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.

Secondary displacement in distal forearm fractures in children: adequate positioning of the wrist in the cast is more important than cast index.

The objective of this study was to assess whether the positioning of the wrist joint in the cast in such a manner that it counteracts the direction of angulation of fragments is more important than the cast index in the prevention of secondary displacements in distal forearm fractures. A retrospective review of all pediatric patients (0-16 years of age) who were hospitalized in our institution with displaced fractures of the distal forearm (either isolated fractures of the distal radius or both bone fractures) who underwent subsequent closed reduction and splinting in the period from August 2018 to October 2020. Patients with physeal fractures and open fractures, and skeletally mature patients were excluded from the study. Patients were divided into two categories - the first one in which the cast index was below 0.9 and the second in which it was above 0.9. In each category, we have identified two groups of patients - the first one in whom the wrist joint was positioned in such a manner that it counteracts the direction of angulation of fracture fragments and the second one in whom the wrist joint was in a neutral position. The two groups in each category have been compared according to age, sex, initial angulation, fracture type (isolated radius or both bone fractures), displacement type (angulation or complete dislocation) and the rate of secondary displacement. In both categories, the two groups were comparable according to age, sex, initial angulation, fracture and displacement type. In both categories (cast index below 0.9 and cast index above 0.9), a statistically significant higher portion of patients with secondary displacement was identified in the group of patients who had the wrist joint in a neutral position ( Z = -2.1997; P = 0.0278 - for cast index <0.9 and Z = -2.1672; P = 0.030216 for cast index >0.9). Our research supports the notion that positioning of the wrist joint in the position that counteracts the force that leads to angulation of fracture fragments is more important than the cast index in the prevention of secondary displacements in pediatric distal forearm fractures.

The association between improved standard of living and paediatric burns.

INTRODUCTION: In the "Children's Hospital Zagreb Referral Centre for Paediatric Trauma of the Ministry of Health Republic of Croatia (MHC)" we observed a significant decline in the number of both hospitalised and ambulatory treated paediatric patients with burn injuries in the period from 2011 to 2018. Our hypothesis is that this decline could be either due to the decline of the paediatric population of Croatia or due to the economic growth and the improvement in the standard of living that Croatians have enjoyed in the past decade. MATERIALS AND METHODS: In this observational study, we analysed data on the numbers of patients treated due to burn injuries from January 2011 to December 2018 in the Children's Hospital Zagreb Hospital. Indicators of standard of living and population size estimates were obtained from Eurostat and the Croatian Bureau of Statistics. Associations between the proportion of people with poor standard of living and the number of treated patients were analysed with logistic regression models. RESULTS: Percentage of the population with low housing standards, percentage of Croatians with low level of education, percentage of children that live in jobless households, and percentage of children at risk of poverty and social exclusion were predictors of the rate of hospital admissions, ambulatory treated patients and total number of treatments. The slight decrease in the rate of treated patients was interrupted with notable decline in 2014 followed by the slight increase in 2015. Over following years, the rate did not change remarkably. CONCLUSION: Apart from the decline of the paediatric population of Croatia, it is reasonable to assume that the improvement in the standard of housing, level of education and employment rate as well as the reduction in the risk of poverty and social exclusion in children had a notable contribution to the decline in the rate of paediatric burns in the observed period.

Darier Disease Presenting with Recurrent Kaposi Varicelliform Eruption in a 10-year-old Boy with Seborrheic Dermatitis.

