Femoral fractures and abuse in children under 36 months old: a Swiss case series.

Abuse should be suspected in infant femoral fractures without significant trauma, especially if the child is non-ambulatory. Review the epidemiological and radiological characteristics of femoral fractures in children under 36 months old to identify those potentially related to child abuse. Cases involving 102 patients presenting with 103 femoral fractures between January 1990 and December 2020 were investigated, paying close attention to mechanisms of injury, fracture patterns, and their possible relations to child abuse. The annual incidence of femoral fractures in patients under 36 months old was estimated at 24.6 per 100 000; the incidence in infants under 13 months was significantly higher than among children between 13 and 36 months old. Most infants under 13 months suffered from transverse or oblique metaphyseal/diaphyseal fractures (93.2%), whereas 67.8% of older children presented with spiral shaft fractures. Data confirmed child abuse in 4.9% of all patients (one with bilateral fractures); femoral fractures were incompatible with their reported mechanisms of injury in 31 patients (30.4%), whereas 12 fractures (11.8%) occurred in unexplained circumstances. More than 50% of femoral fractures occurred with low-energy trauma. The difference in patterns according to patients' ages suggested different mechanisms of trauma in ambulatory and non-ambulatory infants. Confirmed abuses and unclear or inconsistent mechanisms of trauma, raised potential total child abuse cases to 47.1% of our cohort. Level of evidence: Level IV.

Biological Predictors of Osteoarticular Infection Due to K. kingae-A Retrospective Cohort Study of 247 Cases.

Pediatric osteoarticular infections (OAIs) are serious conditions that can lead to severe septic complications, prolonged morbidity with long-term impaired function, and perturbed subsequent bone development. Kingella kingae (K. kingae) is currently accepted as the predominant pathogen in pediatric OAIs, especially among 6-48 month olds. The present study aimed to identify clinical and biological markers that would refine the detection of patients with an OAI due to K. kingae. We retrospectively studied every consecutive case of pediatric OAI admitted to our institution over 17 years. Medical records were examined for patient characteristics such as temperature at admission, affected segment, and biological parameters such as white blood cell (WBC) count, left shift, platelet count (PLT), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). The 247 patients included 52.2% males and 47.8% females and mean age was 18.5 ± 10 months old. Four patients were older than 48 months; none were younger than 6 months old. Mean temperature at admission was 37.4 ± 0.9 °C. Regarding biological parameters, mean WBC count was 12,700 ± 4180/mm3, left shift was only present in one patient, mean PLT was 419,000 ± 123,000/mm3, mean CRP was 26.6 ± 27.8 mg/L, and mean ESR was 35.0 ± 18.9 mm/h. Compared to the modified predictors of OAI defined by Kocher and Caird, 17.2% of our cases were above their cut-off values for temperature, 52.3% were above the WBC cut-off, 33.5% were above the ESR cut-off, and 46.4% were above the CRP cut-off. OAIs due to K. kingae frequently remain undetected using the classic biological parameters for investigating bacterial infections. As an addition to the predictors normally used (°C, WBC, CRP, and ESR), this study found that elevated platelet count was frequently present during OAIs caused by K. kingae. Although this biological characteristic was inconstant, its presence was highly significant and very suggestive of an invasive infection due to K. kingae.

Pediatric Osteoarticular Kingella kingae Infections of the Hand and Wrist: A Retrospective Study.

Our understanding of pediatric osteoarticular infections (OAIs) has improved significantly in recent decades. Kingella kingae is now recognized as the most common pathogen responsible for OAIs in pediatric populations younger than 4 years old. Research has provided a better understanding of the specific types, clinical characteristics, biological repercussions, and functional outcomes of these infections. Hands and wrists are rarely infected, with few reports available in the literature. The present study aimed to examine this specific condition in a large patient cohort, explore the implications for each anatomical area using magnetic resonance imaging (MRI), and critically evaluate the evolution of therapeutic management.

Subacute osteomyelitis due to Staphylococcus caprae in a teenager: A case report and review of the literature.

