Trigger thumb treatment approach: Results of a survey of EPOS members.

Purpose: The aim of this study is to analyze the clinical reality of pediatric trigger thumb among members of the European Paediatric Orthopaedic Society. Methods: A 35-question survey was sent to all European Paediatric Orthopaedic Society members, focusing on surgeon's profile and experience, trigger thumb diagnostic and trigger thumb treatment approach. Descriptive statistics were performed. Results: A total of 99 responses were analyzed. Most important factor considered in the therapeutic approach was the presence of a locked interphalangeal joint (52%). Regarding treatment, 41.4% opt for conservative approach as the first line of treatment, while 30.3% consider surgery and 28.3% just observe. Nevertheless, 76% mention to treat conservatively their patients and 99% to consider surgery at some stage. Regarding surgical technique, 96% do it open and 56% consider 2 years as the minimum age for procedure. Most surgeons perform this procedure in out-patient care (87%), don't administer prophylactic antibiotherapy (80%), use a tourniquet (75%), don't use any postoperative immobilization (64%), and report complications related to surgery (64%), mainly recurrence/incomplete division (59%) and superficial wound infection (30%). Conclusion: Our study shows a significant variability in the initial management of pediatric trigger thumb with a predominance of conservative management, followed by surgery and observation without treatment. The disparity in treatment options and timing, or waiting times before moving on to different therapeutic options, shows us that this is a controversial issue and that the development of prospective randomized controlled studies is needed to analyze the different treatment methods and determine which ones give the best outcomes.

Reverse Ishiguro Extension Block Technique as an Alternative for Irreducible Osseous Mallet Finger.

Subacute or late-presenting unstable osseous mallet finger might be hard to reduce and, therefore, remain subluxed when using the traditional Ishiguro technique. In such cases, we suggest it is best to prioritize correction of joint subluxation over step-by-step adherence to the traditional Ishiguro technique. Specifically, we contend that carrying out the procedure in reverse order typically results in an easier and more stable reduction of both joint and fracture.

Lateralized overgrowth as a guiding sign of abdominal neoplasms for pediatric orthopedic surgeons.

OBJECTIVES: This study aims to increase the awareness of the association between lateralized overgrowth (LO) and abdominal tumor among the pediatric orthopedic community and to evaluate its incidence in our center. PATIENTS AND METHODS: Between January 1997 and December 2021, a total of 166 patients with Wilms tumors and hepatoblastomas were retrospectively analyzed. Data including age, sex, initial clinical signs (hematuria, abdominal mass with or without general discomfort), type of asymmetric regional body overgrowth (isolated or in relation with any syndrome), and tumor stage at diagnosis were recorded. In addition, age at which asymmetric regional body overgrowth was described and age at the time of tumor diagnosis were noted. RESULTS: Of a total of 166 patients, 133 were diagnosed with Wilms tumors (nephroblastomas) and 33 were diagnosed with hepatoblastomas. In 94% of the cases, the initial clinical signs were an abdominal mass and/or hematuria. Overall, five (3%) patients presented with LO. Four patients with Wilms tumor presented it at the initial clinical examinations. In three of these cases (2.3%), we found it isolated and, in the remaining patient (0.75%), it was associated with Beckwith-Wiedemann spectrum. Only one patient affected from hepatoblastoma (3%) presented with an isolated LO at the time of tumor diagnosis. CONCLUSION: Our study results show an incidence of LO in relation to intra-abdominal tumors of 3%. The latest updates recommend genetic testing to identify subgroups with a higher risk for tumor development that are more likely to benefit from tumor protocol surveillance.

Poland syndrome: a new classification system based on a retrospective analysis of 74 cases.

LEVEL OF EVIDENCE: III.

Seymour fracture: Better do not underestimate it.

