Nail changes in children with idiopathic congenital clubfoot deformity.

BACKGROUND/OBJECTIVES: Nail alterations are commonly seen in cases of idiopathic clubfoot and may cause parental concern. The nature of and whether these changes are congenital or develop secondary to treatment has been poorly investigated. The aim of this study was to evaluate toenail morphology in clubfoot patients at presentation, to re-evaluate them during the course of treatment for the clubfoot, and to analyze findings in the light of the few literature reports for healthy children of the same age. METHODS: Thirty infants (21 males and 9 females) with idiopathic clubfoot were prospectively enrolled at the Anna Meyer Children's University Hospital. Nails of affected and non-affected feet were evaluated by a team of pediatric dermatologists at presentation and re-evaluated once per patient during the bracing period of Ponseti treatment. RESULTS: Toenails of affected (47) and non-affected (13) feet were abnormal at presentation in 43.3% of patients, in both clubfeet (40.4%) and non-affected feet (38.5%), but most changes were physiologic or transitory alterations, commonly found in healthy children, with nail concavity (koilonychia) being the most common finding (29.7%). Changes were not related to clubfoot severity or laterality (P > .05). In most (76.9%) unilateral cases, there was concordance of nail changes between clubfoot and non-affected foot. At re-evaluation (follow-up time 410 ± 207 days), nail problems were more frequent (53.3%); ingrown toenail was the most common (21.6%). CONCLUSIONS: The presence of nail alterations seems not to be caused by clubfoot pathology and could be related to unfavorable local condition in the brace.

Comparison of Dimeglio and Pirani score in predicting number of casts and need for tenotomy in clubfoot correction using the Ponseti method.

PURPOSE: The Dimeglio and the Pirani scores are largely used to rate clubfoot at presentation and monitor correction. To date, the accuracy of these scores in predicting appropriate treatment is controversial. The aim of this study was to investigate the accuracy of Dimeglio and Pirani scores in predicting the number of casts and the need for tenotomy in clubfoot correction using the Ponseti method. METHODS: Ninety-one consecutive feet (54 patients; mean age at presentation: 28 ± 15 days) undergoing clubfoot correction using the Ponseti method were prospectively followed from first casting to correction. All feet were scored according to the Dimeglio and Pirani score. The relationships between the two scores, the number of casts and the need for tenotomy were analysed. RESULTS: Initial correction was achieved in all feet. Both Dimeglio (r = .73; p value < .0005) and Pirani scores (r = .56; p value < .000) showed good association with the number of casts. Multiple linear regression showed a high collinearity of the two scores but a more significant contribution of the Dimeglio score. Among subcomponents, hindfoot score, midfoot score, varus and muscular abnormality were independent predictors of the number of casts. Both Dimeglio and Pirani scores were significantly associated with the need for tenotomy (p value = .0000), and odds ratios and cut-off points were calculated. The receiving operator curve (ROC) analysis showed slightly better performance of the Dimeglio in comparison with the Pirani score in predicting the need for tenotomy, but the difference between the two areas under the curve (AUC) was not significant (p = .48). CONCLUSIONS: A quite accurate prediction of the number of casts and the need for tenotomy can be performed in most cases. The Dimeglio score showed slightly better accuracy in predicting both steps of Ponseti treatment.

Residual elbow instability in children with posterior or postero-lateral elbow dislocation.

The purpose of this study is to evaluate the incidence and the severity of residual elbow instability in children treated for posterior (PED) or postero-lateral (PLED) elbow dislocation. This retrospective study included all children younger than 14 years of age with a confirmed diagnosis of acute post-traumatic elbow dislocation (ED). Subjective data such as perceived pain, stiffness and impact of daily activities, and objective data such as skin lesions, surgical-site infections, and range of motion were recorded. All patients underwent the milking test, the chair sign test (CST) and the Drawer test (DT). The functional status has been rated according to the Mayo Elbow Performance Score (MEPS) and the Roberts criteria (RC). Radiographs of the injured arm were performed at the last follow-up visit to evaluate axial alignment, growth disturbances, osteoarthrosis, heterotopic calcifications, and the presence of loose intra-articular bodies. Nineteen patients with a mean age of 9 years and 5 months at the time of injury were available for review. Six patients had PED (31.6%) and 13 PLED (68.4%); in five cases (26.3%) the dislocation was simple and in 14 cases (73.7%) it was complex. None of the patients complained of subjective symptoms of elbow instability, although 2 patients had positive CST, and one of them also had positive milking test. RC and MEPS ranged from good to excellent in all patients. Clinical examination with multiple stability tests is important to detect residual elbow instability in children treated for ED as functional scores alone may underestimate the clinical picture.