BACKGROUND: Staphylococcus caprae (S. caprae) is a human commensal bacterium which can be detected in the nose, nails, and skin. It can be responsible for heterogeneous infections such as bacteremia, endocarditis, pneumonia, acute otitis externa, peritonitis, and urinary tract infections. Bone and joint infections due to S. caprae have also been reported, but most of them resulted from the infection of orthopedic devices, especially joint prostheses and internal osteosynthesis devices. Rare cases of primary osteoarticular infections caused by S. caprae have been described, including osteitis, arthritis, or spondylodiscitis. CASE SUMMARY: We report an unusual case of subacute osteomyelitis in a toe phalanx caused by S. caprae in a 14.5-year-old girl. CONCLUSION: Subacute S. caprae osteomyelitis is a little-known and probably underestimated community-acquired infectious disease. This microorganism's pathogenicity should be seen as more than a classic nosocomial orthopedic device infection.

Transphyseal Hematogenous Osteomyelitis: An Epidemiological, Bacteriological, and Radiological Retrospective Cohort Analysis.

Transphyseal hematogenous osteomyelitis (THO) is a serious condition that can affect the growing physis, yet it is insufficiently recognized in children. The aim of this study was to explore the prevalence and epidemiology of pediatric THO, and to discuss the underlying pathophysiology. All consecutive cases of acute and subacute osteomyelitis admitted to our institution over 17 years were retrospectively studied. Medical records were examined for patient characteristics, bacteriological etiology, and medical and surgical management. Magnetic resonance imaging was reviewed for all patients to identify those with transphyseal spread of infection. For positive cases, the surface area of the transphyseal lesion was estimated relative to the total physeal cross-sectional area. Fifty-four (25.7%) of the 210 patients admitted for acute or subacute osteomyelitis were diagnosed with THO. The study population's ages ranged from 1 month to 14 years old (median age 5.8 years, interquartile range 1-167 months). Fourteen (25.9%) patients were younger than 18 months old; the remaining 40 (74.1%) had a mean age of 8.5 years old. The most common sites of THO were the distal tibia (29.1%), the proximal tibia (16.4%), and the distal fibula (14.5%). Transphyseal lesions were due to acute infection in 41 cases and to subacute osteomyelitis in 14 cases. The two most frequently identified pathogens were Staphylococcus aureus (49.1%) and Kingella kingae (20.0%). An average transphyseal lesion represented 8.9% of the total physeal surface, and lesions comprised more than 7% of the physeal cross-sectional area in 51% of cases. Our study revealed that pediatric THO was more frequent than commonly thought. Transphyseal lesions were frequently above this 7% cut-off, which is of paramount importance since subsequent growth is more likely to be disturbed when more than 7% of the physeal cross-sectional area is injured. THO also affected children older than 18 months, an age at which transphyseal arterial blood supply to the epiphysis is believed to have disconnected. This finding suggests another pathophysiological reason for the transphyseal diffusion of infection, a topic deserving further studies and greater understanding.

Clinical and Biologic Characteristics of Kingella kingae -Induced Septic Arthritis of the Knee in Young Children.

BACKGROUND AND OBJECTIVES: Septic arthritis of the knee is presumed to be the most frequent form of Kingella kingae -induced osteoarticular infection. This study aimed to report on the clinical course, biological parameters, and results of microbiological investigations among children with K. kingae -induced septic arthritis of the knee. It also assessed the modified Kocher-Caird criteria's ability to predict K. kingae -induced septic arthritis of the knee. METHODS: The medical charts of 51 children below 4 years old with confirmed or highly probable K. kingae -induced arthritis of the knee were reviewed. Data were gathered on the five variables in the commonly-used Kocher-Caird prediction algorithm (body temperature, refusal to bear weight, leukocytosis, erythrocyte sedimentation rate, and C-reactive protein level). RESULTS: Patients with K. kingae -induced arthritis of the knee usually presented with a mildly abnormal clinical picture and normal or near-normal serum levels of acute-phase reactants. Data on all five variables were available for all the children: 7 children had zero predictors; 8, 20, 12, and 4 children had 1, 2, 3, and 4 predictors, respectively; no children had 5 predictors. This gave an average of 1.96 predictive factors and a subsequent probability of ≤ 62.4% of infectious arthritis in this pediatric cohort. CONCLUSIONS: Because the clinical features of K. kingae -induced arthritis of the knee overlap with many other conditions affecting this joint, the Kocher-Caird prediction algorithm is not sensitive enough to effectively detect K. kingae -induced septic arthritis of the knee. Excluding K. kingae -induced arthritis of the knee requires performing nucleic acid amplification assays on oropharyngeal swabs and joint fluid from those young children presenting with effusion of the knee, even in the absence of fever, leukocytosis, or a high Kocher-Caird score.

