[Intravenous antibiotic therapy for acute hematogenous osteomyelitis in children: short versus long course]. / Antibiothérapie intraveineuse des ostéomyélites aiguës : traitement long versus court.

The aim of this study was to evaluate the results of two antibiotic therapy protocols for osteomyelitis with different durations of intravenous treatment. This was a prospective randomized study of children treated for acute hematogenous osteomyelitis. Patients in group 1 (G1) received 7 days of intravenous antibiotics, whereas patients in group 2 (G2) received 14 days. Treatment was deemed effective if there were no signs of chronic osteomyelitis at the last follow-up. Fifty-three patients were included in the study (G1=27, G2=26). After a mean follow-up of 11.5 months, none of the patients in either group showed signs of chronic osteomyelitis. In conclusion, a shortened treatment of 7 days of intravenous antibiotic therapy is as effective as a longer treatment.

[Purely lateral elbow dislocation in a child, case report and literature review]. / Luxation latérale du coude chez l'enfant, entité exceptionnelle, à propos d'un cas et revue de la littérature.

Elbow dislocation is a rare condition in children usually associated with medial epicondyle fractures. Most dislocations are posterior, lateral dislocations are only anecdotal. We report the case of a 14-year-old boy presenting with incomplete purely lateral elbow dislocation. Good reduction was achieved by closed method. The authors present a review of the literature highlighting the characteristics and treatment options of this condition.

Microbiological profile of haematogenous osteoarticular infections in children.

INTRODUCTION: Staphylococcus aureus, Kingella kingae and ß-hemolytic streptococcus are presently the most frequently identified bacteria in child haematogenous osteoarticular infection. OBJECTIVE: To determine the microbiological profile (bacteria and antibiotic susceptibility) of osteoarticular infections in a paediatric hospital, so as to adapt treatment protocols to the ecology of the bacteria isolated. PATIENTS AND METHODS: Prospective descriptive study, including children admitted for acute osteomyelitis or septic arthritis. A series of blood cultures was performed systematically on admission. In case of surgery, local samples were taken for bacteriology. Antibiotherapy was initiated and subsequently adapted to the bacteriological findings. RESULTS: One hundred and six children were included. Thirty-five were under (Group 1) and 71 over 3 years of age (Group 2). Ninety-five underwent surgery. Peroperative samples were positive in 61 cases and blood culture in 23. Bacteria were isolated in 22 patients in G1. Extended-spectrum ß-lactamase-producing Klebsiella pneumoniae was isolated in five neonates who had passed through intensive care. Staphylococcus aureus was the most frequently isolated bacterium in G2 (n=40), and was methicillin-resistant (MRSA) in six children. DISCUSSION: Methicillin-susceptible Staphylococcus aureus was the most frequently isolated microorganism. Other than neonates who had passed through intensive care and the six patients with community-acquired MRSA infection, all isolated bacteria were susceptible to second-generation cephalosporins. LEVEL OF EVIDENCE: II, prospective descriptive prognostic study.

Dysplasia epiphysealis hemimelica: a report of four cases.

UNLABELLED: Dysplasia epiphysealis hemimelica (DEH), also known as Trevor's disease, is a rare congenital skeletal developmental disorder in childhood. It is characterized by an asymmetric osteocartilaginous overgrowth arising from epiphyses or epiphyseal equivalents. Lesions have hemimelic topography, usually occur in the lower limbs, most commonly in the ankle and the knee and affect either the medial or lateral part of one epiphysis. OBJECTIVE: The purpose of this study is to describe the imaging features of DEH by reporting four cases. MATERIALS AND METHODS: We present four cases of DEH in one female and three males aged between 7 and 15 years. Lower limb is involved in all cases and patients suffer from pain, limited function and deformity. Radiographs and CT findings were reviewed. All patients were treated by surgical excision. RESULTS: Plain X-ray revealed in all cases an irregular ossification arising from the affected epiphysis. The CT scan revealed an irregular fragmented osteocartilaginous mass involved from the epiphysis, with enlargement of epiphyses and intra-articular extension. CONCLUSION: The early diagnosis and treatment of DEH is necessary in preventing articular function, CT assists in defining the anatomic relationship between the mass and its parent epiphysis and in evaluating the condition of the articular cartilage and soft tissue. The distinct clinical and radiographic features should enable to differentiate the osteochondroma and the DHE.

[An unusual cause of hand nodule: peri-tendon dirofilariasis]. / Une étiologie inhabituelle de nodule de la main : la dirofilariose péritendineuse.

