congenital pseudarthrosis. The mean age was 10.6years (range: 12 to 17years) at the time of reconstruction. The length of the defect to be reconstructed relative to the length of the bone (index of reconstruction, expressed as a percentage) and bone healing was evaluated on standard radiographs. Complications were recorded. RESULTS: The mean index of reconstruction was 32.8% (range: 13.9 to 51%). The mean follow-up was 30months (range: 1 to 63). Bone union was achieved in 9.5months (range: 2 to 25). Complications mainly consisted of non-union in 35% of cases, which consolidated after grafting and rigid fixation. Two cases of wound dehiscence were noted. Massive graft resorption occurred in a single case. DISCUSSION: A technical error was identified in each non-union case (insufficient cement overlap of the bone ends or fixation not stiff enough). These long defects required a large volume of autograft, which constitutes the limiting factor especially in very young children. We used allograft bone chips or a tibial bone strut to increase the graft volume in the largest reconstructions. In this pediatric-only series, an average of one-third of the bone length was successfully reconstructed. Although the technique appears simple, it must be performed rigorously to ensure the cement sufficiently overlaps the bone ends and the defect is properly stabilized to prevent non-union, which is the main complication. LEVEL OF EVIDENCE: Level IV (retrospective study).