We present a case of a 10-year-old boy with a longstanding history of seborrheic dermatitis (SD) referred to the Allergy and Immunology Department for recurrent Kaposi varicelliform eruption (KVE) secondary to herpes simplex 1 (HSV-1) infection and possible primary immunodeficiency. The patient was the second child of non-consanguineous parents, with an older, healthy brother. Family history was negative for primary immunodeficiency and skin disorders. The patient's skin problems began in infancy when he was diagnosed and treated by a dermatologist for SD. From preschool age, he was under the care of a pediatric neurologist and a defectologist for a sensory processing disorder. For the last two years, the patient had been receiving chlorpromazine therapy for aggressive behavior. The first episode of KVE was diagnosed at the age of six, following potent topical corticosteroid therapy for SD and sun exposure, another known risk factor for HSV infection. After the third KVE episode, prophylaxis with oral acyclovir was initiated. The skin changes were treated with topical steroids and oral antibiotics during disease flares, with poor clinical response. On presentation, the patient was in good general health, adipose, and of unremarkable somatic status, except for numerous symmetrical yellowish-brown keratotic papules and plaques on the forehead, cheeks, and the lateral side of the neck (Figure 1). The nail plate had multiple red and white longitudinal streaks and V-shaped notches on the distal free end of the nail plate (Figure 2). The allergy tests revealed increased total immunoglobulin E (IgE) and sensitization to ragweed. Immunological workup showed normal immunoglobulins and good specific immunity (good vaccine response and normal humoral response to HSV-1) but a decreased number of T- cells (CD3+ 1020/µL (1320-3300), CD3+CD8+ 281/µL (390-1100) with normal T-cell response after antigen stimulation. The diagnosis of Darier disease (DD) was confirmed based on medical history, clinical findings and histological finding of focal suprabasal acantholysis and dyskeratosis (Figure 3). Low-dose oral retinoid therapy was initiated with modest clinical response after 6 months of therapy. In the light of recent publication (1), we initiated intravenous immunoglobulin (IVIG) substitution (400 mg/kg every month) with excellent clinical response. After 4 months, the patient's skin improved in terms of reduced inflammation, scab healing, and reduced itching. Acyclovir prophylaxis was continued. The patient had no new episodes of KVE during follow-up. Kaposi's varicelliform eruption (KVE) or eczema herpeticum occurs in a chronic inflammatory skin disease such as atopic dermatitis (AD), SD, Hailey-Hailey disease, allergic contact dermatitis, psoriasis, and DD (2). It is considered a dermatologic emergency due to its high mortality rate if misdiagnosed or left untreated (3). DD is a rare autosomal dominant genodermatosis of variable expressivity caused by mutations in the ATP2A2 gene, which encodes a sarco/endoplasmic reticulum calcium ATPase (SERCA2) highly expressed in keratinocytes (4). The onset of the disease usually occurs between the ages of 6 and 20 years. There are several clinical variants of DD: hypertrophic, verrucous, vesicular-bullous (dyshidrotic), erosive, and predominantly intertriginous forms (4). The fact that skin lesions occurred in infancy and a negative family history for skin diseases could be the reason our patient was initially misdiagnosed with seborrheic dermatitis. Due to the variable expressivity of the disease, it is impossible to exclude the diagnosis in other family members, and genetic testing of the patient and family members is therefore planned. A co-occurrence of neuropsychiatric abnormalities such as epilepsy, mental impairment, and mood disorders have been reported in patients with Darier disease, and these disorders were also present in our patient (5), indicating a correct diagnosis. Patients with DD have a high propensity for severe viral, bacterial, and fungal skin infection, probably due to local disruption of the skin barrier function or as the result of an underlying defect in general host defence (6). The occurrence of KVE in patients with DD is rare (7) and possibly caused by a disturbances in cell-mediated immunity (8). Despite abnormal findings in cellular immunity in some patients with DD, no consistent or specific abnormalities of the immune system have yet been demonstrated (6). Our patient had a decreased number of cytotoxic T-cells with normal T-cell response after antigen stimulation (in contrast with the findings of Jegasothy et al. (6)) and normal humoral response to HSV-1 infection. Recurrent KVE in our patient could be related to immune system dysfunction as an additional risk factor, along with impaired skin barrier. The excellent clinical response to IVIG speaks in favor of the role of antibody immune response in preserving the skin barrier. Occurrence of KVE in patients with mild DD (as in the case of our patient) and in some patients immediately preceding clinical skin manifestations of disease, argues very strongly against the second supposition. The severity of DD is variable and has a chronic course with frequent exacerbations and remissions. Known exacerbating triggers are: heat, sweat, sun exposure, friction, medication, and infection (9,10). The disease is chronic, and management is focused on the improvement of the skin appearance, relief of symptoms (e.g., irritation, pruritus, and malodor), and prevention or treatment of secondary infections. Topical (emollients, corticosteroids, retinoids, 5-fluorouracil, tacrolimus, pimecrolimus), physical (excision, electrodessication, dermabrasion, ablative laser, photodynamic therapy), and systemic (oral antibiotics, antiviral drugs, antimicrobial prophylaxis, vitamin A, retinoids) therapies are among the treatment options, all of which are of limited effect (2,11,12). IVIG substitution could be beneficial in some patients with Darier disease (1). In conclusion, this case highlights the association of DD with impaired cellular immunity and indicates the importance of proper diagnosis due to adequate management and avoidance of possible fatal outcomes. However, whether a subtle abnormality of T-cells in DD predisposes the patient to KVE remains unclear. Possible underlying mechanisms should be investigated further.

The patterns of phalangeal fractures in children and adolescents: a review of 512 cases.