Dirofilariasis is a zoonosis affecting dogs and cats. It was transmitted to man by mosquito bites. Human dirofilariasis is rare. We report a case of 4-year-old girl presented with a subcutaneous palmar nodule of the hand. Surgical excision shows a nodule encircling the forth flexor tendon. The histological examination established the diagnosis by the presence of an adult worm identified as Dirofilaria repens. Surgical excision was curative.

[Hematogenous osteomyelitis of the calcaneus in children: 26 cases]. / L'ostéomyélite hématogène du calcanéum chez l'enfant: à propos de 26 cas.

PURPOSE OF THE STUDY: Osteomyelitis is rarely observed in the calcaneus; about 3 to 10% of the bone infections in children. The diagnosis is often established late because of the less pronounced symptoms in long-bone localizations. We report a series of 26 cases of osteomyelitis of the calcaneus observed in children. MATERIAL AND METHODS: We studied the clinical history, the diagnostic process and the treatments delivered. Outcomes were assessed in terms of complications, anatomy and function at mean two years follow-up (range one to seven years). RESULTS: There were 15 boys and 11 girls, mean age was seven years (range one month to 13 years). Mean time from symptom onset to consultation was 13 days and mean time from consultation to hospital admission was four days, range one to 29 days. The clinical presentation was not specific. Body temperature was not above 38.5 degrees C in 45% of patients. Symptoms were fever, pain in the rear foot and functional impotency of the lower limb. Eight patients (30%) complained of moderate pain, 18 (70%) of intense pain. The pain was focused far from the calcaneus in six patients, retarding the diagnosis. Laboratory tests did not always reveal signs of inflammation. White cell counts above 10,000 were noted in only 61% of patients. The diagnosis of osteomyelitis of the calcaneus was based on: the plain X-ray, which revealed a defect in the calcaneus (n=12), ultrasound (performed in 19 patients) which revealed calcaneal subperiosteal detachment (n=6), collections in the rear foot (n=3) and soft-tissue thickening (n=4). Bone scintigraphy was performed in one child and showed intense uptake in the calcaneus. Magnetic resonance imaging, performed in one patient, demonstrated an anomalous signal in the calcaneus (high-intensity T(2) and low-intensity T(1) with presence of a subperiosteal abscess). Bacteriology was positive in 53% of the children. Medical treatment was delivered for all patients and 23 underwent a surgical procedure. For one of the three patients treated medically, the diagnosis of osteomyelitis of the calcaneus was clinical, since the plain X-ray was normal, the ultrasound yielded no evidence of abscess formation and the bacteriology was negative; but after two months of antibiotic treatment, bone remodelling was in favour of osteomyelitis of the calcaneus. For the two other patients treated medically, the plain X-ray showed a defect in the calcaneus, which had filled after two months of antibiotics. For the 23 patients treated surgically, the procedure was an evacuation of a subperiosteal abscess for 13 (n=6 nonruptured and 7 ruptured). Surgery revealed a bone lesion in nine children allowing curettage of the defect. Articular involvement was noted in eight cases: subtalar osteoarthritis (n=6) and tibiotarsal arthritis (n=2). Two surgical explorations failed to find any abscess formation; blood cultures confirmed the diagnosis and enabled isolation of the causal germ. Outcome was assessed with a mean follow-up of two years, range one to seven years. Nineteen patients (73%) were free of sequelae. Seven patients (27%) presented poor outcome with significant limitation of motion in the rear foot and ankle ankylosis. Seven patients developed chronic fistules, with persistent discharge at last follow-up. The poor results were observed in patients treated late with mean 17 days before consultation. Six of the seven cases of poor outcome were associated with arthritis involving a calcaneal joint (subtalar and tibiotarsal in two patients and subtalar in four). DISCUSSION: The same pathophysiological phenomenon as observed in long-bone localizations is noted for osteomyelitis of the calcaneus; the calcaneus has an apophysis, which is equivalent to the metaphyseal region of long bones, leading to the bone's vulnerability to hematogenous infection. Late diagnosis can be related to the notion of trauma, the manifestations of osteomyelitis being attributed to ligament injury. The positive diagnosis of osteomyelitis of the calcaneus is often established late because of late consultation (13 days in our series) or the minimal expression of general signs. Magnetic resonance imaging contributes significantly to diagnosis by showing an abnormal bone signal; it can also disclose associated abscess formation. Authors differ in their descriptions of the complications. The analysis of our results shows that the prognosis of osteomyelitis of the calcaneus is related to early diagnosis and management. Associated septic arthritis is an element of poor prognosis.

