Hip Spica Table: A Technical Note.

Introduction: Hip spica is a widely used treatment modality in the management of various paediatric orthopaedic conditions. A standardized hip spica table is not universally available and various centerres have devised their own designs. In collaboration with the local engineering team, we have designed a light weight yet sturdy, economical and portable hip spica table. Materials and Methods: Components of the spica table and their measurements are described. Technique of mounting and unmounting the patient off the table has been discussed. We have applied the hip spica using the current design in 141 children between 2009 and 2023. The same table has been used for the children aged 6 months to 10 years. We have not experienced any table breakage during spica application. The acrylic sheet was changed only once during the study period due to attrition. Conclusion: Our design has been used successfully at our center for more than 14 years. It is simple, economical, portable and durable. It can be used in dedicated pediatric orthopedic centers and can be carried easily to the field hospitals. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00935-1.

Closed Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

Background: The described technique is useful for achieving closed reduction of severely displaced (i.e., Judet Type-III and IV) pediatric radial neck fractures. It is widely agreed that radial neck fractures with angulation of >30° should be reduced. Various maneuvers have been described, but none uniformly achieves complete reduction in severely displaced radial neck fractures (Types III and IV)1-4. The aim of the present technique is to achieve closed reduction in these severely displaced radial neck fractures without surgical instrumentation. Description: A stepwise approach is described. First, the radial head is viewed in profile under an image intensifier so that it appears rectangular. Varus stress is applied at the medial aspect of the elbow by the assistant, and thumb pressure is applied at the radial head along the posterolateral aspect of the elbow. This results in partial reduction of the radial head. The elbow is then simultaneously flexed and pronated with continuous pressure over the radial head. This final step anatomically reduces the radial head, and hyperpronating the forearm locks it in the corrected position. Alternatives: Operative alternatives to this technique include intra-focal pin-assisted reduction to achieve closed reduction, the Métaizeau technique of achieving indirect closed reduction of the fracture with the aid of a TENS (Titanium Elastic Nailing System) nail, and open reduction5. Nonoperative techniques have also been described for use with Judet Type-II and III fractures, but not with the severely displaced types described in the present article. Rationale: This technique takes into consideration the anatomy of the capsule and lateral collateral ligament complex. The biomechanical ligamentotaxis helps in achieving anatomic reduction of the radial head. Placing the forearm in pronation tightens the annular and lateral collateral ligaments and prevents redisplacement. There are potential complications with operative treatment, including the risk of nerve injury with percutaneous reduction techniques and the risks of osteonecrosis, premature epiphyseal fusion, and heterotopic ossification with open reduction. These complications can be avoided by the use of the presently described technique. Expected Outcomes: This technique provided satisfactory clinical outcomes in our previous study6, with none of the 10 patients showing signs of growth disturbance, loss of reduction, or reported complications at 12 months. Terminal restriction of supination was observed in 1 patient. No patient had osteonecrosis or elbow deformity. No patient required conversion to an implant-assisted or open reduction procedure. Important Tips: The steps need to be followed sequentially as described in order to achieve an anatomical reduction.After achieving the reduction, it is necessary to keep the forearm in pronation to maintain the reduction with the aid of the lateral ligament complex.This technique may not work in complex fractures with elbow dislocation because of the lack of ligamentous integrity.In the final step, the elbow is pronated and flexed simultaneously, with sustained pressure over the radial head in order to obtain further correction. This is the most critical step of the technique because anatomic reduction of the partially reduced fracture is achieved at this time. Acronyms and Abbreviations: Percut. = percutaneousAP = anteroposteriorCR = closed reductionORIF = open reduction and internal fixation.

Modified Velpeau Sling Application for the Treatment of Fractures Around Shoulder in Infants.

