Management of the Pediatric Pulseless Supracondylar Humeral Fracture: A Systematic Review and Comparison Study of "Watchful Expectancy Strategy" Versus Surgical Exploration of the Brachial Artery.

BACKGROUND: Pulseless hand after a supracondylar humeral fracture (SHF) in children is well known in the bibliography. Although things are clearer in the management of a "pale pulseless hand," controversy still exists about the "pink pulseless hand" (PPH). METHODS: We reviewed the literature from the electronic database PubMed for studies with main object the vascular injuries after SHF in children and especially the pulseless hand. The primary search terms were "supracondylar humeral fracture" and "vascular injuries". In our final study, 16 articles were gathered and analyzed. RESULTS: We collected 608 pulseless SHFs, regardless of the vascular status, 203 PPHs, and 109 pale pulseless hands. We compared two different strategy methods when the hand remained pulseless after the reduction and fixation of the fracture: (1) the close observation strategy and (2) the surgical exploration of the artery. The close observation strategy was the treatment of choice in PPH, whereas the surgical exploration of the brachial artery was mostly performed in pale pulseless hands. CONCLUSIONS: Closed reduction and fixation of the fracture should be the priority in all pulseless SHFs, both pink and pale. In poorly perfused pale hands, after the reduction and fixation of the fracture, there is a chance that radial pulse may return (we found that this chance is approximately 30%). If not, immediate surgical exploration of the artery is strongly indicated. In well-perfused pink hands, the traditional dogma of "watchful waiting" should not be revisited as long as no signs of deterioration of the vascular status appear. LEVEL OF EVIDENCE: Level I-Systematic review of level I studies.

Fixation of a chondral lateral femoral condyle fracture in a 13-year-old boy following patella dislocation using a new suture technique.

Osteochondral or, even more rarely, purely chondral fractures of the lateral femoral condyle following patella dislocation in adolescents are relatively infrequent. Various fixation methods are described in the literature, ranging from traditional screws to bioabsorbable constructs or the use of anchors. Each method possesses its own advantages and limitations. Here, we present a case involving a 13-year-old boy with a large purely chondral fracture of the lateral femoral condyle after patella dislocation, initially overlooked. We introduce a cost-effective suture-bridge technique for the fixation of this fracture, which eliminates the need for a second operation and has yielded favorable outcomes. It is important to know that fractures of this type can be easily overlooked, necessitating a high index of suspicion and the utilization of advanced imaging techniques to prevent potential long-term catastrophic outcomes for the knee joint.

Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis.

PURPOSE: Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. METHODS: A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. RESULTS: Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. CONCLUSIONS: Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.

Cuboid fracture: An extremely rare cause of limping in a 2-year-old child.

The purpose of this case report is to raise awareness of an extremely rare cause of limping, in young children. Clinicians should have a high index of suspicion of a possible cuboid fracture when evaluating a young child who presents with limping.

A case report of osteochondritis dissecans of the first metatarsophalangeal joint treated with autologous cancellous bone and chondral flap reconstruction.

Although osteochondritis dissecans (OD) is well-described in the bibliography, cases of OD in the 1st metatarsophalangeal joint (MTP) are rare clinical situations. We present a 25-year-old male who presented to our department for big toe pain on the left side. Clinical and radiological examination showed the typical findings of OD lesion on the 1st metatarsal head (MH), establishing the diagnosis of OD. Intraoperatively the articular cartilage of the partially detached part of the MH was intact and under it, an empty cavity with a big defect was obvious. Autogenous cancellous bone transplantation from the metatarsal metaphysis, reattachment of the cartilage surface as a chondral flap and edge sealing with fibrin glue was our treatment of choice. OD of the 1st MH should be included in the differential diagnosis of big toe pain, as early diagnosis and treatment are crucial to prevent future osteoarthritis of the 1st MTP.

Impending hand compartment syndrome in an infant: is clinical evaluation enough to perform a fasciotomy?

The purpose of this case report is to raise awareness of the early diagnosis and treatment of compartment syndrome in children. Late diagnosis can lead to irreversible outcomes, including myonecrosis, neurologic injury, functional problems, and even amputation. In this age group, clinical judgment may be enough to proceed with fasciotomy.

Osteochondroma of the distal tibia in an 8-year-old child: Do we need to excise a benign tumor?

Osteochondromas are benign tumors that can be responsible for angular deformities, limb-length discrepancy, and impending fractures of the neighboring bones. The risk of future fractures and joint malalignment is an indication for surgical intervention.

Charcot arthropathy: The diagnostic dilemma of a painless, destructive joint.

The impressive clinical picture of Charcot joint reflects a high energy trauma injury which in the contrary is a progressive, painless arthropathy. Early and accurate diagnosis is crucial. A favorable outcome is elicited when joint is treated promptly, while late or misdiagnosis may lead to amputation.

Flexion-Type Supracondylar Humeral Fracture with Ulnar Nerve Injury in Children: Two Case Reports and Review of the Literature.

BACKGROUND Supracondylar humeral fracture is a common fracture in the pediatric population. Although extension-type is the most common fracture pattern (97% to 98%), flexion-type supracondylar fractures are rarely encountered (2% to 3%). The combination of a flexion-type supracondylar humeral fracture with an ulnar nerve injury represents a real challenge for an orthopaedic surgeon. CASE REPORT We report 2 cases of flexion-type supracondylar humeral fracture with ulnar nerve injury that open reduction and fixation was necessary because closed reduction could not achieve an acceptable result. An anterior approach to the elbow joint was chosen to explore whether any neurovascular structures were entrapped between the fragments. The ulnar nerve was not found to be compressed in the fracture site. After anatomic reduction, cross K-wire fixation of the fracture was performed. At 6-month follow-up, ulnar nerve injuries (in both patients) were resolved. CONCLUSIONS These case reports enhance the existing literature that flexion-type supracondylar fractures with ulnar nerve injury are associated with higher rates of open reduction. Orthopaedic surgeons should be aware, and family members of those patients should be informed, that the likelihood of an open reduction in these types of injuries is extremely high. Open reduction is needed not only to achieve an anatomic reduction of the fracture but to make sure that the ulnar nerve is not entrapped between the proximal and distal fragment.