[Acute hematogenous osteomyelitis of the neck of the femur in children: 28 cases]. / L'ostéomyélite aiguë hématogène du col du fémur chez l'enfant : à propos de 28 cas.

PURPOSE OF THE STUDY: Osteomyelitis of the neck of the femur is uncommon, often with a misleading clinical presentation. We report a series of 28 cases of osteomyelitis of the femoral neck to illustrate the particular clinical and imaging findings related to this localization. MATERIAL AND METHODS: This was a series of 28 children treated in our unit from 1990 through 2004: 17 boys and 11 girls, mean age eight years (range one month to 14 years). We analyzed the data in this series using a standard checklist, which noted the diagnostic and therapeutic measures. Results were analyzed by studying the complications, anatomic and functional outcome at mean follow-up of 3.5 years. RESULTS: Time from symptom onset to consultation was five days on average with a delay of 4.5 days from consultation to hospitalization. Intense pain was noted for eight patients (28%) and total functional incapacity of the limb was noted for 15 (53%). Hip stiffness was observed in 11 patients (39%). The diagnosis of osteomyelitis of the femoral neck was established on the basis of imaging (MRI or scintigraphy) in three patients with bacteriological proof in two, of operative findings which confirmed the neck localization in 19, and on changes in the X-ray image of the neck in six. A positive bacteriology was noted in 71%. The germ was isolated from blood cultures and local samples obtained by arthrotomy in five patients (same germ), only in blood cultures for four, and only in local samples in 11. Met-S Staphylococcus aureus was isolated in 18 patients, Met-R S. aureus in one and a Streptococcus in one. All patients were given medical treatment and 25 underwent surgery. There were five thromboembolic complications and five patients who developed femoral pandiaphysitis. Results were analyzed at mean 3.5 years (range four months to 14 years). Complete hip motion was recovered in 78%. There were four cases of hip stiffness and two cases of ankylosis. Partial cephalic necrosis was noted in two hips and total necrosis of the head and neck in two. DISCUSSION: Little data is available in the literature on isolated osteomyelitis of the femoral neck. Based on the pathogenic mechanisms known for osteomyelitis, an isolated localization in the neck of the femur, with no other site in the hip joint, is quite possible in an early stage of infection. We discuss the specific clinical and imaging features of this localization. Analysis of our findings show that the prognosis of femoral neck osteomyelitis is directly related to time to management. Outcome is poorer when treatment is started late. Prognosis is poor if pandiaphysitis develops.

[Fracture of the ulna and bilateral congenital dislocation of the head of the radius: A case report]. / Fracture de l'ulna et luxation congénitale bilatérale de la tête radiale: à propos d'un cas.

We report a case of bilateral congenital dislocation of the radial head discovered at the time of a fracture of the ulna. The dislocation was missed initially and when considered as part of the Monteggia fracture, raised a problem concerning the therapeutic approach. The purpose of this report is the emphasize the importance of careful physical examination before undertaking treatment of any lesion.

[Prevalence and risk factors for postoperative infection in pediatric orthopedic surgery: a study of 458 children]. / Prévalence et facteurs de risque de l'infection postopératoire en chirurgie orthopédique pédiatrique: á propos de 458 patients.

PURPOSE OF THE STUDY: The incidence of postoperative infection in pediatric surgery has been studied little in the literature. It would be lower than in adults. In the present work, we attempted to define the incidence of postoperative infection in orthopedic pediatric surgery and identify risk factors. MATERIAL AND METHODS: This was a retrospective analysis of 458 children who underwent surgery between 1998 and 1999 for the following conditions: talipes equinus, congenital hip dislocation, supracondylar fracture of the elbow, and femur shaft fracture. We noted the prevalence of infection of the surgical site, the type of infection and its course as well as the principal risk factors incriminated: age, condition, surgical modalities (emergency setting, hour, bleeding) and use of antibiotic prophylaxis. RESULTS: Mean age at surgery was 5.4+/-3.5 years. The sex ratio was 1.6 boys/1 girl. Forty-two patients developed an infection of the surgical site, giving an incidence of 9.2% of the patients and 8.3% of the surgical sites. Postoperative infection was more frequent in the talipes equinus group (19.4% versus 5.8% for supracondylar fractures of the elbow, 2% for femur shaft fractures, and 0% for congenital hip displacement). In 78.6% of the cases, the infection was superficial. The analysis of risk factors showed that talipes equinus is an independent risk factor. The absence of antibiotic prophylaxis increased the risk of infection of the surgical site significantly only in the talipes equinus group (40.7% versus 14%). DISCUSSION: The incidence of infection of the surgical site in pediatric orthopedic surgery was high in our series, 8.3% versus 0.4% and 5.6% reported in the literature. Talipes equinus surgery exposes the child to a significant risk of infection. The principal risk factors related to surgery would be: ischemia, inflammation of cutaneous and subcutaneous tissue due to detachment, the tourniquet, and the absence of antibiotic prophylaxis.

