Pediatric Olecranon Osteochondral Flap Fractures With Subtle Radiographic Abnormality.

Pediatric olecranon osteochondral flap fractures are shear injuries of the humeroulnar joint with elevation of an articular cartilaginous flap from the subchondral bone of the olecranon articular surface. All previously reported cases included an osteochondral flap containing the coronoid, with varying imaging and fixation methods used. We treated 2 pediatric patients with this injury. One of our patients had a large, displaced osteochondral fracture of the medial semilunar notch including the coronoid, in addition to avulsions of the medial flexor mass and distal ulnar collateral ligament. The other patient sustained a displaced, rotated osteochondral fracture including the coronoid with subsequent humeroulnar subluxation. Both fractures were anatomically reduced and fixed with absorbable suture, leading to excellent results at 1 year. A high degree of suspicion, thorough work-up, and anatomical reduction of all injured structures are paramount in treatment of this rare, difficult-to-diagnose injury.

Friberg Equation to Predict Pediatric Distal Forearm Fracture Remodeling.

BACKGROUND: This study is the first to test Friberg's equation's (Vt=V0[e]) accuracy in predicting the residual angular deformity in pediatric distal forearm fractures. METHODS: Angular deformities from distal forearm fractures in 50 children (mean age, 9 y) were retrospectively measured on follow-up radiographs once healed and compared to extrapolated angles at respective follow-up intervals from 2013 to 2015. RESULTS: The predicted and actual angulations from 120 radiographs (mean follow-up, 3mo) showed that the mean predicted angle was similar to the measured angle in the radioulnar plane and only 2 degrees greater than the measured angle in the dorsovolar plane. A strong correlation was observed between predicted and measured angles in both planes. CONCLUSIONS: Friberg's equation is a valid tool for predicting remodeling potential in pediatric distal 25% forearm fractures. LEVEL OF EVIDENCE: Prognostic Study-Level II.

Transgluteal Approach for Drainage of Obturator Internus Abscess in Pediatric Patients.

BACKGROUND: Of the locations of peripelvic pyomyositis, infection of the obturator musculature poses a difficult challenge for operative drainage. The anatomic location of the obturator muscles, especially the obturator internus, complicates operative debridement as the surgical approach must safely bypass a large number of neurovascular structures. Realizing the challenges and risks of approaches to the obturator musculature, the purpose of our study was to review a novel, yet simple, posterior approach to the obturator internus. METHODS: We reviewed a case series of children (age 0 to 18 y), who presented to our institution with obturator internus pyomyositis. The patients' demographics, vital signs, laboratory data, and radiographic findings from the initial evaluation were reviewed. Blood and intraoperative culture results were collected. Duration of symptoms and length of hospital stay were also reviewed. Cases of suspected obturator internus abscess were confirmed by magnetic resonance imaging of the pelvis. All patients in this study who met the operative indications were debrided using the posterior transgluteal approach. RESULTS: Five patients were identified who met criteria for isolated obturator internus pyomyositis. Four out of the 5 patients met operative indications and underwent drainage through a transgluteal approach. One patient responded well to antibiotic treatment; therefore, no surgery was indicated. Purulence was expressed in all 4 operative cases. Hospital length of stay ranged from 6 to 14 days. All patients were treated with an IV antibiotic course for 3 to 6 weeks. All patients returned to normal function and activity levels. There were no surgical complications. CONCLUSIONS: This case series has reviewed a new technique for the drainage of an isolated obturator internus abscess. The transgluteal posterior approach is a simple approach that is performed through a single incision with minimal soft-tissue dissection. It avoids the risks and challenges posed by other approaches. Most importantly, our case series, although small, in our experience, has shown that it is a safe and effective approach for drainage of obturator internus abscess. LEVEL OF EVIDENCE: Level IV.

Pediatric tibial eminence fracture treatment: A case series using a bioabsorbable screw.

