Clinical analysis of 1301 children with hand and foot fractures and growth plate injuries.

BACKGROUND: Fractures of hands and feet are common in children, but relevant epidemiological studies are currently lacking. We aim to study the epidemiological characteristics of hand and foot fractures and growth plate injuries in children and provide a theoretical basis for their prevention, diagnosis, and treatment. METHODS: We retrospectively analyzed the data of children with hand and foot fractures who were hospitalized at Shenzhen Children's Hospital between July 2015 and December 2020. Data on demographic characteristics, fracture site, treatment method, etiology of injury, and accompanying injuries were collected. The children were divided into four age groups: infants, preschool children, school children, and adolescents. The fracture sites were classified as first-level (the first-fifth finger/toe, metacarpal, metatarsal, carpal, and tarsal) and second-level (the first-fifth: proximal phalanx, middle phalanx, distal phalanx, metacarpal, and metatarsal) sites. The changing trends in fracture locations and injury causes among children in each age group were analyzed. RESULTS: Overall, 1301 children (1561 fractures; 835 boys and 466 girls) were included. The largest number of fractures occurred in preschool children (n = 549, 42.20%), with the distal phalanx of the third finger being the most common site (n = 73, 15.57%). The number of fractures in adolescents was the lowest (n = 158, 12.14%), and the most common fracture site was the proximal phalanx of the fifth finger (n = 45, 29.61%). Of the 1561 fractures, 1143 occurred in the hands and 418 in the feet. The most and least common first-level fracture sites among hand fractures were the fifth (n = 300, 26.25%) and first (n = 138, 12.07%) fingers, respectively. The most and least common first-level foot fracture locations were the first (n = 83, 19.86%) and fourth (n = 26, 6.22%) toes, respectively. The most common first-level and second level etiologies were life related injuries (n = 1128, 86.70%) and clipping injuries (n = 428, 32.90%), respectively. The incidence of sports injuries gradually increased with age, accounting for the highest proportion in adolescents (26.58%). Hand and foot fractures had many accompanying injuries, with the top three being nail bed injuries (570 cases, 36.52%), growth plate injuries (296 cases, 18.96%), and distal severed fracture (167 cases, 10.70%). Among the 296 growth plate injuries, 246 occurred on the hands and 50 on the feet. CONCLUSIONS: In contrast to previous epidemiological studies on pediatric hand and foot fractures, we mapped the locations of these fractures, including proximal, shaft, distal, and epiphyseal plate injuries. We analyzed the changing trends in fracture sites and injury etiologies with age. Hand and foot fractures have many accompanying injuries that require attention during diagnosis and treatment. Doctors should formulate accident protection measures for children of different ages, strengthen safety education, and reduce the occurrence of accidental injuries.

Artificial intelligence-based detection of paediatric appendicular skeletal fractures: performance and limitations for common fracture types and locations.

BACKGROUND: Research into artificial intelligence (AI)-based fracture detection in children is scarce and has disregarded the detection of indirect fracture signs and dislocations. OBJECTIVE: To assess the diagnostic accuracy of an existing AI-tool for the detection of fractures, indirect fracture signs, and dislocations. MATERIALS AND METHODS: An AI software, BoneView (Gleamer, Paris, France), was assessed for diagnostic accuracy of fracture detection using paediatric radiology consensus diagnoses as reference. Radiographs from a single emergency department were enrolled retrospectively going back from December 2021, limited to 1,000 radiographs per body part. Enrolment criteria were as follows: suspected fractures of the forearm, lower leg, or elbow; age 0-18 years; and radiographs in at least two projections. RESULTS: Lower leg radiographs showed 607 fractures. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were high (87.5%, 87.5%, 98.3%, 98.3%, respectively). Detection rate was low for toddler's fractures, trampoline fractures, and proximal tibial Salter-Harris-II fractures. Forearm radiographs showed 1,137 fractures. Sensitivity, specificity, PPV, and NPV were high (92.9%, 98.1%, 98.4%, 91.7%, respectively). Radial and ulnar bowing fractures were not reliably detected (one out of 11 radial bowing fractures and zero out of seven ulnar bowing fractures were correctly detected). Detection rate was low for styloid process avulsions, proximal radial buckle, and complete olecranon fractures. Elbow radiographs showed 517 fractures. Sensitivity and NPV were moderate (80.5%, 84.7%, respectively). Specificity and PPV were high (94.9%, 93.3%, respectively). For joint effusion, sensitivity, specificity, PPV, and NPV were moderate (85.1%, 85.7%, 89.5%, 80%, respectively). For elbow dislocations, sensitivity and PPV were low (65.8%, 50%, respectively). Specificity and NPV were high (97.7%, 98.8%, respectively). CONCLUSIONS: The diagnostic performance of BoneView is promising for forearm and lower leg fractures. However, improvement is mandatory before clinicians can rely solely on AI-based paediatric fracture detection using this software.

Flexed position of the wrist in the cast reliably prevents displacement after physeal Salter-Harris I and II distal radius fractures.