Combined fracture of the distal radius and scaphoid in children. Report of 2 cases.

The authors report 2 cases of concomitant scaphoid and distal radial fractures, a rare combination of lesions in children. The first case was in a 13-year-old boy who presented a transverse midscaphoid fracture associated with a Salter type II distal radial fracture. The second concerned a 10-year-old boy who presented a bilateral wrist injury. On the left side, a distal forearm fracture with anterior displacement was associated with a transverse midscaphoid fracture. On the right side, there was only a distal forearm fracture. Scaphoid fracture associated with distal radial fracture seems to have been more frequently reported in the literature during the last decade, probably because it is more frequently recognised. In fact, children with distal forearm injury should be well examined both clinically and radiologically in order to search for an associated scaphoid fracture. Reduction of the radius fracture should be done carefully to avoid possible displacement of the scaphoid fracture.

[Spinal anesthesia in children: comparative study of hyperbaric bupivacaine with or without clonidine]. / La rachianesthésie chez l'enfant: étude comparative de la bupivacaïne hyperbare avec et sans clonidine.

OBJECTIVE: To evaluate the effect of intrathecal clonidine in children. STUDY DESIGN: A prospective randomised study. PATIENTS AND METHODS: 45 children, 6 to 15 years old, were randomised in two groups; receiving either 0.5% hyperbaric bupivacaine or 0.5% hyperbaric bupivacaine added to clonidine 2 micrograms.kg-1. We assessed quality and length of motor and sensory blocks and side effects of clonidine: hypotension, bradycardia and sedation. RESULTS: Clonidine was associated with prolongation of motor block. 190 +/- 42 min vs 150 +/- 35 min (p < 0.01), but the difference was not significant. Postoperative analgesia was longer in clonidine group, 490 +/- 35 min vs 200 +/- 50 min (mean +/- SD), p < 0.001. Clonidine was associated with higher incidence of hypotension 54 vs 36% and bradycardia 30 vs 0%. CONCLUSION: These data suggest that intrathecal clonidine 2 micrograms.kg-1 is associated with extending duration of postoperative analgesia but with moderate side effects.

[Juxtacortical osteosarcoma of the radius in a child]. / Ostéosarcome juxtacortical du radius chez un enfant.

The authors report a rare case of juxtacortical osteosarcoma of the radius in a child. The diagnosis and treatment were delayed because of misleading and wrongly reassuring radiological and histological aspects. The 12-year-old boy was admitted for a tumefaction of the proximal extremity of the right radius noticed after trauma. Physical examination showed a hard and slightly painful swelling. Xrays showed an irregular osseous mass developed from the superior metaphysis of the radius and encircling it. MRI showed a juxtacortical tumor with medullary involvement. A biopsy concluded to a fracture callus. Ten months later, the tumor became painful and homogeneous, regular and well defined on Xrays. A repeat biopsy showed juxtacortical osteosarcoma. Enbloc resection of the tumor was done. After a follow-up of 2 years, the child is alive without recurrence and metastasis and with a satisfactory function of the upper limb.

[Brachial plexus paralysis of infectious origin: report of four cases]. / Paralysie du plexus brachial d'origine infectieuse: à propos de quatre cas.

BACKGROUND: Brachial plexus palsy (BPP) may occur after septic osteoarthritis of the shoulder. BPP is a rare, well recognized complication. The pathophysiology is thought to be either ischemic nerve damage secondary to occlusion of vasa nervorum or extrinsic compression. Early diagnosis and treatment of the infection are needed. CASE REPORTS: We report the cases of three infants aged less than three months and one six-day-old newborn infant who presented with an authentic BPP due to an osteoarthritis of the shoulder. The diagnosis of osteoarthritis relied on clinical, biological and radiological signs. In one case, the causal germ (Enterobacter) was isolated. The diagnosis of the palsy was based on clinical signs. EMG performed on one patient, showed signs of abnormal motor pattern. Following intravenous antibiotics and percutaneous drainage, all infants completely recovered.