BACKGROUND: Pediatric tibial eminence fractures constitute a complex injury with multiple treatment options. We have described a technique that combines direct visualization through an open approach and stable fixation using a bioabsorbable screw. The purpose of this study is to describe our surgical technique for tibial eminence fractures and to compare the radiographic and functional outcomes to previous open or arthroscopic methods. METHODS: We retrospectively reviewed a series of five pediatric patients who underwent open reduction and internal fixation of a tibial eminence fracture with a headless, bioabsorbable poly-L lactic acid (PLLA) screw (Bio-Compression screw, Arthrex Inc, Naples, FL) from 2016 to 2017. The surgical technique involves an open approach, direct fracture reduction, and fixation with a PLLA screw without violating the epiphyseal plate. Postoperative assessment was quantified using the Lysholm knee score (LKS), knee arc of motion (AOM), presence of a pivot shift or Lachman, and knee radiographs with an average of 18.4 months of follow-up. RESULTS: Five patients (average age of 11.3 years) were treated with a biobsorbable screw and followed for an average of 18.4 months. Average LKS was 99.6, AOM was 98.4%, all patients had negative pivot shift and Lachman exams, and all patients went on to radiographic union. No patients required re-operation or implant removal. CONCLUSIONS: The goals of tibial eminence fracture management are fracture union, restoring knee stability, and regaining normal knee motion and kinematics. Our study demonstrates that open treatment with a bioabsorbable screw is an excellent alternative surgical method as it reliably results in rigid fixation, fracture union, excellent knee function scores, and it mitigates the possible need for hardware removal. LEVEL OF EVIDENCE: Therapeutic Level IV - Case series.

Pediatric Tenosynovial Giant Cell Tumor of the Flexor Hallucis Longus Tendon Sheath: A Case Report.

CASE: An otherwise healthy 13-year-old girl presented with a firm nodule on the plantar right forefoot that was tender after cheerleading. Initial workup was unremarkable, but magnetic resonance imaging revealed a multilobulated mass surrounding the flexor hallucis longus tendon. Surgical resection revealed a tenosynovial mass without tendon infiltration. Pathologic examination was consistent with tenosynovial giant cell tumor. The patient resumed cheerleading and remained asymptomatic after 1 year. CONCLUSION: As far as we know, this is the first report of a tenosynovial giant cell tumor of the flexor hallucis longus in a pediatric patient; it illustrates the importance of considering this lesion when diagnosing a pediatric plantar mass.

Distal Tibial Chondroblastoma With Intra-articular Penetration Treated With Gelatin Foam Sponge and Bone Grafting.

A 14-year-old boy presented with sharp left ankle pain for 1.5 years. Evaluation showed an irregular lytic lesion with surrounding sclerosis (diameter, 1.3×1.2×1.1 cm) in the central part of the distal tibial epiphysis, extending from the physis to the plafond with articular penetration. Treatment included intralesional curettage and bone grafting through a mid-anterior epiphyseal bone tunnel with fluoroscopic guidance and use of a gelatin foam sponge to help contain the bone graft within the epiphyseal cavity. Microscopic examination of the excised tissue was consistent with chondroblastoma. Ankle arthroscopy 11 months later showed that the tibial plafond articular surface was fully healed. Two years postoperatively, the patient was asymptomatic and had no recurrence. This case shows that intralesional curettage and bone grafting, with a gelatin foam sponge to prevent graft extrusion, may be used successfully in treating distal tibial epiphyseal chondroblastoma that penetrates the ankle joint. [Orthopedics. 2019; 42(4):e391-e394.].

Deep Infection Following Dry Needling in a Young Athlete: An Underreported Complication of an Increasingly Prevalent Modality: A Case Report.

CASE: Dry needling frequently is performed by a variety of practitioners for pain treatment. A 16-year-old boy had dry needling in the posterolateral aspect of the right thigh for treatment of pain after a knee injury. He developed an abscess on the posterolateral distal aspect of the right thigh deep to the site of the dry needling. Treatment included surgical drainage and intravenous antibiotics. CONCLUSION: Deep infection is a rare but serious complication of dry needling. Standardized guidelines for safety and sterile technique with dry needling are needed to minimize the risk of infection.

