Wide Resection for Pediatric Extremity Vascular Malformation-A Tertiary Hospital's Experience.

BACKGROUND: Vascular malformations of the extremities (VM) are common benign lesions that tend to grow throughout the patient's lifetime. They can cause various issues like pain, swelling, and even limb length discrepancies. Sclerotherapy was the preferred treatment choice in previous studies. However, sclerotherapy and many other treatments have the potential to result in higher recurrence rates. Surgical treatment has been shown to be effective and safe in many cases. Hence, this study aims to evaluate the suitability of wide resection surgery for VM to reduce recurrence. METHODS: Fort-seven VM cases that underwent wide resection were identified retrospectively in the institution of study. Demographics, depth of malformation, whether malformations were local or diffuse, location and size of malformations, and histology records were taken note of. Records of recurrence and postoperative function were also gathered. We utilized self-reported questionnaires, QuickDASH and Lower Extremity Functional Scale, to determine patients' postsurgical physical function. RESULTS: Out of 47 cases that underwent wide resection, we found a recurrence rate of 2.1%. No patients sustained any loss of function postsurgery, with few patients experiencing minor complications like tenderness, hypertrophic scars/keloids, as well as numbness. Good functionality posttreatment was also seen through self-reported questionnaires, with an average score of 2.12 for QuickDASH and 99.96% for LEFS. CONCLUSION: Where margins can be obtained without functional impairment, surgical-wide resection for VM is a viable treatment option to minimize recurrence. LEVEL OF EVIDENCE: Level-IV.

Improved Comfortability and Satisfaction of Hybrid-mesh Casts in the Conservative Management of Pediatric Supracondylar Humeral Fractures: A Randomized Controlled Trial.

BACKGROUND: Cast immobilization is the mainstay of treatment for stable pediatric supracondylar humeral fractures (SCHFs). In recent years, a waterproof and breathable hybrid-mesh (HM) cast has emerged and been marketed to address common complaints such as itch, skin irritation, and malodor. Hence, this randomized controlled trial seeks to assess the overall satisfaction, comfort, and clinical outcomes of using HM casts in the conservative treatment of stable pediatric SCHF. METHODS: Seventy-nine patients (age range: 1 to 10 y) with modified Gartland's classification Type I and Type IIa SCHF were recruited and randomized for immobilization with either fiberglass or HM long-arm cast for 3 weeks. During follow-up visits, patients were assessed for any loss of reduction and skin rash. The weight of casts, the presence of cast breakage, the duration of cast application, and removal were recorded. A self-reported patient comfort and satisfaction questionnaire was also administered during the same visit. RESULTS: The final analysis included 38 patients immobilized with fiberglass casts and 39 patients with HM casts. Despite the significantly longer duration required for HM cast removal (4.18±1.25 min vs. 2.25±0.55 min, P <0.001), the HM cast was significantly lighter than its fiberglass counterpart (162.82±23.94 g vs. 203.95±36.52 g, P <0.001). The HM casts have better comfort (4.05±0.887 vs. 3.47±0.951, P =0.007) and satisfaction (3.69±1.055 vs. 3.11±0.953, P =0.012) scores as compared to fiberglass casts for immobilizing pediatric SCHF without compromising clinical outcome. CONCLUSIONS: HM casts have better comfort and overall satisfaction as compared to conventional fiberglass casts for immobilizing pediatric SCHF without compromising clinical outcomes. LEVEL OF EVIDENCE: Level II-therapeutic studies-investigating the results of treatment.

C-reactive protein of ≥ 20 mg/L and ultrasound finding of an effusion ≥ 7 mm has a high specificity and sensitivity in diagnosing paediatric hip septic arthritis.

