Importance of percutaneous fragment fixation in dislocated supracondylar humerus fractures in children

Uvod: Suprakondilarni prelomi su najčešći prelomi lakta u dečjem uzrastu i spadaju u druge po učestalosti prelome kod dece (16,6%), a po lokalizaciji ovom tipu preloma pripada od 50 do 70% svih preloma lakta kod dece uzrasta do 10 godina. Najčešće nastaju padom na ispruženu ruku. Modaliteti lečenja dislociranih suprakondilarnih preloma humerusa kod dece uglavnom se svode na tri metode: ortopedsku repoziciju sa gipsanom imobilizacijom, ortopedsku repoziciju praćenu perkutanom fiksacijom dislociranih fragmenata (perkutanu fiksaciju) i hiruršku repoziciju sa stabilizacijom Kiršnerovim iglama. Mada još uvek nije postignut konsenzus izmeĎu dečjih ortopeda o izabranom metodu lečenja, perkutana fiksacija je najčešće primenjivana u lečenju dislociranih suprakondilarnih preloma kod dece. Pored toga različiti su stavovi o stepenu hitnosti lečenja suprakondilarnih preloma. Pristalice ranog lečenja (unutar 12 sati od povreĎivanja) ističu bolje rezultate lečenja, manji broj komplikacija lečenja kao i lakše izvoĎenje ortopedske repozicije. Cilj: ovog istraživanja je uporeĎivanje tri najčešće korišćena metoda lečenja suprakondilarnih preloma humerusa kod dece i potvrĎivanje hipoteze o perkutanoj fiksaciji kao metodi izbora u lečenju ovih preloma, kao i da se utvrdi da li su rezultati lečenja bolji kod pacijenata lečenih unutar 12 sati od povreĎivanja (rano lečenje) u odnosu na pacijente lečene posle 12 sati od povreĎivanja (odgoĎeno lečenje), kao i da li odgoĎeno lečenje utiče na povećanje stope konverzija ortopedske u hiruršku repoziciju. Materijal i metode: U retrospektivno-prospektivnoj studiji je analizirano 123 pacijenta sa suprakondilarnim prelomom humerusa tip II i tip III po Wilkinsonovoj modifikaciji Gartlandove klasifikacije koji su lečeni na Univerzitetskoj dečijoj klinici, kroz sedmogodišnji period (od 2006. do 2012. godine). Lečeno je 86 dečaka i 37 devojčica, uzrasta 1,5-11,4 godine (srednja vrednost 6,5 godina). Suprakondilarni prelom tip II dijagnostifikovan je kod 57, a tip III kod 66 pacijenata. Na osnovu ortopedskog metoda lečenja pacijenti su podeljeni u tri grupe: pacijenti lečeni ortopedskom repozicijom sa gipsanom imobilizacijom, perkutanom fiksacijom i hirurškom repozicijom sa stabilizacijom Kiršnerovim iglama. Rezultati: lečenja su procenjivani i uporeĎivani izmeĎu različitih grupa na osnovu Flynnovih kriterijuma, tj. kod pacijenata je procenjivan posebno funkcionalni, a posebno kozmetski rezultat lečenja, zato što kod nekih pacijenata funkcionalni rezultat može biti dobar, a loš kozmetski i obrnuto...Introduction: Supracondylar fractures are the most common elbow fractures in children and the second most common fractures in children, overall (16.6%). Regarding the localization 50 to 70% of all elbow fractures in children, up to 10 years old, are classified as this type of fracture. They most frequently occur as a result of a fall onto an extended hand. Treatment modes of dislocated supracondylar humerus fractures in children usually comprise one of three methods: closed reduction with cast immobilization, closed reduction with percutaneous fixation of dislocated fragments (percutaneous pinning) and open reduction with Kirschner wire stabilization. Although a consensus on the treatment option of choice has not yet been reached among pediatric orthopaedists, percutaneous fixation is the most frequently used method in the treatment of dislocated supracondylar fractures in children. In addition, opinions diverge on the level of urgency of treating supracondylar fractures. Supporters of an early treatment (within 12 hours from injury) emphasize the better treatment results, fewer complications and easier closed reduction. The aim: of this research was to compare the three most commonly used treatment methods for supracondylar humerus fractures in children, to examine the hypothesis on percutaneous fixation as the method of choice in the treatment of these fractures, as well as to determine whether better treatment results are achieved in patients treated within 12 hours from injury (early treatment) compared to those treated after more than 12 hours (delayed treatment) and to investigate whether delayed treatment increases the rate of conversion of closed to open reduction. Materials and methods: A retrospective-prospective study analyzed the treatment results for 123 patients with supracondylar humerus fractures type II and III according to Wilkins's modification of the Gartland classification. The patients were treated at the University Children's Hospital, during a seven-year period (form 2006 to 2012). A total of 86 boys and 37 girls were treated, aged 1.5-11.4 years (mean: 6.5 years). Supracondylar fracture type II was diagnosed in 57 and type III in 66 patients. Based on the orthopaedic treatment method, the patients were classified in three groups: patients treated by closed reduction with cast immobilization, by percutaneous fixation and by open reduction with Kirschner wire stabilization..