[Calcifying aponeurotic fibroma: the case of a 15-year old boy]. / Fibrome aponévrotique calcifiant: a propos d'une observation chez un adolescent de 15 ans.

Calcifying aponeurotic fibroma is a rare benign soft tissue tumor that usually involves distal extremities in children and young adults. It is characterized by a high rate of recurrence. We report a case in a 15-year-old boy who complained of painless swelling of his right foot. Tomodensitometry showed a dense well-circumscribed tumor with peripheral calcification. The tumor was completely removed. The patient is well at 28 months follow-up. Diagnosis relied on microscopic analysis showing fibroblastic proliferation with focal calcification and chondroid differentiation.

[Unusual radiologic signs of bone echinococcosis in children]. / Signes radiologiques inhabituels de l'échinococcose osseuse chez l'enfant.

The authors report 2 cases of 2 children aging 11 and 12-years-old presenting hydatitosis in the upper extremity of 2 long bones femur and tibia. In 2 cases, radiological appearances were atypical. In the femur, plain radiographs revealed multiple lucencies, irregular, located in the superior extremity with a periostal reaction. The CT scan confirmed these data and showed a cortical rupture, extension to soft tissue with contrast enhancement. In the tibia, plain radiographys showed delimitated lucencies, confluent with a rim condensation in the proximal epiphyseal-metaphyseal area. Echography and CT are helpful when radiological appearances are unusual.

[Infantile fibrosarcoma: a clinicopathological and molecular study of five cases]. / Fibrosarcome infantile: étude anatomo-clinique et moléculaire de cinq cas.

We report 5 cases of infantile fibrosarcoma (4 boys and 1 girl) whose average age was 5, 7 months (range 0 days to 14 months). The tumor was congenital in 4 cases. All tumors presented in the extremities (forearm, hand, thigh: 1 case, lower leg: 2 cases). Treatment was based on surgery (3 cases: amputation, 2 cases: local excision) with a favorable course in all cases, even those with marginal excision (follow-up ranging from 5 to 21 years). The lesions were characterized by dense monotonous cells growing in a fascicular pattern, with small necrotic areas and scattered lymphocytes. The mitotic index was high (average 8/10 high-power fields). ETV6-NK3 chimeric RNA was detected by reverse transcriptase polymerase chain reaction in two cases out four cases from paraffin-embedded tissue blocks. The infantile fibrosarcoma is a good prognosis tumor characterized by particular histological features and ETV6-NK3 gene fusion.

[Primary chemotherapy with the Rosen T10 protocol before conservative surgery in limb primitive osteosarcomas: results about 56 cases]. / Chimiothérapie première par le protocole T10 de Rosen avant chirurgie conservatrice dans les ostéosarcomes primitifs des mebres: résultats à propos de 56 cas.

We report the results of a prospective Tunisian study using primary chemotherapy followed by conservative surgery in primitive limb osteosarcoma. From January 1988 to January 1998, 56 patients affected by limb osteosarcoma entered in a prospective study of neoadjuvant chemotherapy with the T10 protocol before surgery with a conservative intent. Initial work-up include: clinical exam with tumor measurements, chest and limb X-rays, limb CT-scan or MRI, chest CT-scan, bone scintigraphy and hematological and renal biological exams. Patients receive pre- and post-operative chemotherapy according to the T10 modified protocol. Fifty-six patients (33 M/23 F) with a mean age of 19 years (8 to 28) are included. Mean clinical and radiological tumor size is around 14 cm. Main histologic type is classic osteosarcoma (50% of cases) and 10 patients (9%) presented with initial metastasis; 42 patients on 56 receive the whole pre-operative protocol. Treatment is well tolerated excluding 18 episodes of mucositis, 29 of leucopenia (< grade 3), 7 of thrombopenia (< grade 3), 4 of cutaneous toxicity, 2 of pulmonary toxicity and 3 of nausea-vomiting. We observe 36% of good histological responders and 64% of bad responders to primary chemotherapy, 27 patients on 49 operated (53%) have a conservative surgery and 18 (47%) a radical surgery. With a median follow-up of 51 months (8 to 128), 29 patients remain alive free of disease (15/17 GR and 14/30 BR), 2 are alive with disease, 2 died by toxicity, 14 died by progressive disease and 9 are lost to follow-up with evolutive disease. Five year disease-free survival is 55% for the 46 non metastatic patients. In univariate analysis, seric alkaline phosphatase level (p = 0.0014) and histological response to chemotherapy (p = 0.0218) are significant factors for prognosis.