Observation versus Cast Treatment of Toddler's Fracture: A Prospective Pilot Study.

"Toddler's fractures" are common in the pediatric population. Traditional treatment recommends casting these fractures, although with their inherent stability, may be unnecessary. This study evaluated if toddler's fractures can be treated with observation alone as opposed to casts. A prospective pilot study was performed with randomization and observational arms. Children were placed in short casts or observed without immobilization. A 21-day log was given to families to record walking. Follow up with radiographs occurred at 3 and 12 weeks. Twenty-one patients enrolled, three randomized and 18 chose their treatment. Thirteen patients were casted, and eight went without immobilization. Ambulation time was similar between groups (p = 0.260). Three without immobilization returned early but none converted to cast. All fractures healed uneventfully. There were no cast complications. Toddler's fractures treated with or without cast immobilization appears to be safe and effective but should be a shared decision between physician and parents. (Journal of Surgical Orthopaedic Advances 32(3):207-211, 2023).

Impact of the COVID-19 pandemic on paediatric orthopaedic trauma workload in central London: a multi-centre longitudinal observational study over the "golden weeks".

Background and purpose - The COVID-19 pandemic has been recognised as an unprecedented global health crisis. This study assesses the impact on a large acute paediatric hospital service in London, evaluating the trends in the acute paediatric orthopaedic trauma referral caseload and operative casemix before (2019) and during (2020) COVID-19 lockdown. Patients and methods - A longitudinal retrospective observational prevalence study of both acute paediatric orthopaedic trauma referrals and operative caseload was performed for the first 6 "golden weeks" of lockdown. These data were compared with the same period in 2019. Statistical analyses included median (± median absolute deviation), risk and odds ratios as well as Fisher's exact test to calculate the statistical significance, set at p ≤ 0.05. Results - Acute paediatric trauma referrals in 2020 were reduced by two-thirds compared with 2019 (n = 302 vs. 97) with a halving risk (RR 0.55) and odds ratios (OR 0.43) of sporting-related mechanism of injuries (p = 0.002). There was a greater use of outpatient telemedicine in the COVID-19 period with more Virtual Fracture Clinic use (OR 97, RR 84, p < 0.001), and fewer patients being seen for consultation and followed up face to face (OR 0.55, RR 0.05, p < 0.001). Interpretation - The impact of the COVID-19 pandemic has led to a decline in the number of acute paediatric trauma referrals, admissions, and operations during the COVID period. There has also been a significant change in the patient pathway with more being reviewed via the means of telemedicine to reduce the risk of COVID-19 transmission and exposure. More work is required to observe for similar trends nationwide and globally as the pandemic has permanently affected the entire healthcare infrastructure.

Double Interphalangeal Joint Dislocation of the Finger in Adolescent Athletes: A Review of Two Cases and the Relevant Literature.

Double interphalangeal joint dislocation of the same finger is a rare condition. We report two cases of adolescent athletes with distal and proximal interphalangeal joint dislocation. The diagnosis was confirmed with plain radiograph, while anatomical reduction was easily obtained with gentle longitudinal traction. A simple immobilization of the injured finger was applied by buddy taping for two weeks. Early mobilization as tolerated was recommended, and they have made a full return to their previous status of activities within 5 months. We also provide a review of the literature detailing demographic characteristics, cause and mechanism of injury with associated injuries, treatment options, and functional outcomes in this population.

The young adult hip: extra-articular causes of hip pain and how to pick the winners.

Hip pain in young adults is not always caused by intra-articular pathology, even in the presence of abnormal examination and imaging findings. Therefore, management of young adult hip pain requires processes that identify patients who are likely to benefit from surgical intervention. An important investigation in the diagnostic pathway is the intra-articular injection; a negative response to this should alert the surgeon to the presence of symptomatic extra-articular causes of hip pain. Our aim was to identify the proportion of patients referred with intra-articular pathology whose primary cause of pain was of extra-articular origin. A total of 143 intra-articular hip injections (local anaesthetic + corticosteroid) were performed over a 2-year period. Mean patient age was 41.95 (95% confidence interval: 39.50-44.41) years with a mean body mass index of 27 (95% confidence interval: 25.77-28.23); 26% of patients (n = 37) had no relief of symptoms after intra-articular injection. Of the patients with no relief, 81.1% (n = 30) were found to have extra-articular pathology as the cause of their pain and the remainder are under on-going investigation. Intra-articular hip injection is an important investigation in the diagnostic pathway of young adult hip pain, as it can highlight and differentiate those patients with referred pain from extra-articular pathology. This benefit may be further enhanced if injections are performed in theatres using image intensifier, under sedation, as it allows direct penetration into the joint without any local anaesthetic infiltration of surrounding tissue. The latter allows immediate objective assessment of symptom relief, eliminating the need to rely on retrospective patient recall of symptom change.

Natural history and treatment of fibrous dysplasia of bone: a multicenter clinicopathologic study promoted by the European Pediatric Orthopaedic Society.

A multicenter study on fibrous dysplasia of bone (FD) was promoted by the European Pediatric Orthopaedic Society in 1999 in order to gain insight into the natural history of the disease and to evaluate current diagnostic and therapeutic approaches. We collected and reviewed clinical, radiographic, pathological, and molecular genetic data when possible, from a total of 64 cases diagnosed as either monostotic FD (MFD), polyostotic FD (PFD), or McCune-Albright syndrome (MAS), evaluated or treated in 11 participating centers. Results from the initial analysis of the series indicate five main points: (1) Significant diagnostic pitfalls affect the diagnosis of MFD and, to a lesser extent, PFD in orthopedic centers and allied radiology and pathology facilities, which may be circumvented by the adoption of stringent diagnostic criteria, and in some cases by the analysis of FD-associated GNAS1 mutations. (2) MFD carries a significant risk for fracture in the face of limited disease in the proximal femur, whereas its tendency to progress is restricted to a minority of cases, and long-term outcome is usually satisfactory, regardless of treatment, in non-progressive cases. (3) The profile of tibial disease, both in MFD and in PFD, is markedly different from that of femoral disease. (4) As expected, MAS patients have the most extensive disease and the most complicated course, regularly experience multiple fractures, and require adequate surgical treatment. It appears that conservative treatment of femoral fracture, or curettage and cancellous bone grafting, or fixation with screws and plates are not indicated for the treatment of femoral fractures in these patients and should all be discouraged. Internal fixation with intramedullary nails provides stabilization of extensively affected bones, and prevents further fractures and major deformities, and thus providing a better option both for acute and elective surgery in patients with extensive involvement of the femur or of other limb long bones. (5) Evaluation of patients with FD at orthopedic centers should include, but rarely does, a thorough evaluation of endocrine profile and phosphate metabolism, and proper pathological and radiographic assessment.