Treatment of Congenital Leg Length Discrepancies in Children Using an Ilizarov External Fixator: A Comparative Study

The purpose of this study was to evaluate the infl uence of intramedullary (IM) alignment used in combination with an Ilizarov external fi xation on the healing index (HI) and lengthening index (LI) in the treatment of congenital leg length discrepancies (LLD). This study included 35 patients aged from 3.5 to 19 (average age 10.73) who underwent the egalisation procedure using an Ilizarov external fi xator. We compared the duration of the external fi xator application, LLD, HI and LI between two groups of children: children in Group I underwent limb lengthening by the conventional llizarov technique using an Ilizarov external fi xator alone, and children in Group II underwent a combination of Ilizarov technique and intramedullary alignment with two Kirschner wires, introduced through two mini-incisions. We found signifi cant differences between the two groups of patients for duration of external fi xator application and HI. Patients with congenital LLD treated with combined method of treatment had benefi t from intramedullary alignment due to its better outcome

Pseudoachondroplasia: A case report

Introduction. Pseudoachondroplasia (PSACH) is an autosomal dominant osteochondrodysplasia due to mutations in the gene encoding cartilage oligomeric matrix protein. It is characterized by rhizomelic dwarfism, limb and vertebral deformity, joint laxity and early onset osteoarthrosis. We present the girl with the early expressed and severe PSACH born to clinically and radiographically unaffected parents. Case Outline. A 6.5-year-old girl presented with short-limbed dwarfism (body height 79.5 cm, <P5; -32%) and normal craniofacial appearance and intelligence. The girl was normal until 3 months of age when she expressed growth retardation with apparently shorter extremities in relation to the torso. With age, her rhizomelic dwarfism became increasingly visible, and since completed 15 months of age, when she started to walk, the disease was complicated with genu varum, lumbar lordosis and abnormal gait. Beside visibly short forearms, short, broad and ulnar deviation of the hands, brachydactyly and joint hyperlaxity, the radiographic picture showed markedly flared metaphyses, small and irregular epiphyses and poorly formed acetabulum. Conclusion. PSACH is an achondroplasia-like rhizomelic dwarfism recognized by the absence of abnormality at birth, normal craniofacial appearance, characteristic epiphyseal and metaphyseal radiographic finding and joint hyperlaxity

