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.

A retrospective epidemiological study of paediatric femoral fractures.

BACKGROUND: Femoral fracture is a significant major trauma in children and adolescents, sometimes resulting in serious complications. This study aimed to determine the epidemiology of femoral fractures and to define associated injuries and mortality incidence in a pediatric population below 16 years old. METHODS: The medical records of all patients with a femoral fracture treated in our hospital from 1997–2016 were reviewed retrospectively. Age, gender, mechanism of the trauma, month and season of fracture occurrence, fracture type, associated injuries, and mortality data were collected. Patients were divided into four age groups and compared. RESULTS: The study included 348 children with 353 femoral fractures. The mean annual prevalence of femoral fracture during the study period was 22.7 per 100,000 children. Except for children less than 1 year old, most fractures occurred in male patients (69%), with a male-to-female ratio of 2.2:1. Road accidents were the most common mechanism at all ages. Femoral fractures were mainly due to low-energy trauma in neonates and infants, to road accidents and low-energy trauma in preschool children, to sports accidents in school-age children, and to road traffic accidents in teenagers. February was the month with the most occurrences of femoral fractures. Winter was the peak season for femoral fractures in children aged <1 year and 6–11 years (37.8% and 46.4% of fractures respectively), whereas autumn was the most common season (29.5%) for preschool children and spring (31.1%) the most common in the teenagers group. Diaphyseal fractures were the most commonly reported lesions in all four age groups, representing 72.3% of all fractures. Only 18 fractures were open (5.1%). Eighty-eight patients (25.3%) presented with associated injuries at admission, 12 presented with Waddell’s triad of injuries, and the mortality rate was calculated to be 1.1% (four cases). CONCLUSION: The circumstances of injury and the seasonality of femoral fractures differed significantly depending on the children’s ages. Moreover, the morbidity of femoral fractures in children was closely correlated with associated injuries. (Level of evidence: Level III).

Kingella kingae and Osteoarticular Infections.

OBJECTIVES: In this study, we aimed to contrast the bacteriologic epidemiology of osteoarticular infections (OAIs) between 2 patient groups in successive 10-year periods, before and after the extensive use of nucleic acid amplification assays in the diagnostic process. METHODS: Epidemiologic data and bacteriologic etiologies of all children presenting with OAIs on admission to our institution over 20 years (1997-2016) were assessed retrospectively. The population was divided into 2 cohorts, using the standardized use of polymerase chain reaction as the cutoff point (2007). The conventional cohort included children with OAIs mainly investigated by using classic cultures, whereas the molecular cohort referred to patients also investigated by using molecular assays. RESULTS: Kingella kingae was the most frequently isolated pathogen, responsible for 51% of OAIs, whereas other classic pathogens were responsible for 39.7% of cases in the molecular cohort. A statistically significant increase in the mean incidence of OAIs was observed, as was a decrease in the mean age at diagnosis after 2007. After 2007, the pathogen remained unidentified in 21.6% of OAIs in our pediatric population. CONCLUSIONS: Extensive use of nucleic acid amplification assays improved the detection of fastidious pathogens and has increased the observed incidence of OAI, especially in children aged between 6 and 48 months. We propose the incorporation of polymerase chain reaction assays into modern diagnostic algorithms for OAIs to better identify the bacteriologic etiology of OAIs.

Radiation-free measurement tools to evaluate sagittal parameters in AIS patients: a reliability and validity study.

PURPOSE: This study aimed to evaluate the intra-rater reliability and validity in comparison with the two-dimensional radiography (XR) of inclinometer (INCL) and rasterstereography (RAST) for assessing spinal sagittal angles of AIS patients. METHODS: Fifty-one AIS patients (13.5 (2.0) years, girls = 32 (63%), Cobb angle = 23.0 (17.4)°) were included in this study. Three repeated measurements of thoracic kyphosis (TK) and lumbar lordosis (LL) were evaluated using the INCL and RAST by the same operator on the same day of the XR examination. Intraclass correlation coefficients (ICC) were used to evaluate the reliability of the INCL and RAST systems. Additionally, Pearson coefficients were computed between the XR and INCL systems and between the XR and RAST systems. RESULTS: Reliability of each radiation-free system was excellent (ICC > 0.75 for INCL and RAST) for both the TK and LL parameters. The Pearson coefficients between each of the radiation-free systems and the XR were high to moderate for the TK (0.50 < RTK < 0.75 for INCL and RAST), high to moderate for the LL as measured with the RAST (0.50 < RLL < 0.75 for RAST) and low for the LL as measured with the INCL (RLL < 0.50 for INCL). CONCLUSION: This study demonstrated that for the RAST and INCL in AIS patients, there was (1) an excellent reliability for the TK and LL, (2) a high-to-moderate validity for measuring the TK and (3) a moderate and low validity for measuring the LL, respectively. These radiation-free systems could be used for the clinical follow-up of AIS patients for the evaluation of the TK. These slides can be retrieved under Electronic Supplementary Material.

[Corrective surgery for lower limb length discrepancy and malalignment in paediatric orthopaedics]. / Corrections d'axes et allongements des membres inférieurs en orthopédie pédiatrique.

Lower limb length discrepancy and malalignment in paediatric orthopaedics constitute a set of acquired or malformative structural pathologies. These anomalies, which may alter statics of lower limbs, are susceptible to engender an asymmetry of mechanical constraints' distribution across joints, and thus to promote the onset of arthritic phenomenons. The purpose of this review's article is to define the limits of tolerance of the various malformations and describe the innovative techniques available in order to correct them.

