Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases.

Objective Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. Methods In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients. Results Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( p = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( p = 0.02) and VAS with load ( p = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( p = 0.02), extension ( p = 0.03), and radial deviation ( p = 0.01). Conclusion ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center. Level of Evidence This is a Level IV study.

Utility of a Pediatric Adaptive Sports Clinic: A Case Series Review.

BACKGROUND: Limited funding is available for athletes with disabilities in the United Kingdom. This compounds the barriers to participation and development that already exist. METHOD: To combat this growing problem, a Multi-Disciplinary Pediatric Adaptive Sports Clinic was formed. RESULT: Fifteen athletes with disabilities attended the Clinic from November 2017 to November 2019. In our cohort, there were 10 males and 5 females (age range: 13-18 years). Most athletes participated at a grassroots level (n = 9). The range of diagnoses included cerebral palsy, Ehlers Danlos syndrome and congenital hand differences. Forty-four appointments were made after the initial meeting with a 95% attendance rate. Improvements beyond the minimal clinically important differences (MCID) for the Patient Specific Functional Scale, Numerical Pain Rating Scale, and Medical Research Council Manual Muscle Testing Scale were noted in over half of cases. CONCLUSION: With a focus on injury prevention and strength and conditioning techniques, this clinic supported athletes to successfully compete from a recreational to an elite level across all types of sports and adolescent ages by providing patient-specific regimens. Our case series provides preliminary evidence to suggest the formation of similar clinics that can support athletes with disabilities across a range of sports.

Early MRI for Pediatric Wrist Injuries-Prospective Case Series of 150 Cases.

Background Pediatric carpal injuries are a clinical challenge due to their non-specific clinical features and occult nature on plain radiography. We hypothesized that early magnetic resonance imaging (MRI) will allow prompt diagnosis and treatment stratification, and that distal pole fracture of the scaphoid requires a shorter duration of immobilization. This study aims to assess the injury pattern and clinical outcomes of under-16-year-olds treated with acute post-traumatic wrist injuries in accordance with the unit's protocol. Methods All patients under the age of 16 years treated for suspected pediatric wrist injuries in our tertiary pediatric hand and upper limb service were included. Prospectively collected data included patient demographics, radiological findings, treatment and adherence to the unit's protocol. Results There were 151 patients with a mean age of 12 years. The majority (72%) had occult bony injury with radiological evidence of fracture on MRI. The sensitivity and specificity of plain film radiography were 42.7% and 71.4%, respectively. Almost one in four patients benefitted from early MRI demonstrating no injuries, permitting early mobilization and discharge. The scaphoid was the most commonly injured carpal bone. Non-displaced fractures of the distal pole of the scaphoid in patients over 10 years old were treated with 4 weeks' immobilization with no adverse outcome. Conclusion Standardized care in our unit has yielded good results with low complication rate and fewer hospital appointments. Our results support the routine early use of MRI and a shorter duration of immobilization in fracture of the distal pole of the scaphoid at 4 weeks. Level of Evidence This is a level IV, case series study.

A "Congenitally Adapted" TFCC Tear in Radial Longitudinal Deficiency: Case Report and Review of Literature.

We present a case of chronic wrist pain in a 14-year-old child with mild radial longitudinal deficiency and radiographic carpal collapse due to the absence of the scaphoid. Wrist arthroscopy demonstrated synovitis and a tear to the TFCC, which would be called "degenerative," according to the Palmer classification. This was debrided, and the patient is still asymptomatic at long-term follow-up. Review of the literature found one paper with a similar observation in a 17-year-old adolescent. We propose that paediatric "degenerative" tears ought to be called "congenitally adapted" tears.

Role of Wrist Arthroscopy in Juvenile Inflammatory Arthritis.

Background and Purposes The wrist is the fourth most common joint to be involved in juvenile inflammatory arthritis (JIA), which is a common rheumatological condition affecting children. Wrist arthroscopy is well established in rheumatoid arthritis, but remains unexplored in JIA. The aim of this study is to investigate the role of wrist arthroscopy in JIA, with focus on those who are refractory to medical management. Methods This is a prospective observational study, including consecutive patients with JIA undergoing arthroscopy between January 2016 and December 2020. Those over the age of 18 years and those with other rheumatological diagnoses were excluded. Data including pre-, intra-, and postoperative variables, demographics, and patient-reported outcomes were collated and are reported using standard measures. Results A total of 15 patients underwent arthroscopy ( n = 20 wrists). Synovitis was noted in all wrists on arthroscopy and synovectomy was performed in all cases. Other procedures were performed as indicated during the procedure. The median follow-up duration was 11.3 (interquartile range [IQR] 8.1-24.2) months. Median reduction of 4 (IQR 2.25-6) points on the Visual Analogue Score for pain on loading was noted postoperatively. Grip strength was improved in n = 11/20 wrists and functional improvement was noted in n = 18/20 wrists. Restriction of range of motion was achieved with a shrinkage procedure in patients with hypermobile joints. There were no postoperative complications, and no patients were lost to follow-up. Conclusion In experienced hands, wrist arthroscopy is feasible, safe, and efficacious in the management of JIA, among patients who are refractory to medical management. Level of Evidence This is a Level II study.