Vertebroplasty: benefits are more than risks in selected and evidence-based informed patients. A retrospective study of 59 cases.

Vertebral compression fractures represent a frequent pathology among elderly population, with potentially devastating consequences. More than 20 years have passed since percutaneous vertebroplasty was initially used in the treatment of angiomas, representing nowadays a widely used treatment for osteoporotic vertebral fractures. The authors present a retrospective review of 59 consecutive patients (in total 94 fractured levels) that underwent polymethylmethacrylate percutaneous vertebroplasty for vertebral compression fractures due to senile or secondary osteoporosis. All fractures were free from neurologic involvement and were classified as A1 type according to Magerl classification. All of patients were initially treated conservatively, by application of orthosis that allows immediate deambulation. At control, patients who complained of pain and limitation of daily activities underwent MRI. If presence of marrow signal changes, especially hypertense signal in T2-weighted images was confirmed, percutaneous vertebroplasty procedure was performed (we could call it "sub-acute" procedure). A limited group of patients that did not tolerate brace and had an insufficient pain control underwent vertebroplasty "in acute", few days after fracture. Immediate post-operative pain reduction and follow-up clinical outcome (estimating quality of life and residual back pain) were evaluated by means of Visual Analogue Scale, SF-36 and Oswestry Disability Index. In the immediate post-operative course a significant pain relief was found in 39 patients (66.1%), moderate pain relief in 17 (28.8%), while 3 (5.1%) did not achieve relevant pain improvement. Pain intensity and life quality was maintained within satisfactory limits after a mean follow-up of 16 months. In conclusion, percutaneous vertebroplasty is an effective and safe procedure for treating vertebral compression fractures in the elderly. It provides immediate pain relief and allows early mobilization, thus avoiding potentially severe complications related to persistent back pain and prolonged bed rest. When performed by experienced surgeon complication rate is low, representing a safe procedure, able to provide a satisfactory outcome.

Flexible intramedullary nailing for supracondylar femoral fractures in children with Duchenne muscular dystrophy.

BACKGROUND Femoral fractures are common in patients with Duchenne muscular dystrophy (DMD) and represent a critical moment in the natural history of the disease. The immobilization required for fracture healing frequently leads to further weakening and worsening (or definitive loss) of functional abilities. Surgical treatment has been advocated in ambulatory and nonambulatory patients with rapid mobilization of patients as the main goal; however, it exposes patients to considerable anesthetic risk. CASE REPORT We present a previously unreported experience of flexible intramedullary nailing (FIN) in 2 DMD patients (aged 11.7 and 12.8 years) who were still able to walk or stand when the supracondylar femoral fractures occurred. The surgical procedures were performed with sufficient reduction and stabilization of fractures. Rapid mobilization of the patients was achieved, including muscle strengthening exercises. A prompt recovery of the upright standing position and successive ambulation was accomplished in the patient with the higher functional status before the fracture, whereas the standing ability was not recovered in the other patient. No increase of knee flexion contractures and no growth disturbances were recorded at the follow-up. CONCLUSIONS The operative treatment option should be considered by a multidisciplinary team; they should evaluate the advantages and risks for each patient considering their functional status. For ambulatory children (or patients still able to stand), FIN can represent a valid, minimally invasive, apparently growth-sparing and sufficiently stable osteosynthesis, allowing rapid rehabilitation of the patient that can limit, but not completely avoid the consequences of the femoral fracture.

The influence of laterality, sex and family history on clubfoot severity.