Les inégalités de longueur et les troubles d'axe des membres inférieurs constituent un ensemble de pathologies structurelles acquises ou malformatives. Ces anomalies, qui altèrent la statique des membres inférieurs, vont engendrer une asymétrie de répartition des contraintes mécaniques sur les différentes pièces osseuses et sur les articulations et, de ce fait, faciliter la survenue de phénomènes dégénératifs arthrosiques. Le but de cet article de synthèse est de définir les limites de tolérance des différentes malformations et de décrire les différentes techniques novatrices pour les corriger.

Primary subacute hematogenous osteomyelitis in children: a clearer bacteriological etiology.

BACKGROUND: This study aimed to describe the spectrum of pediatric primary subacute hematogenous osteomyelitis (PSAHO) and to investigate its bacterial etiology. METHODS: Sixty-five consecutive cases of PSAHO admitted to our institution over a 16-year period (2000-2015) were retrospectively reviewed to assess their laboratory and radiographic imaging features, as well as their bacteriological etiology. RESULTS: On evaluation, white blood cell count and C-reactive protein were normal in 53 (81.5 %) and 34 cases (52.3 %), respectively, whereas the erythrocyte sedimentation rate was superior to 20 mm/h in 44 cases (72.1 %). Blood cultures failed to identify the pathogen in all but one patient, and classic bone sample cultures only managed to isolate the pathogen in five cases (11.6 %). Use of polymerase chain reaction (PCR) assays on bone aspirates or blood allowed the causative microorganism to be isolated in a further 22 cases. Using classic cultures and PCR assays together resulted in pathogen detection in 27 cases (62.8 % of the children bacteriologically investigated), with Kingella kingae being the most frequently reported microorganism. CONCLUSIONS: Two distinct forms of PSAHO should be distinguished on the basis of age of patients and bacteriological etiology. The infantile form affects children aged between 6 months and 4 years and is predominantly due to K. kingae. The juvenile form involves children aged >4 years and Staphylococcus aureus appears to be the main bacteriological etiology. Appropriate nucleic amplification assays drastically improve the detection rate of the microorganisms responsible for PSAHO. LEVEL OF EVIDENCE: Case series, level IV.

Patient positioning on the operative table for more accurate reduction during elastic stable intramedullary nailing of the femur: a technical note.

Elastic stable intramedullary nailing is currently considered a clinical practice standard for the treatment of femoral fractures in children in the age-appropriate group. Malreduction, particularly in rotation, due to the closed reduction technique has been reported. We describe a new technique of positioning on a standard operating table that permits better control of rotational alignment during femoral elastic stable intramedullary nailing.

Osteoarticular infections in young children: what has changed over the last years?

Osteoarticular infections remain a significant cause of morbidity worldwide in young children. They can have a devastating impact with a high rate of serious and long-lasting sequelae, especially on remaining growth. Depending on the localisation of infection, they manifest as osteomyelitis, septic arthritis, a combination of both (i.e., osteomyelitis with adjacent septic arthritis) or spondylodiscitis. Osteoarticular infections can be divided into three types according to the source of infection: haematogenous; secondary to contiguous infection; or secondary to direct inoculation. During the last few years, many principles regarding diagnostic assays and the microbiological causes of these infections have evolved in a significant manner. In the present current-opinion review, we discuss recent concepts regarding epidemiology, physiopathology, and the microbiology of bone and joint infections in young children, as well as clinical presentations, diagnosis, and treatment of these infections. Clinicians caring for children need to be especially well versed in these newer concepts as they can be used to guide evaluation and treatment.

An interdisciplinary study of orthodontic, orthopedic, and otorhinolaryngological findings in 12-14-year-old preorthodontic children.

BACKGROUND AND OBJECTIVE: Malocclusion, the body posture, and the breathing pattern may correlate, but this issue is still controversial. The aim of the study was to examine the relationship between the type of malocclusion, the body posture, and the nasopharyngeal obstruction in 12-14-year-old children. MATERIAL AND METHODS: The study group consisted of 76 orthodontic patients (35 boys, 41 girls) aged 12-14 years (mean age, 12.79 years [SD, 0.98]). All the patients were examined by the same orthodontist (study model and cephalometric radiograph analysis), the same orthopedic surgeon (body posture examined from the front, the side, and the back), and the same otorhinolaryngologist (anterior and posterior rhinoscopy and pharyngoscopy) in a blind manner. RESULTS: The prevalence of a poor body posture and a nasopharyngeal pathology was high in the present study. In total, 48.7% of the orthodontic patients had a kyphotic posture and 55.3% a rib hump in the thoracic region. The nasopharyngeal pathology was diagnosed in 78.9% of the patients. The patients with the kyphotic posture had a higher mandibular plane angle (MP-SN) and a lower sagittal position of the mandible SNB angle. A deeper overbite correlated with shoulder and scapular asymmetry. The kyphotic posture was diagnosed in 55.0% of the patients with the nasopharyngeal pathology. CONCLUSIONS: The sagittal body posture was related to the vertical craniofacial parameters and hypertrophy of the tonsils and/or the adenoids. The study showed no relationship between the degree of crowding, the presence of a posterior cross bite, orthopedic parameters, and a breathing pattern.