Nedostatak alfa-1 antitripsina kod dece - kliničke odlike i dijagnostika

Introduction Alpha-1-antitrypsin deficiency (AATD) is a relatively rare and clinically very heterogeneous autosomal recessive disorder. Objective Presentation of clinical characteristics of AATD in the first months after birth, as well as the significance of testing brothers and sisters for its presence. Methods Objectives of the study were analyzed on a sample of eight children (four male and four female, aged 63 months (mean14.81±23.96 months; range 1-63 months) with AATD confirmed based on its low serum value and pathological phenotype. Results Of the total of eight patients, six manifested cholestasis syndrome (three male and three female, mean age 2.25±1.37 months; range 1-4.5 months), while two patients, a 3.5-year-old girl and a 5.25-year-old boy, were without symptoms and clinical-laboratory signs of the disease, disclosed during family testing. Serum alpha-1-antitrypsin level rated 0.30-0.66 g/L (0.37±0.12), among which seven were with ZZ phenotype 0.30-0.39 (0.33±0.04), and in a boy with FZ the phenotype was disclosed on family screening, 0.66 g/L. In the group of patients with cholestasis syndrome (serum GTT 444.80±203.15 U/L; range 201-676 U/L), three had mild to moderate hepatomegaly, one had longitudinal growth delay ( lt P3; -10.50%) and two had icterus with conjugated hyperbilirubinemia (92 and 109 μmol/L) and prolonged prothrombin time (PT 14.8 and 17 sec). All children with cholestasis syndrome also had hypertransaminasemia (ALT 80.83±33 U/L; range 37-124 U/L and AST 116.67±62.82 U/L; range 58-230 U/L). Conclusion Cholestasis syndrome represents a basic manifestation of AATD in the first months after birth, while early testing of brothers and sisters enables early disclosure and adequate treatment of the subclinical forms of the disease.Uvod Nedostatak alfa-1 antitripsina (AATD) je relativno redak i klinički veoma heterogen autozomno recesivni poremećaj. Cilj rada Cilj rada je bio da se prikažu kliničke odlike AATD u prvim mesecima po rođenju, kao i značaj testiranja braće i sestara na ovaj poremećaj. Metode rada Ispitano je osmoro dece (četiri dečaka i četiri devojčice) uzrasta od mesec dana do 63 meseca (prosečno 14,81±23,96 meseci) sa AATD, koji je dokazan na osnovu niske vrednosti alfa- 1 antitripsina u serumu i patološkog fenotipa. Rezultati Kod šestoro dece (tri dečaka i tri devojčice) uzrasta od mesec dana do četiri i po meseca (prosečno 2,25±1,37 meseci) ispoljio se holestazni sindrom, dok su dva deteta (troipogodišnja devojčica i dečak uzrasta od 5,25 godina) bila bez simptoma i kliničko- laboratorijskih znakova AATD, ali je bolest otkrivena u sklopu porodičnog testiranja. Nivo alfa- 1 antitripsina u serumu bio je 0,30-0,66 g/l (prosečno 0,37±0,12 g/l), pri čemu kod sedmoro dece sa ZZ fenotipom 0,30-0,39 g/l (prosečno 0,33±0,04 g/l), a kod dečaka sa FZ fenotipom, otkrivenog porodičnim skriningom, 0,66 g/l. U grupi bolesnika sa holestaznim sindromom (nivo GGT u serumu bio je u proseku 444,80±203,15 IU/l; raspon 201-676 IU/l), kod tri deteta je utvrđena blaga do umerena hepatomegalija, kod jednog deteta je uočen zastoj u longitudinalnom rastu ( lt P3; -10,50%), dok je kod dvoje dece zabeležen ikterus sa konjugovanom hiperbilirubinemijom (92 i 109 μmol/l) i produženim parcijalnim vremenom (14,8 i 17 s). Kod sve dece s holestaznim sindromom utvrđena je i hipertransaminazemija s vrednostima ALT 80,83±33 IU/l (raspon 37-124 IU/l) i AST 116,67±62,82 IU/l (raspon 58-230 IU/l). Zaključak Holestazni sindrom je osnovna manifestacija AATD u prvim mesecima po rođenju deteta, dok testiranje braće i sestara obolelih omogućava rano otkrivanje i odgovarajuće lečenje supkliničkih oblika bolesti

LIJEČENJE JEDNOKOMORNIH KOŠTANIH CISTA KOD DJECE: KOMPARATIVNA STUDIJA

Unicameral bone cysts (UBC) are benign bone tumor-like lesions. Mostly they are located in the metaphyseal-diaphyseal region of long bones in children and adolescents. The etiology of UBC is still unclear. There is no consensus about the protocol of UBC treatment. The aim of this study was to evaluate the effectiveness of three different techniques for the treatment of UBC. This study included 129 pediatric patients with UBC treated at University Children’s Hospital in Belgrade during the 8-year period. The mean follow up was 7.14 years. The following parameters were observed: gender, age, site, length of cyst, cyst index, cortical thickness, presentation of pathologic fracture, healing of cyst, treatment complications and length of hospitalization. These parameters were correlated to three treatment modalities, i.e. intracystic methylprednisolone acetate injection (group 1), curettage with bone grafting (group 2) and osteoinductive procedure using demineralized bone matrix (group 3). We found statistically significant differences in healing of the cysts and length of hospital treatment between groups 1 and 2, and between groups 2 and 3. In conclusion, complete healing of UBC can be achieved only using open surgery procedure. Intracystic methylprednisolone acetate instillation can be considered a good option for initial treatment of UBC.Solitarne koštane ciste (SKC) su dobroćudne koštane lezije slične tumorima. Najčešće su lokalizirane u metafizno-dijafiznoj regiji dugih kostiju djece i adolescenata. Etiologija SKC nije razjašnjena. Ne postoji konsenzus o protokolu liječenja SKC. Cilj studije bio je procijeniti učinkovitost tri različite tehnike liječenja SKC. Studija je obuhvatila 129 bolesnika liječenih u Sveučilišnoj dječjoj bolnici u Beogradu tijekom 8 godina (2007.-2014.). Srednje razdoblje praćenja bilo je 7,14 (2,5-10) godina. Parametri za uključivanje bili su: spol, dob, lokacija ciste, veličina ciste, indeks ciste, debljina korteksa, patološka fraktura, cijeljenje ciste, komplikacije liječenja i trajanje hospitalizacije. Usporedili smo navedene parametre s tri različite tehnike liječenja: apliciranje metilprednisolon acetata (MPA) unutar ciste (skupina 1), kiretaža i umetanje koštanog presatka (skupina 2) i osteoinduktivni postupak upotrebom demineralizirane koštane međustanične tvari (DKM) (skupina 3). Utvrđena je statistički značajna razlika u cijeljenju cista i trajanju hospitalizacije između skupina 1 i 2 te između skupina 2 i 3. U zaključku, potpuno liječenje SKC može se jedino postići otvorenom kirurškom tehnikom i time spriječiti mogući rizik od zaostalih lezija i fraktura. Minimalno invazivna metoda aplikacijom MPA unutar ciste može se smatrati dobrom opcijom za početno liječenje SKC dugih kostiju