PURPOSE: Differentiating septic arthritis (SA) from transient synovitis (TS) in children remains a diagnostic challenge. Several algorithms have been developed to diagnose SA including Kocher's criteria and its subsequent modifications, but reports show variable efficacy. This study aims to examine the diagnostic utility of a novel method only using C-reactive protein (CRP) and ultrasound (US) findings of effusion in differentiating SA from TS, determine the optimal values for these predictors and validate this method against existing clinical predictors. METHODS: A 5-year retrospective study was performed including all paediatric patients with acute, non-traumatic hip pain with a suspicion of SA. All patients were evaluated using Kocher's criteria, Caird's criteria, and the novel method. Multivariate logistic regression was performed to identify independent clinical predictors of SA. The degree of agreement between the various methods were assessed using Cohen's kappa (k). Receiver operating characteristics (ROC) curves were used to examine the diagnostic accuracy of this novel method as well as to determine optimal cut-offs for US effusion and CRP in diagnosing SA. RESULTS: Hundred and one patients were recruited. CRP and effusion on US were found to be independent predictors of SA. Both Kocher's and Caird's method showed good specificity (98.9%) but extremely poor sensitivity for SA (0%). When Kocher's four clinical predictors were present, probability of SA was only 59.16%. The k for both Kocher's and Caird's methods, was -0.017 indicating poor agreement. However the k in the novel method was 0.641, indicating good agreement. CONCLUSION: Our study showed that the novel method using CRP (≥ 20 mg/L) and US finding of effusion (≥ 7 mm) has a high specificity (97%) and sensitivity (71%) in diagnosing SA.

Prophylactic fixation or surveillance: predicting subsequent displacement of lateral condyle of humeral fractures based on soft tissue swelling.

BACKGROUND: Nondisplaced or minimally displaced fractures (≤2 mm) of the lateral condyle of the humerus (LCH) could undergo subsequent displacement (>2 mm), which would be a potential surgical indication. We describe a new method to quantify soft tissue swelling in LCH fractures and to identify a threshold value to predict subsequent displacement of LCH fractures. We hypothesized that the larger the soft tissue swelling, the more likely a subsequent displacement would occur. METHODS: Elbow x-ray images (anteroposterior view) at initial presentation in 87 patients with subsequent displacement and in 87 patients with no subsequent displacement were compared. All fractures were initially nondisplaced or minimally displaced. The lateral elbow swelling-to-humeral shaft diameter (LES-H) ratio was measured. A threshold value for diagnosing a subsequent displacement was identified from the receiver operating characteristic curve analysis. RESULTS: Both groups had similar age (subsequent displacement: 5.1 ± 2.3 years vs. no subsequent displacement: 5.7 ± 3.2 years; P = .459). The LES-H ratio was significantly larger in the subsequent displacement group (1.8 ± 0.4 vs. 1.4 ± 0.4, P < .001). The area under the receiver operating characteristic curve was 0.728, which was moderately accurate in predicting subsequent displacement. A threshold LES-H ratio of 1.90 had a sensitivity of 41.4% and specificity of 90.8% in diagnosing subsequent displacement. The odds ratio of having subsequent displacement with LES-H ratio of ≥1.90 was 6.1 (95% confidence interval, 2.7-13.8; P < .001). CONCLUSION: The LES-H ratio could be used to objectively quantify soft tissue swelling in LCH fractures. An LES-H ratio of ≥1.90 was used as threshold value to predict subsequent displacement.

Using the Medial and Lateral Humeral Lines as an Adjunct to Intraoperative Elbow Arthrography to Guide Intraoperative Reduction and Fixation of Distal Humerus Physeal Separations Reduces the Incidence of Postoperative Cubitus Varus.

BACKGROUND: Distal humerus physeal separations are rare pediatric elbow fractures that are often misdiagnosed and difficult to treat. Adequate reduction is often technically challenging and up to 71% of children develop postoperative cubitus varus. We propose using the medial and lateral humeral lines as an adjunct to elbow arthrography in order to guide intraoperative fixation of distal humerus physeal separations to reduce the incidence of postoperative cubitus varus. METHODS: From 2009 to 2014, all pediatric patients under the age of 3 diagnosed with a distal humerus physeal separation and treated surgically at our institution were included for analysis. Two senior pediatric orthopaedic surgeons separately reviewed the preoperative, intraoperative, and postoperative images of all patients and measured the position of the ulnar axis relative to the medial and lateral humeral lines. The medial and lateral humeral shafts were defined as parallel lines drawn along the medial and lateral humeral diaphysis. Adequate reduction was defined by reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines. Patients were assessed at latest follow-up for cubitus varus and any other surgical complications. RESULTS: Thirteen patients fulfilled the inclusion criteria and were on average 1.70 years old, ranging from 0.62 to 3 years old. Intraoperatively and immediately postoperatively, all 13 patients (100%) were noted to have adequate reduction of the ulnar axis within the boundaries medial and lateral humeral lines. None of the patients required intraoperative arthrography (0%). At the date of latest follow-up, 12 patients (92.3%) had no angular deformities compared with the contralateral limb and 1 patient (7.7%) had developed cubitus varus. No surgical complications were noted (0%). CONCLUSION: Intraoperative reduction of the ulnar axis within the boundaries of the medial and lateral humeral lines is associated with a lower incidence of postoperative cubitus varus in the treatment of distal humerus physeal separations in children. LEVEL OF EVIDENCE: Level IV.