BACKGROUND: Salter-Harris I and II fractures of the distal radius are common injuries. In our facility, immobilisation is performed in a way that counteracts angulation forces. The aim of our study was to determine whether there are significant differences between patients with and patients without a loss of reduction treated with this method and to determine what degree of flexion reliably prevents secondary displacement. PATIENTS AND METHODS: We conducted a retrospective study of 112 patients (mean age: 12 years) who had sustained a Salter-Harris type I or II fracture of the distal radius and were treated with reduction. Patients were grouped according to fracture type and whether they sustained a loss of reduction or not. Patients were compared for gender, age, initial angulation, angulation after reduction, degree of flexion/extension of the wrist in the cast, residual angulation, duration of immobilisation, and complication rate. We also analysed whether a 45-degree flexed position of the wrist in plaster provides reliable protection against secondary displacement. RESULTS: In group I, patients with no loss of reduction had a significantly greater degree of wrist flexion in the cast, a significantly shorter duration of immobilisation and significantly less residual angulation. Patients with an apex-volar deformity with the wrist immobilised at more than 45 degrees of flexion had no loss of reduction at all and had significantly less residual angulation compared with patients with the wrist immobilised at less than 45 degrees of flexion. In this patient group, loss of reduction was noted in 28% of cases. The patients in group II with loss of reduction showed a significantly higher angulation after the reduction. During the follow-up examination, one patient experienced physeal arrest followed by an ulnar impaction syndrome. Other complications recorded were minor. CONCLUSIONS: In summary, based on our results, we recommend that all physeal fractures of the distal radius with an apex-volar angulation can be safely treated with reduction and immobilisation counteracting the forces of angulation. For apex-dorsal fractures, palmar flexion of 45° allows for reliable reduction.

Child Fractures: Are We Getting More Surgical? / Fraturas na criança: Estamos ficando mais cirúrgicos?

Abstract Historically, surgeries on the immature skeleton were reserved for open or articular fractures. In recent years, the improvement in the quality and safety of anesthesia, new imaging equipment, implants designed especially for pediatric fractures, associated with the possibility of shorter hospitalization time and rapid return to social life has demonstrated a new tendency to evaluate and treat fractures in children. The purpose of this update article is to answer the following questions: (1) Are we really turning more surgical in addressing fractures in children? (2) If this is true, is this surgical conduct based on scientific evidence? In fact, in recent decades, the medical literature demonstrates articles that support better evolution of fractures in children with surgical treatment. In the upper limbs, this is very evident in the systematization of the reduction and percutaneous fixation of supracondylar fractures of the humerus and fractures of the forearm bones. In the lower limbs, the same occurs with diaphyseal fractures of the femur and tibia. However, there are gaps in the literature. The available published studies show low scientific evidence. Thus, it can be inferred that, even though the surgical approach is more present, the treatment of pediatric fractures should always be individualized and conducted according to the knowledge and experience of the professional physician, taking into account the presence of technological resources available for the care of the small patient. All possibilities, non-surgical and/or surgical, should be included, always instituting actions based on science and in agreement with the family's wishes.

Resumo Historicamente, as cirurgias no esqueleto imaturo eram reservadas às fraturas expostas ou articulares. Nos últimos anos, a melhora na qualidade e segurança das anestesias, novos equipamentos de imagem, implantes desenhados especialmente para fraturas pediátricas, associados à possibilidade de menor tempo de hospitalização e rápido retorno ao convívio social vêm demonstrando uma nova tendência de avaliar e tratar fraturas na criança. O objetivo deste artigo de atualização é responder às seguintes questões: (1) estamos realmente ficando mais cirúrgicos na abordagem das fraturas em crianças? (2) Caso isto seja verdadeiro, esta conduta cirúrgica está baseada em evidências científicas? De fato, nas últimas décadas, a literatura médica demonstra artigos que suportam melhor evolução das fraturas na criança com o tratamento cirúrgico. Nos membros superiores, isto fica muito evidente na sistematização da redução e fixação percutânea das fraturas supracondilianas do úmero e das fraturas de ossos do antebraço. Nos membros inferiores, o mesmo ocorre com fraturas diafisárias do fêmur e tíbia. No entanto, há lacunas na literatura. Os estudos publicados são geralmente com baixa evidência científica. Assim, pode-se deduzir que, mesmo sendo a abordagem cirúrgica mais presente, o tratamento de fraturas pediátricas deve ser sempre individualizado e conduzido de acordo com o conhecimento e experiência do médico profissional, levando em conta a presença de recursos tecnológicos disponíveis para o atendimento do pequeno paciente. Deve-se incluir todas as possibilidades, não cirúrgicas e/ou cirúrgicas, sempre instituindo ações baseadas na ciência e em concordância com os anseios da família.

Experimental study on internal fixation with screws through femoral epiphyseal plate / 中国骨伤

<p><b>OBJECTIVE</b>To explore the effect of internal fixation with screw through femoral epiphyseal plate on growth in- hibition via an experimental study.</p><p><b>METHODS</b>Forty New Zealand rabbits were randomly divided into 4 groups and 10 rabbits in each group. Epiphyseal plate was injured by penetrating of screws, and the size of damage area was controlled by changing the number of threads. Group A: blank group; group B: injury area accounted for 4% of the epiphyseal plate; group C: injury area accounted for 6%; group D: injury area accounted for 8%. The internal fixation was removed after 2 weeks, and the results were observed with X-ray film for 4 groups to judge the complications such as early closure of epiphyseal.</p><p><b>RESULTS</b>In each group, there were no statistical differences in the length of the femoral neck, the diameter of femoral neck, the diameter of the femoral head, and the epiphyseal plate closure time. The growth speed of the length and diameter of the femoral neck, as well as the diameter of femoral head, were quicker on the early phase, and the speed was slowest when the epiphyseal plate was being closed.</p><p><b>CONCLUSION</b>The injury area of epiphyseal plate under 8% is safe for its growth. Because no evidences demonstrate the growth inhibition of epiphyseal plate, the screws can be used for rabbit epiphyseal plates.</p>