Prophylactic fixation of the unaffected contralateral side in children with slipped capital femoral epiphysis seems favorable:A systematic review

BACKGROUND Slipped capital femoral epiphysis (SCFE) occurs in adolescents and has an incidence of around 10 per 100000 children. Children presenting with a unilateral SCFE are 2335 times more likely to develop a contralateral SCFE than the general population. Prognostic factors that have been suggested to increase the risk of contralateral slip include a younger patient, an underlying endocrine disorder, growth hormone use and a higher radiographic posterior sloping angle. However, there is still much debate on the advantages and disadvantages of prophylactic fixation of the unaffected side in an otherwise healthy patient. AIM To investigate the risk rate of contralateral SCFE and assess the (dis)advantages of prophylactic fixation of the contralateral hip. METHODS A systematic literature search was performed in the Embase, Medline, Web of Science Core Collection and Cochrane databases. Search terms included ‘slipped capital femoral epiphysis,’ ‘fixation,’ ‘contralateral,’ and derivatives. The eligibility of the acquired articles was independently assessed by the authors and additional relevant articles were included through cross-referencing. Publications were considered eligible for inclusion if they presented data about otherwise healthy children with primarily unilateral SCFE and the outcomes of prophylactically pinning their unaffected side, or about the rates of contralateral slips and complications thereof. The study quality of the included articles was assessed independently by the authors by means of the methodological index for non-randomized studies criteria. RESULTS Of 293 identified unique publications, we included 26 studies with a total of 12897 patients. 1762 patients (14%) developed a subsequent symptomatic contralateral slip. In addition, 38% of patients developed a subsequent slip on the contralateral side without experiencing clinical symptoms. The most outspoken advantage of prophylactic fixation of the contralateral hip in the literature is prevention of an (asymptomatic) slip, thus reducing the increased risk of avascular necrosis (AVN), cam morphology and osteoarthritis. Disadvantages include an increased risk of infection, AVN, peri-implant fractures, loss of fixation as well as migration of hardware and morphologic changes as a consequence of growth guidance. These risks, however, appeared to only occur incidentally and were usually mild compared to the risks involved with an actual SCFE. CONCLUSION The advantages of prophylactic pinning of the unaffected side in otherwise healthy patients with unilateral SCFE seem to outweigh the disadvantages. The final decision for treatment remains to be patient-tailored

Physician preferences in diagnostics and treatment of juvenile osteochondritis dissecans are diverse across the knee, ankle and elbow:an ESSKA survey

Purpose: To investigate the current preferences regarding the work-up and treatment choices of juvenile osteochondritis dissecans (JOCD) of the knee, ankle and elbow among orthopaedic surgeons. Methods: An international survey was set up for all European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) members, which assessed various questions on diagnosis and treatment of JOCD of different joints. Respondents answered questions for one or more joints, based on their expertise. Proportions of answers were calculated and compared between joints. Consensus was defined as more than 75% agreement on an item; disagreement was defined as less than 25% agreement. Results: Fifty physicians responded to the survey, of whom forty-two filled out the questions on the knee, fourteen on the ankle and nine on the elbow. Plain radiography and MRI were the most used imaging modalities for the assessment and follow-up of JOCD in the knee and ankle, but not for the elbow. MRI was also the preferred method to assess the stability of a lesion in the knee and ankle. There was universal agreement on activity and/or sports restriction as the non-operative treatment of choice for JOCD. Size, stability and physeal closure were the most important prognostic factors in determining the operative technique for the elbow. For the knee, these factors were size and stability and for the ankle, these were size and location. Conclusion: Activity and/or sports restriction was the non-operative treatment of choice. Furthermore, plain radiography and MRI were the preferred imaging modalities for the knee and ankle, but not for the elbow. For determining the operative technique, physicians agreed that the size of the lesion is an important prognostic factor in all joints. These findings help us understand how juvenile osteochondritis dissecans is treated in current practice and may provide opportunities for improvement. Level of evidence: Level V.</p

Fractures around the shoulder in the skeletally immature:A scoping review

Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 – 2/3 shaft width) in the current literature.</p

Diagnosis and Treatment of Children with a Radiological Fat Pad Sign without Visible Elbow Fracture Vary Widely:An International Online Survey and Development of an Objective Definition

Children often present at the emergency department with a suspected elbow fracture. Sometimes, the only radiological finding is a ‘fat pad sign’ (FPS) as a result of hydrops or haemarthros. This sign could either be the result of a fracture, or be due to an intra-articular haematoma without a concomitant fracture. There are no uniform treatment guidelines for this common population. The aims of this study were (1) to obtain insight into FPS definition, diagnosis, and treatment amongst international colleagues, and (2) to identify a uniform definition based on radiographic measurements with optimal cut-off points via a receiver operating characteristic (ROC) curve. An online international survey was set up to assess the diagnostic and treatment strategies, criteria, and definitions of the FPS, the probability of an occult fracture, and the presence of an anterior and/or posterior FPS on 20 radiographs. Additionally, the research team performed radiographic measurements to identify cut-off values for a positive FPS, as well as test–retest reliability and inter-rater reliability via intraclass correlation coefficients (ICC). A total of 133 (paediatric) orthopaedic surgeons completed the survey. Definitions, further diagnostics, and treatments varied considerably amongst respondents. Angle measurements of the fat pad as related to the humeral axis line showed the highest reliability (test–retest ICC, 0.95 (95% CI 0.88–0.98); inter-rater ICC, 0.95 (95% CI 0.91–0.98)). A cut-off angle of 16° was defined a positive anterior FPS (sensitivity, 1.00; specificity, 0.87; accuracy, 99%), based on the respondents’ assessment of the radiographs in combination with the research team’s measurements. Any visible posterior fat pad was defined as a positive posterior FPS. This study provides insight into the current diagnosis and treatment of children with a radiological fat pad sign of the elbow. A clear, objective definition of a positive anterior FPS was identified as a ≥16° angle with respect to the anterior humeral line

Advances in Pediatric Fracture Diagnosis and Treatment Are Numerous but Great Challenges Remain

Broken bones are very common during childhood [...