The Use of C-reactive Protein as a Guide for Transitioning to Oral Antibiotics in Pediatric Osteoarticular Infections.

BACKGROUND: In the treatment of pediatric osteoarticular infections, early transition to oral antibiotics is desirable to shorten hospital stays and complications of prolonged intravenous therapy. C-reactive protein (CRP) is an acute phase reactant with a short half-life and is utilized at our institution to monitor progress and determine the transition to oral antibiotics. We hypothesized that patients can be safely transitioned from parenteral antibiotics to oral antibiotics when patients improve clinically and CRP halves over a period of 4 days. MATERIALS AND METHODS: A retrospective review was conducted of all pediatric patients between the ages of 1 month and 18 years admitted and treated for acute bacterial osteomyelitis and/or septic arthritis at the authors' institution. We recorded all relevant data, inpatient progress, and outpatient follow-up. RESULTS: Thirty-seven patients fulfilled the selection criteria and were reviewed for this study. Patients were an average of 8.37±4.91 years old. Surgery was performed in 33 patients (89.2%). The average duration of intravenous antibiotics was 11.00±5.61 days and the average duration of oral antibiotics was 28.76±8.69 days, with an average total duration of antibiotics of 39.16±9.08 days. The average peak CRP was 156.91±97.81 mg/L and the average CRP at discharge was 24.94±22.36 mg/L. Thirty-four patients (91.89%) experienced a 50% decline in CRP over 4 days. Of these patients, only 1 (2.94%) went on develop complications in the follow-up period. The average hospitalization period was 11.50±6.55 days. The average duration of follow-up was 7.83±6.56 months. CONCLUSIONS: We found that the combination of clinical improvement and a specific reduction of 50% in CRP levels over 4 days, or 5 CRP half lives, could be used to determine when to transition children with osteoarticular infections from parenteral to oral therapy. Complicated outcomes were associated with negative cultures, longer hospitalizations, and persistently elevated CRP levels.

Severity of playground-related fractures: more than just playground factors?

INTRODUCTION: Despite the establishment of playground safety standards, playground-related injuries are still a significant cause of extremity fractures in Singapore. This prospective study evaluates the dimensions and characteristics of our playgrounds, and their effect on fracture severity in an Asian population. We aim to correlate various playground risk factors with severity of the fractures and give recommendations on future safety standards. Our data also allows us to compare the demographics of patients in our study group with that collected in our earlier study in 2004. METHODS: From June 2005 to 2006, children who presented with extremity fractures to KK Women's and Children's Hospital after a playground injury were enrolled. Their clinical data were collected prospectively. Relevant playground details were collected on-site independently by another investigator. For analysis of severity, fractures were "major" if they required reduction or operative fixation and were "minor" if they did not. RESULTS: Supervision at time of injury, especially from the child's parents or siblings, resulted in a lower likelihood of "major" fractures (P=0.002, likelihood ratio=1.97). Conversely, supervision from grandparents or maids was found to result in a higher likelihood of "major" fractures. Increased weight of patients was directly related to severity of fractures (P=0.000), and a body mass index (BMI) of less than 19.8 kg/m resulted in lower likelihood of "major" fractures (P=0.010, likelihood ratio=2.22). Height of equipments and other playground-related factors were not linked to severity of fractures. CONCLUSIONS: Supervision at the playground, preferably from the child's parents or siblings, and keeping a child's BMI within limits as guided by the BMI charts, may potentially reduce the occurrence of severe fractures. LEVEL OF EVIDENCE: Level I-prognostic study.

Use of cryotherapy in the postoperative management of paediatric anterior cruciate ligament reconstruction: a prospective randomised controlled trial.