Epidemiological Study of Equestrian Trauma in Geneva.

BACKGROUND: Horse-related activities are increasingly popular among young people but are frequently associated with severe injuries requiring hospital treatment. There are few data on the incidence of equestrian injuries, especially in child populations, or on means of prevention. Thus, this study's purpose was to highlight the epidemiological data on specific injuries due to equestrianism and serve as the groundwork for future studies on the prevention of equestrian accidents. METHODS: A retrospective study collected data on all children younger than 16 years old who attended our regional emergency department after involvement in an equestrian accident. The study covered the periods from 1990 to 2003 and 2011 to 2018. Twenty-two years of data on trauma circumstances, injury patterns (mechanism, anatomic site, and severity), treatment protocols, and hospital lengths of stay were analyzed. RESULTS: This study confirmed that more young females participating in equestrian sports attended our emergency department than males. The leading cause of equestrian injury was falling from a horse (80.2%). Orthopaedic injuries represented around 60% of all reported lesions, far ahead of head injuries (30%). More than half of the injured children required hospitalization for inpatient medical care, and almost 50% of these underwent a surgical procedure, especially for upper extremity fractures (72% of all fractures). One patient died due to severe cerebral injury. CONCLUSIONS: Horse riding injuries occur more frequently and are more serious than in many other sporting activities. There is an urgent need to reassess preventive measures to reduce the incidence and severity of equestrian injuries. LEVEL OF EVIDENCE: Level IV.

Complications of intrathecal baclofen pump treatment in children with spastic cerebral palsy. A comparative analysis of patients weighing over or under 20 kg at the time of implantation.

The purpose of this study was to investigate the incidence of complications in pediatric spastic cerebral palsy (CP) patients weighing less than 20 kg at the time of intrathecal baclofen (ITB) pump implantation and to compare it with spastic CP patients heavier than 20 kg. Twenty-seven patients with spastic CP (14 males) treated with ITB implantation at our institution between January 2002 and January 2018 were retrospectively reviewed. Eight of the 27 patients had a bodyweight below 20 kg (group A) and 19 had weight above 20 kg (group B). Group A had a significantly more important proportion of patients with the Gross Motor Function Classification System V compared to group B (88 vs. 42%). The median follow-up was respectively 2.5 (1.8-4.6) and 4.6 (1.9-10.0) years in groups A and B. Median age at the time of ITB implantation was 7.4 (2.8-12.8) and 13.7 (6.5-16.8) years in groups A and B (P = 0.002). The proportion of patients with complications or reoperation was NS between groups A and B (P > 0.05). No postoperative infections were recorded in any of the groups. During follow-up, five patients died (63%) in group A and three (16%) in group B (P = 0.049) within 3.8 years on average after ITB implantation. ITB therapy in spastic CP patients weighing less than 20 kg seems to be as well tolerated and effective as it is in heavier (>20 kg) pediatric patients.

Fracture Nonunion of the Clavicle After Surgical Reduction in a 13-Year-Old Girl: A Case Report.

CASE: Although congenital nonunion of the clavicle is a well-known pathology in children, posttraumatic nonunion is a rare entity. Nonunion after open reduction and internal fixation of a clavicle fracture is exceptional in the pediatric population. We report on a patient presenting posttraumatic pseudarthrosis of the clavicle after surgical treatment. Pseudarthrosis was resected, and the defect was bridged with an iliac crest autograft, supplemented with bone morphogenetic protein, and fixed with an elastic stable intramedullary nail. CONCLUSION: This procedure offered enough stability for achieving fracture consolidation and is a safe alternative to plating in clavicle nonunion.

Proximal Interphalangeal Hyperextension Injuries in Children: The Development of a Clinical Decision Guide.