Diagnosis, treatment and complications of radial head and neck fractures in the pediatric patient

Radial head and neck fractures represent up to 14% of all pediatric elbow fractures and can be a difficult challenge in the pediatric patient. In up to 39% of proximal radius fractures, there is a concomitant fracture, which can easily be overlooked on the initial standard radiographs. The treatment options for proximal radius fractures in children range from non-surgical treatment, such as immobilization alone and closed reduction followed by immobilization, to more invasive options, including closed reduction with percutaneous pinning and open reduction with internal fixation. The choice of treatment depends on the degree of angulation and displacement of the fracture and the age of the patient; an angulation of less than 30 degrees and translation of less than 50% is generally accepted, whereas a higher degree of displacement is considered an indication for surgical intervention. Fractures with limited displacement and non-surgical treatment generally result in superior outcomes in terms of patient-reported outcome measures, range of motion and complications compared to severely displaced fractures requiring surgical intervention. With proper management, good to excellent results are achieved in most cases, and long-term sequelae are rare. However, severe complications do occur, including radio-ulnar synostosis, osteonecrosis, rotational impairment, and premature physeal closure with a malformation of the radial head as a result, especially after more invasive procedures

Pediatric Clavicle Fractures and Congenital Pseudarthrosis Unraveled

Clavicle fractures are commonly seen in the pediatric and adolescent populations. In contrast, congenital pseudarthrosis of the clavicle is rare. Although both conditions may present with similar signs and symptoms, especially in the very young, clear differences exist. Clavicle fractures are often caused by trauma and are tender on palpation, while pseudarthrosis often presents with a painless protuberance on the clavicle, which becomes more prominent as the child grows. Its presence may only become apparent after trauma, as it is usually asymptomatic. The diagnosis is confirmed on plain radiography, which shows typical features to distinguish both entities. Both clavicle fractures and congenital pseudarthrosis are generally treated conservatively with a high success rate. Operative treatment for a fracture can be indicated in the case of an open fracture, severely displaced fracture, floating shoulder, neurovascular complications or polytrauma. Congenital pseudarthrosis requires operative treatment if the patient experiences progressive pain, functional limitation and late-onset thoracic outlet symptoms, but most operations are performed due to esthetic complaints

A systematic review of the optimal drainage technique for septic hip arthritis in children

Introduction: The hip is one of the most commonly affected joints in paediatric septic arthritis. Drainage can be performed using arthrocentesis (articular needle aspiration), arthroscopy or arthrotomy. The objective of this systematic review was to identify the most effective drainage technique for septic hip arthritis in the paediatric population. Materials and methods: The electronic MEDLINE, EMBASE and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the paediatric hip. Outcome parameters were additional drainage procedures, clinical outcomes and radiological sequelae. The quality of each of the included studies was assessed with the Methodological Index for Non-randomized Studies (MINORS) score. Results: Out of 2428 articles, 19 studies with a total of 406 hip joints were included in the systematic review. Additional arthroscopy or arthrotomy was performed in 15% of the hips treated with arthrocentesis, in 14% after arthroscopy and in 3% after arthrotomy. Inferior clinical outcomes and more radiological sequelae were seen in patients treated with an arthrotomy. A meta-analysis could not be performed due to the diversity and low quality of the studies (MINORS median 4 [range 2–15]). Conclusions: This systematic review gives a comprehensive overview of the available literature on treatment for septic hip arthritis in children. Arthrocentesis and arthroscopic procedures may have a higher risk of additional drainage procedures in comparison with arthrotomy. However, arthrotomy might be associated with inferior outcomes in the longer term. The included studies are diverse and the scientific quality is generally low

Indications and Timing of Guided Growth Techniques for Pediatric Upper Extremity Deformities: A Literature Review

Osseous deformities in children arise due to progressive angular growth or complete physeal arrest. Clinical and radiological alignment measurements help to provide an impression of the deformity, which can be corrected using guided growth techniques. However, little is known about timing and techniques for the upper extremity. Treatment options for deformity correction include monitoring of the deformity, (hemi-)epiphysiodesis, physeal bar resection, and correction osteotomy. Treatment is dependent on the extent and location of the deformity, physeal involvement, presence of a physeal bar, patient age, and predicted length inequality at skeletal maturity. An accurate estimation of the projected limb or bone length inequality is crucial for optimal timing of the intervention. The Paley multiplier method remains the most accurate and simple method for calculating limb growth. While the multiplier method is accurate for calculating growth prior to the growth spurt, measuring peak height velocity (PHV) is superior to chronological age after the onset of the growth spurt. PHV is closely related to skeletal age in children. The Sauvegrain method of skeletal age assessment using elbow radiographs is possibly a simpler and more reliable method than the method by Greulich and Pyle using hand radiographs. PHV-derived multipliers need to be developed for the Sauvegrain method for a more accurate calculation of limb growth during the growth spurt. This paper provides a review of the current literature on the clinical and radiological evaluation of normal upper extremity alignment and aims to provide state-of-the-art directions on deformity evaluation, treatment options, and optimal timing of these options during growth