To investigate the efficacy of cryotherapy in relieving postoperative pain and restoring knee range-of-motion (ROM) after paediatric anterior cruciate ligament reconstruction (ACLR). Patients undergoing primary ACLR were randomised into cryotherapy or non-cryotherapy groups. Those receiving cryotherapy were subjected to a standardised icing protocol. Icing schedules were used to assess compliance. Standard postoperative rehabilitation protocol was followed for both groups. Outcome measurements were visual analogue scale at rest and movement and knee ROM. Patients were assessed on postoperative day 1 (POD1), 1, 4 and 6 weeks. Twenty-one out of 42 patients received cryotherapy. Both groups were similar in demographics, surgical technique and use of intraoperative anaesthesia. Patients in the cryotherapy group reported lower overall mean pain scores throughout the study duration at rest (0.61 ±â€…1.70, 95% CI = 0.23-0.99 vs. 1.06 ±â€…2.03, 95% CI = 0.60-1.53) and on movement (2.19 ±â€…2.68, 95% CI = 1.59-2.79 vs. 3.13 ±â€…2.75, 95% CI = 2.51-3.75; P = 0.032). Knee flexion in the cryotherapy group showed better recovery of knee flexion from week 4 onwards. Improvement of knee flexion from POD1 is statistically significant at week 6 (98.7 ±â€…19.1°, 95% CI = 89.5-107.9 vs. 65.4 ±â€…49.9°, 95% CI = 42.7-88.1; P = 0.010) and overall mean (71.2 ±â€…35.9°, 95% CI = 61.2-81.1 vs. 45.3 ±â€…55.5°, 95% CI = 30.4-60.2; P = 0.005). The cryotherapy group reported statistically significant better degree of overall mean knee extension (1.2 ±â€…3.3°, 95% CI = 0.5-2.0 vs. 2.6 ±â€…4.6°, 95% CI = 1.6-3.7; P = 0.032). The use of cryotherapy in postoperative ACLR recovery in paediatrics is a simple yet effective measure resulting in short-term pain relief and improvement in knee flexion.

Systematic review of paediatric pulseless pink humerus supracondylar fractures.

The supracondylar humeral fracture (SCHF) is the most common fracture seen in children, forming up to 70% of all pediatric elbow fractures. The decision to surgically explore the brachial artery in a well-perfused, pulseless arm remains a controversial one among vascular and orthopedic surgeons and is something we seek to explore in this article. We reviewed the literature from electronic databases such as PubMed and Embase for studies focusing on the management of the pink pulseless hand (PPH) following SCHF. We gathered a total of 23 articles to be analyzed in this review. We found 336 PPH postreduction and evaluated the management as well as the follow-up and complications of the PPH involved. Most recent articles have cited the close observation strategy as the most reliable strategy. It is clear that the management of a SCHF requires immediate reduction and fixation. In the management of a postoperatively pulseless pink humerus, we do agree with the latest conclusion of Delionitis et al. who advocate the traditional dogma of watchful waiting in the case of a PPH postreduction and fixation as long as no signs of vascular deterioration appear. However, the outcome of this study also advocates for the monitoring of up to 24-48 h postreduction and the use of noninvasive tools such as ultrasound Doppler, Color flow duplex Ultrasound and pulse oximetry to monitor perfusion as they all have had good outcomes in the articles cited in this review. Still, in the event of vascular deterioration or development of complications of the hand, immediate vascular exploration is still indicated.

Evaluation of risk factors associated with fragility fractures and recommendations to optimise bone health in children with long-term neurological condition.

Introduction: The growing years are paramount for bone growth and mineral accrual. Children with long-term neurological condition (LTNC) have multiple risk factors for poor bone health and fragility fractures. In Singapore, this has not been studied systematically. Therefore, we aimed to evaluate the risk factors associated with fragility fractures in children with LTNC. Methods: In this study, the search for fragility fractures was done by a retrospective review of patients with LTNC on follow-up in the paediatric neurology clinic and patients who presented with fracture to the paediatric orthopaedic clinic. Information on patients' demographics, medical history, intervention, biochemical bone markers and fracture history was collected. Results: In a tertiary clinic population of 136 patients with LTNC, 65% were dependent on mobility (Gross Motor Function Classification System [GMFCS] V), 60% were underweight and 60% were fed via gastrostomy or nasogastric tube, or were on oral pureed diet. Furthermore, 60% were on anticonvulsants. The fracture rate was 3% in this population and was associated with low-impact activities such as transfer and dressing. Only 7.4% and 33% of the patients had undergone measurements of vitamin D and calcium levels, respectively. Conclusion: The local prevalence of fragility fractures in children with LTNC on follow-up at the neurology clinic was found to be 3%. Risk factors identified were limited ambulation and compromised nutritional status associated with feeding difficulty. Recommendations to optimise bone health in children with LTNC were made. These include promoting weight-bearing activities, looking out for underweight children, avoiding vitamin D deficiency and ensuring adequate calcium intake.