OBJECTIVE: To develop a clinical decision guide for the diagnosis and treatment of hyperextension injuries of long fingers. STUDY DESIGN: Consecutive patients age <16 years (n = 300) with an acute proximal interphalangeal (PIP) joint hyperextension injury were included. High-risk and low-risk measures for severe injury were established with a standardized clinical examination and anteroposterior and lateral radiographs of the injured finger. Four clinical variables were assessed: location of pain; swelling and bruising, stability, and mobility. Pathological radiographic findings were compiled, and the risk of late complications was analyzed. The predictive value of the clinical examination in the identification of low-risk injuries was assessed. RESULTS: The majority (67%) of children consulting for a hyperextension finger trauma did not have a fracture. No child with a low-risk clinical examination had a subsequent high-risk diagnosis (eg, relevant intra-articular fracture, dislocation). Among 64 clinical high-risk diagnoses only 12 significant fractures were found. CONCLUSION: Treatment decisions after PIP hyperextension injuries can be based on a clinical examination using a standardized evaluation protocol. Application of the clinical decision guide presented here has a sensitivity of 100% to rule out a significant injury. Present results showed that the majority of radiographs currently performed are avoidable. Once the decision rule is validated, its clinical application will improve patient care, reduce waiting times in emergency departments, avoid unnecessary radiation exposure, and possibly reduce costs.

Osteoarticular Infections of the Chest Wall Due to Kingella Kingae: A Series of 8 Cases.

Osteoarticular infections of the chest wall are relatively uncommon in pediatric patients and affect primarily infants and toddlers. Clinical presentation is often vague and nonspecific. Laboratory findings may be unremarkable in osteoarticular chest wall infections and not suggestive of an osteoarticular infection. Causative microbes are frequently identified if specific nucleic acid amplification assays are carried out. In the young pediatric population, there is evidence that Kingella kingae is 1 of the main the main causative pathogens of osteoarticular infections of the chest wall.

Proximal Radioulnar Translocation Associated with Posterior Fracture-Dislocation of Elbow in an Adolescent Girl: A Case Report.

CASE: A 14-year-old girl sustained a posterior elbow dislocation and presented with a proximal radioulnar translocation (PRUT) and a displaced fracture of the radial head. Reduction of the elbow dislocation and the proximal radioulnar translocation were achieved by external manipulation in the operating room. The radial head was not amenable to closed reduction and remained entrapped in the anteromedial compartment of the elbow. So open reduction and internal stabilization was carried out. CONCLUSIONS: In PRUT, closed reduction should be attempted. The radial head should be preserved even if it is fully dislocated from metaphysis. Retrograde intramedullary radial nailing provides enough stability of the fracture to promote early mobilization and facilitate union.

Mechanism and predisposing factors for proximal tibial epiphysiolysis in adolescents during sports activities.

BACKGROUND: Proximal tibial epiphysiolysis (PTE) can have debilitating consequences for young athletes. The mechanism and predisposing factors for this lesion have yet to be determined. To find a common denominator and a biomechanical explanation for PTE, we were using a retrospective analysis of 15 cases in combination with a systematic review of literature. METHODS: A retrospective review of medical charts was performed to identify all PTE between 2003 and 2012. Records were screened for patient age and gender, sports activity, mechanism of injury, and treatment protocols. Additionally, a literature review (MEDLINE/PubMed database, the Cochrane Library, online search engines) was conducted. RESULTS: Medical charts of 14 adolescents (15 Salter-Harris I and II fractures) were analyzed. The literature review revealed additional 75 fractures. The predominant mechanisms were landing from a jump, takeoff for a jump, stop and go movements, and eccentric muscle contraction with the knee in flexion. The main sports-activities implicated in these injuries were basketball. CONCLUSIONS: Landing from a jump with a decreased knee and hip flexion movement increases tensile forces on the proximal tibia epiphysis. During physiological epiphysiodesis, the growth plate displays an increased vulnerability and such increased tensile forces can lead to a growth plate failure. Neuromuscular fatigue can alter coordination and proprioceptive accuracy during landing from a vertical jump and thus perturbs sagittal shock absorption. In our opinion, trainers should instruct young athletes in techniques that help avoiding uncontrolled high impact landings. LEVEL OF EVIDENCE: Level IV.

The helminth product, ES-62 modulates dendritic cell responses by inducing the selective autophagolysosomal degradation of TLR-transducers, as exemplified by PKCδ.