PURPOSE: Epidemiological studies on idiopathic clubfeet have shown a typical distribution consistent across ethnic groups: bilaterality in about 50% of cases and a male to female ratio of 2:1. Whether this corresponds also to differences in severity according to laterality and sex has been poorly evaluated. As well, the correlation between family history and severity has not been previously investigated. The aim of this study was to investigate how laterality, sex and family history influence severity and treatment. METHODS: In all, 97 infants with idiopathic clubfoot (81 male, 16 female; 55 unilateral, 42 bilateral; 19 with a first or second-degree relative affected) consecutively treated with Ponseti method were prospectively enrolled. Initial severity (according to Dimeglio and Pirani scores) and treatment (number of casts and need for tenotomy) were analyzed in the different subgroups. RESULTS: Initial severity according to Pirani (p = 0.020) and Dimeglio score (p = 0.006), number of casts (p = 0.000) and tenotomy (p = 0.045) were significantly higher in bilateral than in unilateral cases. In bilateral cases, a significant correlation was found between the right and left foot of each patient in terms of initial severity, number of casts and tenotomy performed. No statistically significant difference was found according to sex and family history. CONCLUSIONS: This study has confirmed the different behaviour of bilateral cases reported by previous studies; bilateral cases are more severe and show similar features in their right and left foot. This could be the result of different pathogenic mechanisms, likely on a genetic basis. Sex and family history did not seem to influence severity. LEVEL OF EVIDENCE: Level of evidence II.

Extraskeletal Chondroma: A Rare Cause of Trigger Finger in Children.

INTRODUCTION: Trigger finger is ten times less common than trigger thumb in infants and children and, unlike trigger thumb, may arise from a variety of underlying causes. To our knowledge, we describe the first case of pediatric trigger finger secondary to an extraskeletal chondroma. CASE PRESENTATION: We report the case of an 11-year-old girl presenting with a typical history of triggering of the fourth finger, in whom a nodule attached to the flexor digitorum superficialis was found; clinical, ultrasound, and operative findings are described. Histological analysis was diagnostic of extraskeletal chondroma, also known as chondroma of soft tissues. CONCLUSION: This is a very uncommon benign cartilaginous tumor, mostly reported in patients aged 30 to 60 years (just one pediatric extraskeletal chondroma of the hand has been described), and presentation with trigger finger has been reported just once, in a 76-year-old man. This condition should be considered in the differential diagnosis of pediatric trigger finger.

Surgical treatment of patellar dislocation in children with Down syndrome: a 3- to 11-year follow-up study.

We report results of surgical treatment of ten knees affected by patellar dislocation in six children with Down syndrome. Four knees showed a dislocatable patella (grade III according to Dugdale), two a dislocated reducible patella (grade IV) and four a dislocated irreducible patella (grade V). Symptoms included frequent falls, limping and pain. In all the cases a Roux-Goldthwait-Campbell procedure was performed. Mean age at surgery was 10 years (range 6 years and 6 months to 13 years and 4 months). Patients were reviewed at an average follow-up of 8 years and 8 months (range 3 years and 6 months to 11 years and 5 months). None showed signs of recurrence of the dislocation. The median Lysholm score improved from 57.5 to 91/100. Statistical analysis showed a significant effectiveness of the procedure in improving function, and that surgery was significantly more effective in patients with more severe disability.

Arthroscopic treatment of septic arthritis of the shoulder in a 6-year-old boy.

Septic arthritis of the shoulder in children is a rare condition. The diagnosis may present some difficulties and, consequently, appropriate treatment often is delayed. Main sequelae are humeral shortening, joint instability, premature arthritis and limited range of motion. We report a case of septic arthritis of the shoulder in a child who was treated by means of shoulder arthroscopy. A 6-year-old boy presented with a history of fever, pain and functional impairment of the shoulder that were lasting despite having undergone antibiotic therapy for 28 days (amoxicillin per os, and then teicoplanin intravenously combined with meropenem intravenously) and an arthrocentesis (no organisms were identified) in another hospital. Clinical examination (pain, swelling, warmness, functional impairment), laboratory tests (white blood cell count, 6.900/mm(3); C-reactive protein, 6.44 mg/dL; erythrocyte sedimentation rate, 119 mm), and imaging studies (radiographs, ultrasonography, computed tomography scan, magnetic resonance imaging, bone scan) performed in our department suggested the diagnosis of a stage IV (with osseous involvement) septic arthritis. Arthroscopic irrigation, debridement, synoviectomy and shaving of the osteochondral erosions were performed, in association with antibiotic therapy (teicoplanin and ceftriaxone disodium intravenously, and then amoxicillin/clavulanate per os). At 22-month follow-up, the patient was asymptomatic and showed a full range of motion. No limb length-discrepancy was found. Radiographs showed irregular profile of the humeral epiphysis without any physeal disturbances. Arthroscopic treatment for septic arthritis of the shoulder in children, though rarely reported, represents an adequate procedure for cases without bone involvement and may lead to good results, even in stage IV cases. Open arthrotomy should be reserved for cases with concomitant osseous infection after failure of arthroscopic treatment.