Exploiting frequent and specific expression of PRL3 in pediatric solid tumors for first-in-child use of PRL3-zumab humanized antibody.

Phosphatase of regenerating liver 3 (PRL3) is a specific tumor antigen overexpressed in a broad range of adult cancer types. However, its physiological expression in pediatric embryonal and mesenchymal tumors and its association with clinical outcomes in children is unknown. We sought to profile the expression of PRL3 in pediatric tumors in relation to survival outcomes, expression of angiogenesis markers, and G-protein-coupled receptor (GPCR)-mitogen-activated protein kinase (MAPK) signaling targets. PRL3-zumab, a first-in-class humanized antibody, was administered in a dose escalation schedule in a first-in-child clinical trial to study toxicity, pharmacokinetics, and clinical outcomes. Among 64 pediatric tumors, PRL3 was most frequently expressed in neuroblastoma (100%), rhabdomyosarcoma and non-rhabdomyosarcoma soft tissue sarcomas (71%), and renal sarcomas (60%) but absent in paired normal tissues. PRL3 was expressed in 75% of relapsed tumors and associated with shorter median event-free survival. Microarray profiling of PRL3-positive tumors showed elevation of angiogenin, TIMP1 and TIMP2, and GPCR-MAPK signaling proteins that commonly interacted with PRL3. The first use of PRL3-zumab in a pediatric patient saw no adverse events. A 28.6% reduction in maximum target lesion diameter was achieved when PRL3-zumab was administered concurrently with hypofractionated radiation. These findings support wider exploration of PRL3 expression in embryonal and mesenchymal tumors and further clinical application of PRL3-zumab in pediatric patients.

Epidemiology and outcome of septic arthritis in childhood: a 16-year experience and review of literature.

INTRODUCTION: Septic arthritis (SA) is a devastating infection with a high rate of sequelae. The aim of this retrospective study was to determine the epidemiology, clinically significant sequelae and risk factors for developing these sequelae in children admitted to our hospital with SA. METHODS: Patients with bacteriologically and/or radiologically confirmed SA from January 1999 to December 2014 were identified from discharge and laboratory records. Data was collected through a retrospective review of the case notes. RESULTS: A total of 75 patients (62.7% male) met the inclusion criteria. The median age at presentation was six years (range two weeks to 15 years), and six patients were neonates. Microbiologic aetiology was determined in 40 (53.3%) patients, with Staphylococcus aureus being the most common organism. 68.0% of the patients underwent arthrotomy, and the average hospital stay was 15.3 days. Sequelae of SA were observed in nine patients on follow-up. Univariate and multivariate statistical analyses showed that young age, pyogenic bacterial isolation and concomitant osteomyelitis were significant risk factors for developing sequelae. CONCLUSION: Our study demonstrated that young age, pyogenic bacterial isolation and concomitant osteomyelitis are associated with a high risk of sequelae. Timely microbiologic diagnosis by novel polymerase chain reaction methods and the use of magnetic resonance imaging in high-risk children to identify adjacent infection could possibly prevent lifelong disabling sequelae in SA.

Retrospective analysis: risk factors predicting failure of closed reduction in pediatric diaphyseal forearm fractures treated with elastic stable intramedullary nails (ESINs).

LEVEL OF EVIDENCE: Level IV.

Using the radiocoronoid line for diagnosis of elbow dislocation.