OBJECTIVES: This study aims to analyze the functional results, management, and complications of acute Seymour fracture treatment and to generalize the understanding of Seymour fractures, as well as awareness about its controversial treatment and critical sequelae. PATIENTS AND METHODS: Between January 1994 and December 2019, a total of 29 patients (20 males, 9 females; mean age: 7.9±3.9 years; range, 1 to 15 years) who presented within the first 24 h of injury and were diagnosed with Seymour fractures and treated in the emergency setting were retrospectively analyzed. Clinical and radiological data were collected from medical records at the time of diagnosis and during follow-up, within a week after the treatment and in the visits required until fracture healing, and no sequelae were observed. In the event of complications, a minimum of one year of follow-up was carried out. Radiographs were taken of the anteroposterior and lateral views during each visit. RESULTS: The mean follow-up was 10.8±8.6 (range, 2 to 36) months. Surgical treatment in the operating room was performed in 24 (82.7%) patients using a single longitudinal Kirschner wire (K-wire) fixation through the distal phalanx and the distal interphalangeal joint in 21 patients. Non-operative treatment based on closed reduction and splinting was performed in five (17.3%) patients. There was no statistically significant difference in the final passive range of motion and physeal growth arrest in relation to the use or non-use of K-wires. The use of antibiotics in any of the three possible administrations (intravenous antibiotic regimen, intravenous and later oral antibiotic at-home or oral antibiotics), in relation to the non-use of antibiotics seemed to be a protective factor against infections (odds ratio=0.04; 95% confidence interval: 0.006-0.2; p=0.001). CONCLUSION: The identification of Seymour fractures is crucial for applying the correct treatment and reducing the risk of complications, such as osteomyelitis and physeal alterations. Based on our study results, we can suggest that the use of an antibiotic regimen causes a lower risk of infections in acute Seymour fractures. The prompt identification of these fractures with a standardized protocol covering irrigation, debridement, reduction, fixation, and prophylactic antibiotics is needed to avoid complications.

Radial Polydactyly. What's New?

BACKGROUND: Thumb duplication, also called radial or preaxial polydactyly, is classified as an alteration of the radio-ulnar axis in the formation and differentiation of the hand plate, according to the Oberg, Manske and Tonkin classification. OBJECTIVE: Radial polydactyly is a common upper limb malformation. This paper is a comprehensive analysis of radial polydactyly, its genetic explanation, classification, surgical techniques, functional results, as well as present and future scientific evidence on this congenital pathology. CONCLUSIONS: Radial polydactyly occurs most frequently as an isolated defect, but it may also occur in association with other abnormalities, or as part of a syndrome. The Wassel classification is the universal classification for thumb duplication. One of the limitations of it is the misclassification of the immature epiphysis. The Wassel classification not only refers to the pathoanatomy of the polydactyly but also guides the selection of various surgical techniques. Three well-defined surgical objectives should be ensured: thumb alignment, stability, and an acceptable final esthetic appearance. Tada score is a validated functional scale that takes into account the most common and limiting complications, namely clinodactyly and instability. Based on some recent strong research evidence, the JSSH assessment system provides the most reliable outcome of scores. More studies are required to provide evidence-based conclusions regarding the treatment of radial polydactyly.

Surgical Techniques for Displaced Radial Neck Fractures: Predictive Factors of Functional Results.

BACKGROUND: Fractures of the radial neck represent about 1% of all childhood fractures and 5% to 10% of childhood traumatic lesions involving the elbow. Management of these fractures in children is still controversial. Intramedullary percutaneous nail reduction (Métaizeau technique) is considered the most effective surgical technique because of its excellent results and easy learning curve. Complications may arise, however, especially in Böhler technique, in which a percutaneous pin is placed over the radial head. When this technique does not provide correct reduction, open reduction must be performed. Because open reduction is traditionally associated with a high risk of complications, however, its use is restricted to severely displaced fractures and only when the percutaneous techniques have failed or their application contraindicated because of associated injuries to the distal radius. METHODS: In this retrospective study, we evaluated 51 children between the ages of 6 and 15 years who presented to our institution from 1996 to 2012 with Métaizeau-modified Judet grades 3, 4a, and 4b radial head fractures. The surgical techniques used were closed reduction and casting under general anesthesia (n=7), closed reduction and intramedullary nailing using Métaizeau technique (n=27), and Métaizeau technique and open reduction with intramedullary nailing (n=17). Functional results of the 3 surgical techniques were evaluated using the Mayo Elbow Performance Score (MEPS) and compared by modified Judet classification using χ analysis. RESULTS: No statistic significant association was found between type of surgery and final MEPS was observed (P=0.110). However, a significant association was found between initial modified Judet grade and final MEPS. CONCLUSIONS: In the present study, final functional outcome seems to be not affected by open reduction but was significantly associated with initial modified Judet grade. LEVEL OF EVIDENCE: Level III-retrospective study comparing closed and open reduction techniques, performed at the same institution.

