Infrequent Pediatric Subungual Injury Diagnosed by Intraoperative Anatomopathological Material: A Case Report.

Subungual lesions are very common in clinical practice. We present the clinical case of a 10-year-old female patient who presented with progressive nail deformity. The onset of the condition was approximately five years prior to presentation with an injury in the left hallux, according to the mother. She denied pain or change in the color of the area from the onset of the injury to the day of consultation. There was no previous trauma. Examination revealed subungual bone injury to the distal extremity (distal phalanx of the left hallux), and imaging tests (X-ray and soft tissue ultrasound) found bone injury. Subungual exostosis was considered as a possible diagnosis, thus prompting the indication for exeresis of the tumoral process. After surgical removal, the resected specimen was sent for pathological assessment, which found that an intraosseous hemangiolymphangioma was the origin of the tumor. A subungual exostosis is a slow-growth benign osseous tumor mainly located in the distal phalanx of the hallux that especially affects young adults, being less frequent in children. This condition results from a process of bone neoformation involving different stages, the clinical symptoms of which depend on its size and associated processes. Hemangiolymphangiomas are angiomatous lesions of the blood and lymphatic vessels that have a controversial etiology and present slow, painless, and progressive growth; these lesions are mostly benign. It is worth emphasizing that subungual injuries are not always caused by an underlying bone; therefore, potential differential diagnoses, both benign and malignant, should be considered, based on the location of the injury.

Management of Pediatric Humeral Supracondylar Fractures in a Referral Center From a Developing Country: A Comparison With American Academy of Orthopaedic Surgeons (AAOS) Guidelines.

Introduction Supracondylar fractures are the predominant type of pediatric elbow fractures. The usual mechanism of injury is falling over the hand with the elbow extended and the hand open. The management of these fractures encompasses a range of treatment options, and their goal is to recover the anatomy and achieve a stable contact area between them. There are some controversies on the management of these injuries mainly focused on those that present some degree of displacement. A review and analysis of the current treatment at our institution and a comparison with the guidelines suggested by the American Academy of Orthopaedic Surgeons (AAOS) for the treatment of these fractures in the pediatric population were performed. Materials and methods This was an observational, analytical, retrospective study of consecutive pediatric patients with displaced supracondylar humeral fracture treated at Hospital de Trauma "Manuel Giagni" in Asunción, Paraguay, from January 2016 to December 2021. Demographic and clinical data were assessed, and patients were clinically and radiologically followed for at least 12 months. The management of supracondylar humeral fractures at our hospital was compared with the guidelines suggested by the American Academy of Orthopaedic Surgeons (AAOS) by analyzing whether these guidelines were applied in each case. The mechanism of injury was divided into three groups, initial X-rays were measured, extension-type fractures were categorized into three groups, and the type of treatment was divided into two groups: non-operative and operative. Furthermore, trauma-related preoperative complications and postoperative complications were reported. Outpatient follow-up was performed for at least 12 months in all cases. Results Of the 843 patients analyzed, 71.5% were male, with a mean age of 5.6 years. It was observed that 57.5% of injuries were caused by falls on the same level. The most frequent type of injury was Gartland type III, accounting for 55% of the cases, and associated injuries were found in 4% of the cases. With regard to the type of treatment, 91.8% of patients were treated with closed reduction and percutaneous pin fixation. Complications on admission were found in 12% of the cases and late complications in 12% of the cases. Most patients (82%) had excellent Mayo Elbow Performance Score. Conclusion Supracondylar fractures were more frequent in males and in schoolchildren. Garland type III fractures were the most common type of injury. The treatment of choice was predominantly closed reduction and percutaneous pin fixation. The Mayo Elbow Performance Score was excellent in most patients. Our service, a referral center of a public hospital in a developing country, complies with the guidelines recommended by the AAOS.

Femoral fractures in the immature skeleton: Characterization, risk factors, and treatment options in a developing country.

INTRODUCTION: Femur fracture is one of the most frequent reasons for admission to paediatric trauma units and has a bimodal incidence. The trauma mechanism varies according to the patient's age. Non-operative treatment continues to be performed, although surgical treatment has gained popularity in recent years. Paediatric orthopaedic traumatologists should always bear in mind the already known general principles of treatment. In this study, we aimed to provide a general characterization of femoral fractures, risk factors, and current definitive treatment methods in a developing Latin American country. MATERIALS AND METHODS: This is an observational, analytical, retrospective study with a non-probabilistic sample of consecutive cases of skeletally immature patients with femoral fractures treated at a trauma hospital in Asunción, Paraguay, from January to December 2022. Patients with diseases fragile bones and femoral fractures were excluded. Demographic and clinical characteristics of the study population were analysed. RESULTS: Traffic accidents were the most frequent cause of femoral fractures in our population. Femur fractures were more common in males. The femoral shaft was the most frequent fracture site. Age was one of the most important criteria for defining the treatment approach, considering non-operative management in children younger than 4 years. CONCLUSIONS: Fracture of the femoral shaft in male patients is the most frequent presentation at our Institution. Summer vacations and traffic accidents are the main risk factors identified in Paraguayan children who suffer a femoral fracture. Non-operative treatment is preferred in children under 4 years of age, while surgical treatment is preferred in children aged 5 years and above. Paediatric orthopaedic traumatologists should be involved in parent education to promote children's safety, especially by increasing care and vigilance during school vacations and dangers related to traffic accidents.