The radiocapitellar line (RCL) has been widely used to diagnose elbow dislocation. However, there are limitations to the RCL, with the cartilaginous portion of bone making interpretation of radiographs difficult. The study aims to show that the radiocoronoid line, which connects two points on the medial aspect of the radius, proximal to the radial tuberosity, is more suited to diagnose elbow dislocations in the anterior-posterior projection. This study also observes factors affecting accuracy of the radiocapitellar line. The radiographs of 50 normal and 17 laterally dislocated elbows were obtained. An unbiased independent reviewer drew the radiocoronoid and radiocapitellar line (RCL). Four other blinded independent reviewers drew the RCL and the radiocoronoid line for 20 radiographs and repeated the process a week later. The accuracy of the RCL was assessed using distance away from bisection point of capitellum, and ratio (distance from the point where line crosses capitellum to lateral aspect of capitellum over the total width of capitellum). The relationship of the radio-coronoid line and the lateral aspect of coronoid fossa was assessed, with dislocation being the line lateral to it and normal being medial to or on it. The radiocoronoid line had a higher accuracy (95.5%) compared to RCL (32.8%), higher specificity (94%) compared to RCL (10%) as well as higher positive predictive value (85%) compared to RCL (27.4%). There was no intra- or inter-observer variability for the radio-coronoid line. Skeletal age statistically predicted the ratio for the male population ( P < 0.05), however, the independent variables did not statistically predict the dependent variables for the female and total population. The radiocoronoid line serves as an additional method to assess radiocapitellar joint lateral dislocation. It is more accurate and reliable than the radiocapitellar line in the anterior-posterior projection. Sex and skeletal age also influence the accuracy of the radiocapitellar line with the radiocapitellar line nearing the bisection point as skeletal age in males increases.

Dose reduction for minimizing radiation in displaced paediatric supracondylar humerus fractures: single vs. automated pulse mode.

Conventional C-arm image intensifiers (CCA) are an essential and indispensable aid in modern orthopaedic surgery. CCAs are defaulted to auto-pulse mode which emit multiple pulses (or bursts) of radiation to obtain optimum image quality. The number of pulses per shot can be configured manually. The purpose of this study is to investigate the efficacy of the single pulse mode of CCA in reducing and fixing paediatric supracondylar humeral fractures (SCHF). A retrospective chart review of 99 paediatric patients who underwent closed reduction and percutaneous pinning of displaced SCHF was performed. Fifty-one consecutive cases operated with auto-pulse mode (group A). Another 48 consecutive cases were operated with the single-pulse mode (group B). Baumann's angle, operative duration and average radiation dose rate were recorded for comparison between both groups. Twenty postpinning images were randomly selected (10 from each group) to study intra- and interobserver reliability. Twelve doctors were recruited and tasked to identify if each X-ray was taken with the auto-pulse or single-pulse mode. This was repeated after 2 weeks. The patients in the auto-pulse mode group had a significantly higher mean radiation dose of 40.4 ± 32.51 cGycm2/min compared to that of 14.8 ± 3.24 cGycm2/min for the single-pulse group (P ≤ 0.001). All patients in both groups had Baumann's angle within normal range of 64-81°. No significant difference was noted in average intraoperative timings between both groups (P = 0.869). In the majority of cases, the doctors were unable to visually differentiate between the modes of CCA used. The single-pulse mode is an excellent alternative to the auto-pulse mode in fixing SCHF. It gives significantly lower radiation without compromising the surgical outcome. Level of evidence: Level III retrospective comparative study.

Rare right acetabulum aneurysmal bone cyst treated with curettage and local adjuvants in a 4-year-old girl.

Aneurysmal bone cysts are locally aggressive benign bone tumours with a high risk of recurrence. We describe a case in a 4-year-old girl, involving the right acetabulum. A direct posterior approach was used and the lesion ablated with curettage and local adjuvants with bone grafting. The cyst resolved swiftly with an uncomplicated recovery.

Comparison of K-wire versus screw fixation after open reduction of transitional (Tillaux and triplane) distal tibia fractures.

Our study aimed to compare the clinical and radiographic outcomes of transitional distal tibia fractures treated with K-wire fixation versus screw fixation after open reduction. A retrospective study was performed on all displaced transitional distal tibia fractures that underwent operative fixation. Following open reduction, surgical fixation was performed using either percutaneously inserted 2.0 mm K-wires, or 4.0 mm partially-threaded cannulated cancellous screws. Clinical and radiographic outcomes between the two groups were assessed using the modified Weber score. Other outcome measures assessed were surgical time, casting duration, follow-up duration and duration before return-to-sports. We recruited 49 patients with transitional distal tibia fractures requiring open reduction and surgical fixation. There were 18 patients in the K-wiring group (KWG), and 31 patients in the screw fixation group (SFG). All patients in both groups had excellent clinical and radiographic outcome based on the modified Weber's scoring, full radiological healing, and no residual displacement upon final follow up. The KWG had significantly shorter surgical time (41.0 min versus 75.1 min, P < 0.0001) and shorter follow-up duration needed before discharge (5.4 months versus 8.7 months, P = 0.024). However, they required a longer post-operative casting duration (7.3 weeks versus 5.3 weeks, P = 0.006). No significant difference was found for the duration before return to sports between both groups. Complications were few in this study group. Superficial pin site infection was noted in one patient in the KWG, and valgus deformity of the ankle was noted in one patient in the SFG. In our study, surgical treatment of transitional distal tibia fractures demonstrated equally excellent outcomes when treated by open reduction with either K-wire or cannulated screw fixation. Level of evidence: III.