INTRODUCTION: Fractures of the phalanges in children can often be underappreciated by the physician of first contact. Therefore it is necessary to point out which of these fractures, because of the risk of possible future complications, need special mention. MATERIALS AND METHODS: A retrospective review of 512 fractures of the phalanges in children and adolescents during an one year period. Fractures were subdivided into the following categories - physeal fractures, intraarticular (phalangeal neck and condylar) fractures, shaft fractures, tuft fractures, "mallet finger" fractures, volar plate avulsion injuries and collateral ligament avulsion injuries. Main outcome measures was the necessity for operation while the average age at which the injury has occured, the cause of the injury, the frequency of injury of each finger, the necessity for reduction, and the duration of splinting were the secondary outcome measures. RESULTS: Collateral ligament avulsion injuries and intraarticular (phalangeal neck and condylar) fractures were injuries which most often necessitated operative treatment. Physeal injuries were the most common injuires with avulsions of the volar plate being the second most common. Accidents during sport was by far the most common cause of injuires in all categories apart from tuft injuries. CONCLUSION: The findings regarding the incidence and the cause of these injuries in this study support the already published dana in the literature. The physician of first contact has to be capable to recognise the problematic fractures - intraarticular (phalangeal neck and condylar), significantly displaced Salter-Harris type III and IV fractures and collateral ligament avulsion injuries and Seymour fractures.

[THE SCALP AS A SPLIT-THICKNESS GRAFT DONOR IN THE TREATMENT OF A MASSIVE THERMAL INJURY]. / VLASISTE KAO DONOR TRANSPLANTATA DJELOMICNE DEBLJINE KOZE U LIJECENJU MASIVNE TERMALNE OZLJEDE.

We are presenting our initial experience with the utilization of the scalp as a donor for split thickness skin grafting in the treatment of massive thermal injuries. Rapid donor reepithelization, absence of hypertrophic scarring in the donor area, inconspicuous donor area and a large area for the procurement of grafts in the pediatric population are the advantages that are emphasized in the literature. The outcome in a 3-year-old boy who suffered a burn injury from an open fire in the family house on the 57% of his total body surface area (48% full thickness burn) showed that the "take rate", in the absence of a massive local infection, was around 80% and that the scalp can be utilized again as a donor area after a period of 14 days. Folliculitis and alopecia are complications that should be kept in mind when using this technique.

[INITIAL EXPERIENCE WITH TOPICAL NEGATIVE PRESSURE THERAPY IN THE TREATMENT OF PEDIATRIC BURNS].

We are presenting the experience of the Referral Centre for Pediatric Traumatism of the Croatian Ministry of Health in the usage of topical negative pressure therapy (TNP) method for the treatment of pediatric burns. In the period of 20 months we have used negative pressure wound therapy method in eight children aged between 1.5 and 10 years. Burn injuries total body surface area ranged between 3% and 30%. TNP was used either for the wound bed conditioning or for the fixation of skin grafts. Average skin graft "take" was 86% eight days after surgery according to the evaluation by the senior author. Based on our initial experience, we can confirm that TNP is a very useful tool which enables good wound bed conditioning as well as a good fixation tool for skin grafts if the burned area does not exceed 30% of total body surface area.

Isolated fallopian tube torsion with partial hydrosalpinx in a premenarcheal girl: a case report.

INTRODUCTION: Isolated fallopian tube torsion as a complication of a preexisting hydrosalpinx is a rare finding in pediatric patients. The obvious rarity of this condition, its subtle diagnostic features and dissonant previous reporting about the appropriate therapeutic approach according to age, future conception capacity and potential complications of possible pregnancies make the decision about which surgical approach to use very difficult. In this report, we describe the case of a patient with such a presentation and review the literature. Very few similar reports of neosalpingostomy in pediatric patients have been published to date. CASE PRESENTATION: In our present report, we describe the case of an 11-year-old Caucasian prepubertal girl who presented to our hospital with complaints of abdominal pain in the right lower quadrant, nausea and vomiting. The diagnostic workup led us to conclude that she had a torsion of the right ovary, which was cystically altered. Exploratory surgery revealed a partial hydrosalpinx and consecutive isolated torsion of the fimbrial part. The proximal isthmic part of the fallopian tube was intact and vital. Restorative surgery was performed to create a neosalpingostomy on the viable isthmic part of the tube and remove the cystic and twisted fimbrial and infundibular parts. CONCLUSION: The surgical procedure described in this report is technically simple and feasible, but leaves doubts about the final outcome.