Fractura de cadera en la Infancia: serie de casos / Hip fracture in childhood: case series

Objetivos: Mostrar los resultados obtenidos, describiendo el manejo y experiencia, sabiendo que el tiempo de demora quirúrgica está muy alegado de lo recomendado en las guías actuales. Materiales y Método: Estudio retrospectivo de casos consecutivos de fracturas de cadera en el rango de 0 a 16 años, con seguimiento mínimo de 12 meses. Donde se analizaron variables epidemiológicas, demora en la llegada al Hospital, demora en el tratamiento quirúrgico, complicaciones y funcionalidad según los criterios de Ratliff. Resultados: Veintiún casos de fracturas de cadera. Promedio de edad de 9 años, 71% de afectación del lado izquierdo, un caso de presentación bilateral. El mecanismo de trauma fue en un 42,8% relacionado con accidente de tránsito. Hubo lesiones asociadas en 33,3%. Predominio de tipo IV y tipo III según la clasificación de Delbet. Tratamiento quirúrgico en 95% de los casos. El tiempo de demora de llegada al hospital fue de 1,6 días en promedio, con un retraso en el tratamiento de 5,45 días. Seguimiento promedio de 29 meses (12 a 54 meses). Se obtuvieron resultados funcionales excelentes en el 66,6% de los casos, regular en el 23,8% y 9,5 de malos resultados. Las complicaciones se presentaron en 7 casos, siendo la NOA 19% pacientes, coxa vara en 8,5% y 4% de discrepancia de longitud (4%). Conclusiones: Son fracturas raras. Debemos, como ortopedistas infantiles, estar actualizados en el manejo de cada tipo de lesiones, para ofrecer el tratamiento adecuado que disminuya las secuelas que potencialmente puedan existir. La meta debe ser la obtención de reducciones anatómicas y fijaciones estables. Y la demora quirúrgica no es sinónimo de malos resultados.

Objectives: Show the results obtained, describing the management and experience, knowing that the surgical delay time is very close to what is recommended in current guidelines. Materials and Method: Retrospective study of consecutive cases of hip fractures in the range of 0 to 16 years, with a minimum follow-up of 12 months. Where epidemiological variables, delay in arrival at the Hospital, delay in surgical treatment, complications and functionality were analyzed according to Ratliff criteria. Results: Twenty-one cases of hip fractures. Average age 9 years, 71% left side involvement, one case of bilateral presentation. The mechanism of trauma was 42.8% related to a traffic accident. There were associated injuries in 33.3%. Prevalence of type IV and type III according to the Delbet classification. Surgical treatment in 95% of cases. The delay time to arrival at the hospital was 1.6 days on average, with a delay in treatment of 5.45 days. Average follow-up of 29 months (12 to 54 months). Excellent functional results were obtained in 66.6% of the cases, fair in 23.8% and poor results in 9.5%. Complications occurred in 7 cases, with NOA in 19% patients, coxa vara in 8.5% and length discrepancy in 4%. Conclusions: These are rare fractures. We must, as children's orthopedists, be up to date in the management of each type of injury, to offer the appropriate treatment that reduces the sequelae that may potentially exist. The goal should be to obtain anatomical reductions and stable fixations. And surgical delay is not synonymous with bad results.

Recomendaciones para el seguimiento de niños con asimetría en la longitud de los miembros inferiores: consenso de expertos / Recommendations for the follow-up of children with leg length discrepancy: expert consensus