Epidemiology of paediatric orthopaedic-related trauma injuries sustained across a lockdown period during the COVID-19 pandemic.

OBJECTIVES: Lockdowns have been implemented by countries to slow down SARS-CoV-2 transmission. Singapore's lockdown was enforced between 7 April 2020 and 1 June 2020. The objective of this study was to compare the epidemiology of paediatric orthopaedic trauma injuries during and immediately after the lockdown, with a non-pandemic period in 2019. METHODS: All paediatric outpatients and inpatients seen in our hospital following an orthopaedic-related traumatic injury from the 8-week lockdown and 8 weeks post-lockdown were evaluated. Cases for matched periods in 2019 were identified retrospectively for baseline comparison. Patient demographics, venue of injury, anatomic location of injury, caregiver supervision and location of procedures performed in the hospital were assessed. RESULTS: 968 and 2810 injuries were observed in 2020 and 2019, respectively. While the proportion of injuries sustained by pre-schoolers and toddlers increased, those sustained by primary and secondary school children decreased in 2020 (p < 0.001). Majority of the injuries during the lockdown were sustained at home compared to schools or public recreational facilities (p < 0.001). Hand (26.2%) and elbow (20.8%) injuries were the most common during the lockdown. The proportion of procedures performed in the Children's Emergency during the lockdown was more than twice that of the same period in 2019 (p < 0.001). CONCLUSION: Our study showed a 2.9-fold decrease in orthopaedic-related injuries seen during the peri-lockdown period compared to a non-pandemic period. Pre-schoolers seem to be most vulnerable to injuries during the lockdown. Hand and elbow injuries were most common.

The single visit treatment of pediatric distal radius buckle fractures-A center's experience with the treatment algorithm.

INTRODUCTION: This descriptive study aims to review and evaluate the implementation of a single visit treatment protocol for pediatric distal radius buckle fractures at our center - its success, learning points and limitations. It hopes to raise awareness of the efficacy of the protocol and its benefits to promote its utilization. METHODS: Following a pilot study, the protocol was implemented from 1 March 2017. A retrospective review of clinical records over 2 years since implementation for patients with a new-visit diagnosis of "distal radius buckle fracture" was conducted. Data collected included age at time of injury, gender, side of injury, whether the patient was enrolled into the protocol, number of clinic visits, and number of radiographic examination(s) performed. Each record was reviewed up to 3 months post-injury to check for any complications or return visits. Costs of specific treatment interventions were also obtained from the hospital's finance department. RESULTS: 286 patients with buckle fractures of the distal radius eligible for enrolment into the single visit treatment protocol were identified. Of these, 202 patients (70.6%) were enrolled and managed with the protocol, while 84 patients (29.4%) were treated with conventional management. Of the 202 protocol-managed patients, all fractures healed without complications. Only 4 patients returned for additional clinic visits. Another 4 patients had additional X-rays taken on top of their initial injury film. A breakdown of expenses for treatment also showed cost savings of USD 110.67 and USD 320.80 for residents and non-residents respectively for single visit treatment. CONCLUSION: Single visit treatment of pediatric distal radius buckle fractures is recommended and supported by evidence, with advantages of convenience, cost reduction, and being less labor intensive.

Lateral Pinning of the Pediatric Phalangeal Neck Fracture.

Closed reduction and percutaneous pinning is the treatment of choice for displaced pediatric phalangeal neck fractures. Multiple techniques have been described to address challenges in managing these unstable fractures. We describe our technique of closed reduction and percutaneous pinning, which avoids the physis and increases the wire insertion accuracy, minimizing the number of attempts and wire passes made at percutaneous pinning.