A 10-year follow-up of asymptomatic Charcot hip joints caused by CIPA syndrome (congenital insensitivity to pain with anhidrosis) with failure of any surgical reconstructive treatment.

Congenital insensitivity to pain with anhidrosis (CIPA) is a rare genetic disorder. Patients with CIPA lack among other things the protective sensation of pain. Orthopaedic manifestations are fractures, infections and hip joint dislocation. We report a 10-year follow-up of late developing hip dysplasia with CIPA and the result of several reconstructive surgical procedures. The final outcome was asymptomatic Charcot hip joints with superior migration and dislocation of both hips without pain. In conformance with the literature standard operative techniques in these rare cases usually seem to fail. A multidisciplinary conservative approach with close observation and activity modification is the proposed treatment of choice.

Hip Arthroscopy as Part of a Salvage Procedure for Avascular Necrosis (AVN) in a 7-Year-Old Child.

BACKGROUND Avascular necrosis of the femoral head (AVN) is one of the most serious complications following developmental dysplasia of the hip (DDH). Treatment options focus mainly on improving the biomechanics and kinematics of the affected hip joint. In the past, femoral and pelvic osteotomies were the mainstay of treatment. Over the last years, the use of hip arthroscopy has also grown and allows reconstructive treatments in pediatric hip disorders. CASE REPORT We present a 7-year old patient with AVN of the proximal femoral head after open reduction of her dislocated hip (DDH). The patient presented to our department with limb length discrepancy, limited internal rotation of the right hip and groin pain. We performed a two-stage procedure including a) valgus proximal femur osteotomy combined with Dega acetabuloplasty and b) hip arthroscopy to address the formation of CAM impingement that was the result of excessive femoral head necrosis and our re-orientation procedure. CONCLUSIONS AVN following closed or open reduction for DDH is a potentially devastating complication. Hip arthroscopy can be an extremely useful tool that can be used in addition to the well-known osteotomy procedures to improve joint congruency. Hip arthroscopy in the pediatric population is a new growing field that can be used in managing disorders of the pediatric hip, as the indications will continue to evolve.

Surgical Treatment of Bilateral Tibia Deformity in a 9-Year-Old Child Suffering from Osteogenesis Imperfecta Type III: A Case Report.

BACKGROUND Osteogenesis imperfecta is a rare inherited connective tissue disorder that is mainly characterized by long bone deformities and increased susceptibility to bone fractures. The aim of this study was to present a surgical technique in a child suffering from osteogenesis imperfecta and progressive, severe bowing deformity of both tibias, as an alternative method to advanced, innovative surgical systems. CASE REPORT A 9-year-old child (male) was referred to our orthopedic clinic for inability to walk independently due to extreme anterior bowing of both tibias. After the diagnosis of osteogenesis imperfecta type III was established, bilateral surgical treatment with multiple osteotomies and intramedullary, flexible Titanium Elastic Nail System (TENS) nails was decided. Six months post-operatively callus formation was obvious in x-rays and at the latest follow-up (1 year post-operatively) the patient regained the ability to walk independently. CONCLUSIONS In types of osteogenesis imperfecta which are characterized by extreme deformities (type III) surgical intervention seems to be the only solution for these patients to walk again. We present a relatively simple technique of correcting such deformities, indicating that no matter which technique will be used (simple or more complicated) the final goal should be to restore the walking ability with as little complications as possible.

Blount's disease: The importance of early diagnosis and early treatment.

The purpose of this image is to raise awareness of the early diagnosis and treatment of Blount's disease. Failure to distinguish between physiologic genu varum and early onset of Blount's disease can lead to irreversible outcomes, including progressive deformity with gait deviations, limb-length discrepancy, and premature arthritis of the knee.

The pulseless supracondylar humeral fracture: Our experience and a 1-year follow-up.

BACKGROUND: Although the pulseless supracondylar humeral fracture (SHF) in children is well known in the bibliography, controversy still exists regarding the treatment strategy. The purpose of this study was: (a) to describe our policy with pulseless hands following SHF and (b) evaluate the functional outcome in a 1-year follow-up. METHODS: During the years 2013 to 2018 in our department, 23 of 210 children with type III SHF presented with a pulseless hand (20 with a PPH and 3 with a cold, pulseless hand). Fracture reduction was attempted in all patients followed by reevaluation of the vascular clinical status (including a Doppler ultrasound). RESULTS: In PPH, a palpable radial pulse was present in all patients in less than 48 hours after surgery. Closed reduction was able to improve the vascular status in 1 patient with pale pulseless hand but surgical exploration of the brachial artery was performed in the other two patients. A palpable radial pulse was present 24 hours after surgery in these 3 patients. All patients had good/excellent outcomes at 1-year follow-up. CONCLUSION: With our study, we want to enhance the traditional dogma of "watchful waiting" in pink pulseless hands following SHF, and we believe that it should not be revisited. In pale pulseless hands following SHF, at least one attempt of reduction and fixation of the fracture is recommended. If the pulse does not return or the vascular status does not improve, immediate surgical exploration of the artery is strongly indicated. LEVEL OF EVIDENCE: Case series prognostic study, level IV.