Pediatric Psoas Abscess, Early Diagnosis of a Challenging Condition.

INTRODUCTION: Psoas abscess is a rare entity at the pediatric stage of life. The clinical presentation of psoas abscess is insidious and not specifi c, and this usually causes diagnostic delay. Early diagnosis is relevant to prevent devastating consequences of this condition. AIMS: This study aimed to describe the natural history of psoas abscess, present our experience in a children's hospital, determine warning signs and symptoms that may lead to early diagnosis, and describe differential diagnoses. We also discuss the devastating consequences of misdiagnosing psoas abscess. METHODS: This retrospective study was performed at Sant Joan de Déu Children's Hospital (Barcelona, Spain) from 2008 to 2016. All patients younger than 18 years old (n = 12) with psoas abscess who were diagnosed by imaging tests were included. RESULTS: The initial clinical presentation of the patients was variable. Painful hip mobility at extension (7 cases), limping (5 cases), and fever (4 cases) were the most frequent presentations. Laboratory parameters were abnormal in nine patients. The main responsible bacteria was Staphylococcus aureus (9 cases). The mean hospital stay was 28 days (range, 10-71 days). Percutaneous drainage under ultrasound control was applied in two patients. Surgical debridement was performed in seven patients, and repeated procedures were required in three of them. CONCLUSIONS: Because of the erratic presentation of psoas abscess, its suspected diagnosis is essential for an early diagnosis, which will minimize the risk of diagnostic delay. One or more signs and symptoms at the same time might be considered as initiation of psoas abscess. Physicians should be aware of risk factors, such as previous traumatism and a known disturbed immunological system or temporal circumstances, which might lead to psoas abscess. Laboratory parameters may provide more confi dence in diagnosis, and early imaging tests provide a defi nitive diagnosis.

Prognostic value of age and Wassel classification in the reconstruction of thumb duplication.

BACKGROUND: Various surgical techniques for thumb duplication have been described. The main goal in thumb reconstruction is to achieve optimal function, stability, and shape. Few publications have quantified the functional results of each surgical option and factors that may affect these outcomes. METHODS: We performed a retrospective review during the period from 1990 to 2011 of 115 surgery patients, 99 of whom had a mean postoperative follow-up of 44.1 months. They were classified according to the Wassel classification. We assessed the surgical technique, functional results, and complications, and evaluated the probable prognostic value of age and Wassel classification. RESULTS: This case series comprised mainly female patients (62 %) and the right hand (74 %), with a mean age at operation of 20 months. The most common group was Wassel type IV (54 %). On the basis of the Tada scoring system, we obtained 91 good results (91 %). Complications occurred in 27 patients (27 %), mainly instability and axis deformation. In a comparison of preoperative factors (age at the time of surgery and Wassel classification) with the final results (Tada score and complications), the association between older age at surgery and complications (p = 0.0001) and Wassel types III and IV and complications (p = 0.0210 and p = 0.0095) was statistically significant. CONCLUSIONS: Following the basic concepts of anatomical reconstruction, we obtained good results in most patients. The main complications were instability and axial deformity. These were most common in patients who underwent operations at an age of more than 12 months, and patients with Wassel types III and IV deformities.