Remodelling and overgrowth after conservative treatment for femoral and tibial shaft fractures in children.

One thousand nine hundred and eighty-four children who had received conservative treatment for shaft (diaphyseal and metadiaphyseal) fractures of lower limbs (1162 femoral, 822 tibial fractures) at an average age of 8.5 years (range 0-14 years) were reviewed by clinical and radiographic investigations at an average follow-up of 6.6 years (1-15 years). Particularly, two main features were evaluated: remodelling of (angular and rotational) deformities and post-traumatic overgrowth. Mechanisms underlying these processes are discussed, based on a review of the literature, and parameters conditioning their evolution are analysed. Finally, criteria for an acceptable reduction (and limits for residual deformities that may be tolerated) at the time of conservative treatment are proposed.

Outcomes after surgical treatment of missed Monteggia fractures in children.

BACKGROUND: Chronic dislocation of the radial head treatment in Monteggia fracture dislocation is still controversial. We present a large series of patients treated in our Institution. MATERIALS AND METHODS: The outcome of 22 children treated surgically between 1988 and 2011 for post-traumatic chronic radial head dislocation is reported. There were 12 girls and 10 boys with a mean age at surgery of 7.2 years (4.1-13.6). The mean interval between injury and treatment was 15.7 months (1-128). Nine patients underwent open reduction with removal of interposed tissue and repair (7) or Bell-Tawse reconstruction (2) of the annular ligament. Ten patients underwent osteotomy, gradual lengthening and angulation of the ulna by external fixation. Two patients underwent angular osteotomy of the proximal ulna with open wedge, open reduction in the radial head and reconstruction of the annular ligament. One patient admitted to the hospital 10 years after injury underwent radial head excision at 13.7 years of age. RESULTS: After a mean follow-up of 5.5 years (1-24.3), the radial head stayed reduced in 15 patients and subluxated in 5. In one case, redislocation occurred. All patients but five were pain-free. The elbow performance score (Kim score) was excellent in 14 cases, good in four and fair in four, with a mean score of 91, corresponding to a good result. Complications included a transient posterior interosseus nerve palsy (1), and one non-union of the ulna. DISCUSSION AND CONCLUSION: Chronic Monteggia lesions must be treated. The clinical outcomes are usually better than the congruency of the radiocapitellar joint.

Sternoclavicular physeal fracture associated with adjacent clavicle fracture in a 14-year-old boy: a case report and literature review.

We report a very rare association of a physeal fracture of the medial clavicular growth plate with a fracture of the adjacent clavicle in a 14-year-old boy who fell on his shoulder while playing football. Clinical, radiographic and computed tomographic (with three-dimensional reconstruction) features are described. Open reduction, internal fixation of the lateral fracture (with a reconstructive plate) and suture of the periosteum were performed.

Freeman-Sheldon syndrome. A case report and review of the literature.

The Authors describe a case of Freeman-Sheldon Syndrome, a rare congenital autosomal dominant disorder (gene mapped on chromosome 11p15.5) characterized by microstomia with crinkled lips, camptodactyly with ulnar deviation of the fingers and equinus-varus-supine clubfoot. The autosomal recessive form, even rarer and difficult to recognize, has a more severe clinical manifestation. The symptomatology is worsened by breathing and swallowing disorders due to the small orifices of the mouth and nose, which sometimes require tracheotomy to avoid obstruction of the airways.