Pediatric Hammertoe Recurrence-Considerations for Revision Surgical Technique and Hypoperfusion Management: A Case Report.

CASE: A 7-year-old girl presented with a recurrent hammertoe deformity causing pain with shoe wearing after a prior corrective surgery. Surgical revision required a unique approach that included a staged corrective osteotomy of the proximal phalanx because of hypoperfusion management and the application of a rotational skin flap previously described for camptodactyly correction in the hand to avoid harvesting a skin graft. CONCLUSION: Revision surgery for recurrent pediatric hammertoe deformity requires a heightened awareness of the risk for toe hypoperfusion and subsequent wound closure challenges.

Malignant Granular Cell Tumor of the Lower Extremity in an Adolescent Male.

Granular cell tumors (GCTs) are extremely rare soft tissue tumors, with only 2% of tumors being malignant. Malignant GCTs are more often seen in women between the ages 40 and 60. There has been no case reported of a malignant GCT in a pediatric patient. We present a case of a 14-year-old male who presented with a large mass in his left lower extremity. After being biopsied, the mass was diagnosed as a malignant GCT. The tumor was completely excised with wide margins and close follow-up with the patient continued.

Pediatric Lawn-Mower Injuries Presenting at a Level-I Trauma Center, 1995 to 2015: A Danger to Our Youngest Children.

BACKGROUND: Unintentional injuries are the leading cause of morbidity and mortality among children 0 to 18 years of age in the U.S. An estimated 9,400 to 17,000 pediatric lawn-mower injuries occur each year. The aims of this study were to better define the epidemiology of lawn-mower injuries and to identify predictors of severe lawn-mower injuries to optimize public education and injury prevention. METHODS: All patients 0 to 18 years of age who presented to Children's Mercy Hospital (CMH), Kansas City, Missouri, during the period of 1995 to 2015 after sustaining a lawn-mower injury were identified using International Classification of Diseases, 9th Revision (ICD-9) codes. Demographic information and data regarding primary outcome measures (death, amputation, need for prosthesis, Injury Severity Score [ISS]) and secondary outcome measures were collected. Bivariate and multivariate analyses were used to identify risk factors for severe lawn-mower injuries. RESULTS: One hundred and fifty-seven patients were identified, with a bimodal age distribution peaking at 4 and 15 years of age. Seventy-five percent of the subjects were male. Sixty-six percent of the patients were admitted to the hospital, with a mean length of stay of 6 days. An average of 3 operations were performed. Nineteen percent of the patients lived in a nonmetro/rural location. Lower-extremity injuries were most prevalent, affecting 84% of the patients. Forty percent of the patients experienced at least 1 traumatic amputation. Thirteen percent of the patients required a prosthesis after the injury. The average ISS was 8. Significant predictors of a higher ISS included an age of 0 to 9 years, a riding lawn mower, a grandparent operator, and a nonmetro/rural location. Younger children were more likely to be injured from a riding lawn mower, be the passenger of the mower or a bystander, be injured with a grandparent operator, and live in a nonmetro/rural location. Younger children also had a higher ISS and amputation rate, longer LOS, and more surgical procedures. CONCLUSIONS: Education to protect younger patients should target parent, grandparent, and older sibling operators. Education for the older, teenage group should include safe mowing techniques. Efforts should also target nonmetro/rural populations and grandparents, specifically highlighting the severe dangers of riding lawn mowers when young children are passengers or bystanders. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical variables and Staphylococcus aureus virulence factors associated with venous thromboembolism in children.

OBJECTIVES: Children with Staphylococcus aureus (SA) bacteremia risk developing venous thromboembolism (VTE). We sought to identify clinical variables and bacterial virulence factors associated with VTE in SA bacteremia. STUDY DESIGN: This is a single-institution retrospective study of 229 children with SA bacteremia hospitalized from 2005 to 2008. Clinical data were abstracted from patient charts. Two-hundred three SA isolates were analyzed by polymerase chain reaction. The Pediatric Health Information System (PHIS) database was queried to identify subjects with a central venous line (CVL) or complex chronic conditions (CCC). Logistic regression analysis was employed to determine which factors most greatly influenced VTE. RESULTS: VTE was present in 9.2% (n=21/229). Superficial thrombi were excluded. Mortality was greater in patients with VTE [24% vs. 6% (p=0.016)]. Among SA isolates available for virulence testing, the majority (70%; n=139) were methicillin-sensitive SA (MSSA). Methicillin-resistant SA (MRSA) infection was associated with VTE (p=0.01). The most common sites of thrombosis were extremity deep vein (58%; n=14/24), head/neck (29%; n=7), and visceral (13%; n=3). One subject had a pulmonary embolism. The presence of a CVL or a CCC was not associated with VTE. Independent predictors of VTE were C-reactive protein (CRP)≥20mg/dl [OR 4.2, 95% CI 1.16-15.25] and hemoglobin nadir ≤9g/dl [OR 5.2, 95% CI 1.3-20.64]. CONCLUSIONS: In addition to MRSA infection, CRP≥20mg/dl and hemoglobin nadir ≤9g/dl were associated with VTE in SA bacteremia. These factors may serve as markers for increased risk of VTE with invasive SA disease.

Giant cell tumor of bone in a child with Goltz syndrome.

Giant cell tumor of bone is a neoplasm that is rarely seen in children. Goltz syndrome is a disorder that affects multiple ectodermal and mesodermal tissues and has occasionally been associated with giant cell tumors of bone. Our case of giant cell tumor in a 5-year-old girl with Goltz syndrome suggests that this syndrome provides a unique situation wherein the practitioner should consider giant cell tumor of bone, even in a pediatric setting.

Bisphosphonates for pain management in children with benign cartilage tumors.

OBJECTIVES: Cochrane meta-analyses have shown significant benefit in bone pain from bisphosphonate therapy in adults with bone diseases such as multiple myeloma, Paget disease, breast and prostate cancer. Our aim was to assess if bisphosphonate treatment could alleviate severe pain in children with Ollier disease and hereditary multiple exostoses that are refractory to standard analgesics. METHODS: We report our clinical experience with bisphosphonate therapy in 2 children with cartilage tumors, one with Ollier disease, and the other with hereditary multiple exostoses. RESULTS: We found bisphosphonate therapy to be helpful for pain relief and improving overall ability to carry out daily activities. DISCUSSION: One can consider bisphosphonate therapy in children with Ollier disease and hereditary multiple exostoses who have debilitating pain that is refractory to standard analgesic treatment.