Efficacy of mTOR inhibitors (sirolimus) in isolated limb overgrowth: a systematic review.

We systematically assessed the literature on the use of sirolimus for the treatment of isolated limb overgrowth conditions and its various modalities of administration in PubMed, Scopus, Ovid MEDLINE, Web of Science, Google Scholar, Cochrane Database of Systematic Reviews, references of journals and grey literature using pre-trialled Medical Subject Headings terms and articles. Eleven articles were included, and 39 patients were identified for review. Sirolimus was given orally in 38 patients and topically in one patient. Sirolimus was found to be highly effective in treatment of isolated limb overgrowth conditions with improvement of symptoms (physical, emotional, social) reported in all but one patient. Dosage and adverse effects seemed to be closely correlated. The result of our study suggests that sirolimus should be considered as an adjuvant or first-line management in isolated limb overgrowth in prospective trials.

Wrist Ganglion Cysts in Children: An Update and Review of the Literature.

Ganglion cysts are the most common soft tissue tumor of the hand and wrist, affecting pediatric and adult populations. Despite their frequency, there is no consensus within the literature regarding the best management of pediatric wrist ganglia, and there are few recent publications examining this topic. We provide an up-to-date literature review examining the current issues and controversies in the management of pediatric wrist ganglia.

Scaphoid Fractures below the Age of 10: Case Series and Review of the Literature.

Background Scaphoid fractures are relatively uncommon in children, especially below the age of 10 due to the ossification of the scaphoid bone, which starts around 4 to 6 years of age and continues until 13 to 15 years of age, where pediatric scaphoid fractures peak. This makes the diagnoses challenging in this age group. Methods The primary aim of this study was to analyze prospectively collected data in managing scaphoid fractures. All cases in children up to the age of 10 years, treated in a tertiary pediatric hand and upper limb from January 2014 to June 2018 were included. Parameters studied were patient demographics, clinical presentation, mechanism of injury, investigations, type of fracture, associated injuries, treatment offered, outcomes and complications. The secondary aim was to review the literature due to the limited knowledge about these fractures in these low age groups. Results A total of 23 patients with documented scaphoid fractures in children up to the age of 10 years were found. Final diagnosis in all these patients was done with magnetic resonance imaging (MRI). The mean age was 9.8 years, with female preponderance. Scaphoid waist was the most common location. Five patients had associated fractures of the capitate and one patient had associated second metacarpal base fracture. All patients were managed nonoperatively. The average time of immobilization was 6.6 weeks (range: 4-10 weeks). A majority of patients had minor symptoms after the fracture, most likely due to the immobilization time. Conclusion Scaphoid fractures are rare in the pediatric population up to the age of 10. MRI is most often needed to confirm diagnosis. Nonoperative management of most scaphoid fractures in this age group is safe and feasible with no significant long-term morbidity. Surgical management of scaphoid fractures might be required in very selected cases. Level of Evidence This is a Level IV study.

Pediatric Scaphoid Nonunions: A Case Series, Review of the Literature, and Evidence-Based Guidelines.

Background Scaphoid fractures represent less than 3% of hand and wrist fractures in the pediatric population. Nonunions are very rare. We present a case series ( n = 18) of nonunions in skeletally immature children and adolescents. We further present a review of the literature on pediatric scaphoid nonunions. Materials and Methods We reviewed the literature by searching the main databases on pediatric scaphoid nonunions, but to identify factors that lead to nonunion, we also searched for databases on scaphoid fractures. Seventy articles were found for the period between 1961 and 2019, all with level 4/5 evidence. Results The nonunion rate of pediatric scaphoid fractures in the literature is on average 1.5%, occurring mostly as a result of missed or underdiagnosed injuries, similar to our presented case series. Half ( n = 9) of the injuries in our case series were missed initial injuries, leading to scaphoid nonunions and half developed nonunions after initial treatment. We found excellent outcomes and with surgical and nonoperative management, with few complications. Not surprisingly, the duration of immobilization is longer with nonoperative management. Conclusions Based on the literature, we recommend a period of nonoperative management before surgery in undisplaced nonunions. In displaced nonunions, open reduction and internal fixation ± bone grafting is necessary. In pediatric scaphoid fractures, similar to adult cases, we identified that suspicious scaphoid fractures should be considered for initial immobilization, and repeat X-rays and early magnetic resonance imaging (MRI) or computed tomography (CT) scans should be considered at follow-up. Immobilization time and type of plaster should be appropriate in relation to the fracture site, similar to the adult scaphoid fracture. Level of Evidence This is a Level IV study.