BACKGROUND: Fractures around the shoulder region in infants are treated by arm-chest bandaging, adhesive strapping, or sling application. These conventional treatment methods are associated with issues like skin irritation, excoriation, movement of bone fragments causing muscle spasm, and difficulty in nursing care. We describe the technique of modified Velpeau sling application and reviewed its efficacy at a long-term follow-up. METHODS: A retrospective study was conducted with 19 infants who presented between 2009 and 2018 to a tertiary care center in western India with either clavicle or humerus fracture. Inclusion criteria was any infant with humerus or clavicle fracture that underwent modified Velpeau sling application and had a minimum follow-up of 2 years. Patients were followed at weekly intervals until sling discontinuation based on the fracture healing. At further follow-up, children were assessed for the presence of angular or rotational malalignment and limb length discrepancy. Functional outcome was measured by the Paediatric Adolescent Shoulder Survey at the final follow-up. RESULTS: Seven clavicle and 12 humerus fractures were treated with this technique. The mean age at presentation was 50 days (range, 1 d to 7 mo). The average follow-up was 6 years (range, 2 to 10 y). Two infants had underlying osteogenesis imperfecta. Infants without underlying pathology had no angular/rotational malalignment or limb length discrepancy, while both infants with underlying osteogenesis imperfecta had a varus alignment and shortening of the humerus. Infants without underlying pathology demonstrated good functional outcomes measured by the Paediatric Adolescent Shoulder Survey questionnaire, while those with pathology had functional limitations. CONCLUSIONS: The modified Velpeau method is an effective way of treating fractures around the shoulder region in infants without underlying pathology. Several advantages such as accessibility of sling material, easy application, inexpensive material, and absence of skin-related complications make this an effective treatment. LEVEL OF EVIDENCE: Level IV-therapeutic study.

Close Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

INTRODUCTION: Radial neck fractures account for 5-10% of paediatric elbow trauma. Radial neck fractures have been classified by Judet into five types (I-IVb). There is a global agreement to reduce radial neck fractures with angulation more than 30° (Type III, IVa and IVb). Various maneuvers have been described but none of them uniformly achieved complete reduction in severely displaced radial neck fractures (Type IVa and Type IVb Judet). In this case series, we are presenting our experience with close reduction of ten severely displaced paediatric radial neck fractures to achieve complete anatomical reduction. METHODS: We attempted close reduction in ten consecutive children with average age of 8.59 ± 1.68 years (range, 6-12 years) who presented with severely displaced radial neck fracture (Type IVa and IVb Judet). There were five girls. All patients had close injuries and presented to us within 24-48 h. One of the patients had associated undisplaced lateral condyle fracture. We have excluded two patients with associated elbow dislocation. Close reduction was performed within 48 h of initial injury. RESULTS: We were able to obtain complete anatomical reduction in all of our patients with this technique. None of the patients required fixation of fracture. At 1 year of follow-up, (12 ± 2.07 months, range 9-16 months) all patients demonstrated almost full range of elbow and forearm motion. Final radiographs revealed complete union without any evidence of avascular necrosis. CONCLUSION: This technique offers an option of close reduction for the most severely displaced radial neck fractures, which were otherwise being treated by surgical intervention. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s43465-020-00168-6) contains supplementary material, which is available to authorized users.

Protrusio acetabulae as a sequel to septic arthritis of the hip with obturator internus pyomyositis.

Pyomyositis is defined as a pyogenic infection of skeletal muscles principally caused by Staphylococcus aureus. It can present either primarily without any associated soft tissue or bone infection or secondary to any surrounding or distant infection focus. Hip pericapsular pyomyositis is one of the most common types of primary pyomyositis. Although many cases are increasingly being described both in tropical and temperate climates, there is no published study regarding the sequelae of untreated pericapsular pyomyositis around the hip joint. The purpose of this study is to describe the sequelae of unaddressed obturator internus abscesses in four adolescent patients and compare their outcome with patients where obturator abscess was also drained using Vanderbilt medial approach. A retrospective study was done with eight patients divided equally into two groups. All the patients were diagnosed as septic arthritis with pyomyositis of obturator internus. Group 1 includes patients treated in between 2012 and 2014 with only hip arthrotomy through anterior approach. Group 2 includes patients treated after 2014 with anterior hip arthrotomy along with drainage of obturator internus abscess. All patients in group 1 had frequent episodes of pain in the first postoperative year with persistent restriction of hip range of motion. Two patients required re-drainage of the hip joint within the first month of indexed surgery. Final follow-up (average 6 years) X-rays revealed grade 2 protrusio acetabuli in three cases and grade 3 in one case as per the Sotelo-Garza and Charnley classification. In contrast to the group 1, group 2 patients had an excellent outcome with an average Iowa Hip Score of 93 at average follow-up of 4.25 years with near normal range of motion, no radiological deterioration and residual pain. The possibility of pericapsular pyomyositis should always be kept in mind, in older children with acute hip pain. A high index of suspicion is required for its early diagnosis. MRI is the gold standard investigation for confirming diagnosis and planning the preferred early surgical treatment. Safe and effective surgical drainage of obturator internus abscess through a minimally invasive Vanderbilt medial approach may prevent long-term sequelae of chronic pain, protrusio acetabuli and secondary osteoarthritis.