Bilateral femoral neck fractures associated with complex pelvic ring injuries in a pediatric patient: a case report.

Femoral neck and pelvic fractures are rarely encountered in the pediatric population secondary to the resilient nature of the immature skeleton. Both fracture types usually result from high-energy blunt trauma including motor vehicle collisions, motor vehicle-pedestrian accidents, and falls from height. Considerable studies have been published on the natural history, management, and complications of pediatric pelvis and femoral neck fractures. However, few case reports have documented both fracture types in the same patient. Management of concomitant injuries presents unique challenges both for operative stabilization and for clinical postoperative care. After appropriate consent was obtained, a thorough review was performed of the patient's hospital records and imaging history. The senior author of the report also provided insight into the management of the patient's initial injuries and subsequent complications. Our case involves a 4-year-old female who was overrun by an all-terrain vehicle. Her orthopedic injuries included a nondisplaced Delbet type 3 fracture of the right femoral neck, a completely displaced Delbet type 3 fracture of the left femoral neck, bilateral sacroiliac fracture-dislocations, severe comminution of her left pubic rami, and a free-floating right pubic rami segment spanning from the triradiate cartilage to the pubic symphysis with severe rotational deformity. Her postoperative recovery was complicated by refracture of her left femoral neck (Delbet type 1), left hip osteomyelitis, and left femoral head avascular necrosis. The salient features of her operative management, subsequent complications, and functional recovery are described in this report. Cases of bilateral femoral neck fractures and multiple pelvic fractures in pediatric patients are sparsely documented in the literature because of their infrequent occurrence. Pediatric pelvic fractures typically do well with conservative treatment secondary to the incredible remodeling ability of the immature pelvis. Femoral neck fractures, in contrast, are highly associated with complications including coxa vara, nonunion, infection, physeal closure, and avascular necrosis. This case report documents two rare fracture types in the same patient and describes the challenges encountered throughout the duration of her recovery. LEVEL OF EVIDENCE: Level V, Case report.

Cardiofaciocutaneous syndrome (CFC) with congenital peripheral neuropathy and nonorganic malnutrition: an autopsy study.

Many phenotypic manifestations have been reported in cardiofaciocutaneous (CFC) syndrome, but none, to date, are pathognomonic or obligatory. Previous histopathological studies reported findings in skin and hair; no autopsy studies have been published. We report the clinical and autopsy findings of a 7-year-old boy with severe CFC syndrome and malnutrition of psychosocial origin. Manifestations of CFC, reported previously, included macrocephaly and macrosomia at birth; short stature; hypotonia; global developmental delays; dry, sparse thin curly hair; sparse eyebrows and eyelashes; dilated cerebral ventricles; high cranial vault; bitemporal constriction; supraorbital ridge hypoplasia; hypertelorism; ptosis; exophthalmos; depressed nasal bridge; anteverted nostrils; low-set, posteriorly-rotated, large, thick ears; decayed, dysplastic teeth; strabismus; hyperelastic skin; wrinkled palms; keratosis pilaris atrophicans faciei; ulerythema ophryogenes; hyperkeratosis; gastroesophageal reflux; and tracheobronchomalacia. Additional findings, not previously reported, include islet cell hyperplasia, lymphoid depletion, thymic atrophy and congenital hypertrophy of peripheral nerves with onion bulb formations. Although the islet cell hyperplasia, lymphoid depletion, and thymic atrophy are nonspecific findings that may be associated with either CFC or malnutrition, the onion bulb hypertrophy is specific for a demyelinating-remyelinating neuropathy. These findings implicate congenital peripheral neuropathy in the pathogenesis of the developmental delays, feeding difficulties, respiratory difficulties, ptosis and short stature in this case. Additional studies of other cases of CFC are needed.