La asimetría de la longitud de los miembros inferiores es una afección en la cual la longitud de una pierna difiere de la contralateral, motivo de consulta frecuente en el consultorio del pediatra y del ortopedista infantil. El objetivo de nuestro trabajo fue desarrollar recomendaciones de seguimiento, planificación prequirúrgica y tratamiento de niños con asimetría de la longitud de los miembros inferiores mediante el consenso de expertos. Material y métodos. Se utilizó el método Delphi. Un grupo coordinador seleccionó el panel de expertos, diseñó y analizó cada una de las rondas de consulta. Los cuestionarios semiestructurados fueron enviados por correo electrónico en forma personalizada. Se estableció como criterio de consenso un acuerdo entre los expertos > 80 %. En cada una de las rondas, se reformularon los aspectos no consensuados y se agregaron nuevos sugeridos en la ronda anterior. Se consideró como medida de estabilidad para concluir la consulta cuando más del 70 % de los expertos no modificó su opinión en rondas sucesivas. Resultados. Participaron del consenso 8 expertos en ortopedia y 6 en diagnóstico por imágenes. Luego de 3 rondas de consulta, se logró el consenso en 39 recomendaciones referentes a seguimiento, planificación prequirúrgica y tratamiento. Fueron reagrupadas en 32 recomendaciones finales. Conclusiones. Estas son las primeras recomendaciones para el seguimiento de niños con asimetría de la longitud de los miembros inferiores mediante el consenso de expertos.

Leg length discrepancy is when the length of one leg is different from the other, and is a common reason for consultation at the pediatrician's and pediatric orthopedist's office. The objective of this study was to develop recommendations for the follow-up, pre-surgical planning, and treatment of children with leg length discrepancy based on expert consensus. Material and methods. The Delphi method was used. A coordinating group selected a panel of experts, designed and analyzed each of the rounds of consultations. Semistructured questionnaires were sent by personalized e-mail. Agreement among experts ≥ 80 % was established as the criterion for consensus. At each round of consultation, non-consensual aspects were reformulated and new aspects suggested in the previous round were included. A measure of stability to conclude the consultation was determined when more than 70 % of experts sustained their opinion in successive rounds. Results. Eight experts in orthopedics and six experts in imaging studies participated. After three rounds of consultations, consensus was reached in terms of 39 recommendations for follow-up, pre-surgical planning, and treatment. These were reorganized into 32 final recommendations. Conclusions. These are the first recommendations for the follow-up of children with leg length discrepancy agreed by expert consensus.

Recommendations for the follow-up of children with leg length discrepancy: expert consensus. / Recomendaciones para el seguimiento de niños con asimetría en la longitud de los miembros inferiores: consenso de expertos.

INTRODUCTION: Leg length discrepancy is when the length of one leg is different from the other, and is a common reason for consultation at the pediatrician's and pediatric orthopedist's office. The objective of this study was to develop recommendations for the follow-up, pre-surgical planning, and treatment of children with leg length discrepancy based on expert consensus. MATERIAL AND METHODS: The Delphi method was used. A coordinating group selected a panel of experts, designed and analyzed each of the rounds of consultations. Semistructured questionnaires were sent by personalized e-mail. Agreement among experts > 80 % was established as the criterion for consensus. At each round of consultation, non-consensual aspects were reformulated and new aspects suggested in the previous round were included. A measure of stability to conclude the consultation was determined when more than 70 % of experts sustained their opinion in successive rounds. RESULTS: Eight experts in orthopedics and six experts in imaging studies participated. After three rounds of consultations, consensus was reached in terms of 39 recommendations for follow-up, pre-surgical planning, and treatment. These were reorganized into 32 final recommendations. CONCLUSIONS: These are the first recommendations for the follow-up of children with leg length discrepancy agreed by expert consensus.

La asimetría de la longitud de los miembros inferiores es una afección en la cual la longitud de una pierna difiere de la contralateral, motivo de consulta frecuente en el consultorio del pediatra y del ortopedista infantil. El objetivo de nuestro trabajo fue desarrollar recomendaciones de seguimiento, planificación prequirúrgica y tratamiento de niños con asimetría de la longitud de los miembros inferiores mediante el consenso de expertos. Material y métodos. Se utilizó el método Delphi. Un grupo coordinador seleccionó el panel de expertos, diseñó y analizó cada una de las rondas de consulta. Los cuestionarios semiestructurados fueron enviados por correo electrónico en forma personalizada. Se estableció como criterio de consenso un acuerdo entre los expertos > 80 %. En cada una de las rondas, se reformularon los aspectos no consensuados y se agregaron nuevos sugeridos en la ronda anterior. Se consideró como medida de estabilidad para concluir la consulta cuando más del 70 % de los expertos no modificó su opinión en rondas sucesivas. Resultados. Participaron del consenso 8 expertos en ortopedia y 6 en diagnóstico por imágenes. Luego de 3 rondas de consulta, se logró el consenso en 39 recomendaciones referentes a seguimiento, planificación prequirúrgica y tratamiento. Fueron reagrupadas en 32 recomendaciones finales. Conclusiones. Estas son las primeras recomendaciones para el seguimiento de niños con asimetría de la longitud de los miembros inferiores mediante el consenso de expertos.