We have previously shown that ES-62, a phosphorylcholine (PC)-containing glycoprotein secreted by the parasitic filarial nematode Acanthocheilonema viteae targets dendritic cell (DC) responses, specifically by suppressing TLR4 signalling to inhibit Th1/Th17-driven inflammation. We have now investigated the molecular mechanisms underpinning such immunomodulation and show here that ES-62-mediated downregulation of protein kinase C-δ (PKC-δ), a TLR4-associated signalling mediator required for full activation of LPS-driven pro-inflammatory responses, is associated with induction of a low level of autophagic flux, as evidenced by upregulation and trafficking of p62 and LC3 and their consequent autophagolysosomal degradation. By contrast, the classical TLR4 ligand LPS, strongly upregulates p62 and LC3 expression but under such canonical TLR4 signalling this upregulation appears to reflect a block in autophagic flux, with these elements predominantly degraded in a proteasomal manner. These data are consistent with autophagic flux acting to homeostatically suppress proinflammatory DC responses and indeed, blocking of PKC-δ degradation by the autophagolysosomal inhibitors, E64d plus pepstatin A, results in abrogation of the ES-62-mediated suppression of LPS-driven release of IL-6, IL-12p70 and TNF-α by DCs. Thus, by harnessing this homeostatic regulatory mechanism, ES-62 can protect against aberrant inflammation, either to promote parasite survival or serendipitously, exhibit therapeutic potential in inflammatory disease.

The helminth product, ES-62, protects against airway inflammation by resetting the Th cell phenotype.

We previously demonstrated inhibition of ovalbumin-induced allergic airway hyper-responsiveness in the mouse using ES-62, a phosphorylcholine-containing glycoprotein secreted by the filarial nematode, Acanthocheilonema viteae. This inhibition correlated with ES-62-induced mast cell desensitisation, although the degree to which this reflected direct targeting of mast cells remained unclear as suppression of the Th2 phenotype of the inflammatory response, as measured by eosinophilia and IL-4 levels in the lungs, was also observed. We now show that inhibition of the lung Th2 phenotype is reflected in ex vivo analyses of draining lymph node recall cultures and accompanied by a decrease in the serum levels of total and ovalbumin-specific IgE. Moreover, ES-62 also suppresses the lung infiltration by neutrophils that is associated with severe asthma and is generally refractory to conventional anti-inflammatory therapies, including steroids. Protection against Th2-associated airway inflammation does not reflect induction of regulatory T cell responses (there is no increased IL-10 or Foxp3 expression) but rather a switch in polarisation towards increased Tbet expression and IFNγ production. This ES-62-driven switch in the Th1/Th2 balance is accompanied by decreased IL-17 responses, a finding in line with reports that IFNγ and IL-17 are counter-regulatory. Consistent with ES-62 mediating its effects via IFNγ-mediated suppression of pathogenic Th2/Th17 responses, we found that neutralising anti-IFNγ antibodies blocked protection against airway inflammation in terms of pro-inflammatory cell infiltration, particularly by neutrophils, and lung pathology. Collectively, these studies indicate that ES-62, or more likely small molecule analogues, could have therapeutic potential in asthma, in particular for those subtypes of patients (e.g. smokers, steroid-resistant) who are refractory to current treatments.

Gene inactivation confirms the identity of enzymes involved in nematode phosphorylcholine-N-glycan synthesis.

An unusual feature of nematodes is the covalent attachment of immunomodulatory phosphorylcholine (PC) moieties to N-type glycans. Our previous work on the filarial nematode glycoprotein ES-62 has enabled us to predict the identity of enzymes necessary for PC-N-glycan biosynthesis. Here, we addressed these predictions using gene knockout technology applied to C. elegans and present two pieces of confirmatory data. Employing a triple null mutant worm lacking all three genes that encode active UDP-N-acetyl-D-glucosamine: alpha-3-D-mannoside beta1, 2-N-acetylglucosaminyltransferase I (GnT I) we have confirmed our earlier prediction that a crucial step in the generation of the substrate for PC transfer is addition of terminal GlcNAc to the alpha1-3-linked mannose residue of the glycan by GnT I. Second, by silencing genes responsible for expressing enzymes of the Kennedy pathway of phosphatidylcholine biosynthesis by RNA interference (RNAi), we have confirmed our belief for a role for diacylglycerol: choline phosphotransferase (CPT) in PC-N-glycan biosynthesis.