The Safety and Efficacy of the Continuous Peripheral Nerve Block in Postoperative Analgesia of Pediatric Patients

Postoperative analgesia is imperative in the youngest patients. Pain, especially if experienced during childhood, has numerous adverse effects—from psychological, through complications of the underlying disease (prolonged treatment, hospital stay, and increased costs of the treatment) to an increase in the incidence of death due to the onset of the systemic inflammatory response. Peripheral blocks provide analgesia for 12–16 h, and are safer due to rare side effects that are easier to treat. The continuous peripheral block (CPNB) has been increasingly used in recent years for complete and prolonged analgesia of pediatric patients, as well as a part of multidisciplinary treatment of complex regional pain syndrome. It has been shown that outpatient CPNB reduces the need for parenteral administration of opioid analgetics. It has also been proved that this technique can be used in pediatric patients in home conditions. Safety of CPNB is based on the increasing use of ultrasound as well as on the introduction of single enantiomers local anesthetics (ropivacaine and levobupivacaine) in lower concentrations. It is possible to discharge patient home with catheter, but it is necessary to provide adequate education for staff, patients, and parents, as well as to have dedicated anesthesiology team. Postoperative period without major pain raises the morale of the child, parents. and medical staff

Isolated dislocation of the pisiform bone in a 10-year-old boy

Introduction. Isolated dislocation of the pisiform bone is a very rare condition due to robust ligamentous attachments that stabilize the pisiform to the carpus. This type of injury is usually a result of direct trauma to the ulnar and volar aspect of the wrist. Case outline. We present an isolated dislocation of the pisiform, with no other carpal bone injuries, treated successfully with closed reduction. Diagnosis was based on clinical findings, plain radiographs, and computer tomography examination of the wrist. Elongation and partial rupture of the pisometacarpal ligament was found on magnetic resonance imaging. Conclusion. Fracture and dislocation of the pisiform is an extremely rare injury in children, which could be easily neglected or misdiagnosed. Closed reduction with plaster cast immobilization should always be considered as the first method of treatment in the pediatric population, since the conservative approach provides excellent results

Incidence of penile curvature in various forms of hypospadias

Introduction. Hypospadias is a congenital anomaly of the penis, characterised by ectopically positioned urethral meatus and associated anomalies (cryptorchidism, inguinal hernia, penile curvature). Proximal forms of hypospadias, as severe cases, are particularly accompanied by penile curvature (chordee). Distal types are considered to be mild degrees. Objective. To determine the incidence of congenital curvature within various forms of hypospadias in order to signify preoperative and intraoperative diagnosis of chordee as a part of hypospadias repair. Methods. The total of 454 patients with hypospadias were treated surgically in a five-year period (2001-2006.) at the University Children's Hospital of Belgrade. The patients were divided into two groups according to the surgeon who had treated them. Only the first group of patients was tested for chordee as a part of standard procedure and complete treatment. In both groups we analyzed the number of patients treated for penile curvature within various types of hypospadias. We also compared scores in the two groups using Fisher test and χ2-test. Results. Scanning retrospective, 104 cases (22.9%) of diagnosed and surgically corrected chordee were determined. In 31.6% of patients from the first group and 11.6% of patients from the second group we diagnosed and corrected some form of penile curvature was. Chordee was significantly more frequent in the first group, regarding hypospadias in general (p&lt;0.01), as well as distal (p&lt;0.05) and mid shaft forms (p&lt;0.01). Conclusion. Penile curvature is not uncommon in hypospadias. In this study we report a significantly higher frequency as related to the patients in the second group who were not tested for curvature during hypospadias treatment. This is why standard techniques in hypospadias repair should definitely include the diagnosis and surgical correction of penile curvature

Displaced supracondylar humeral fractures in children: Comparison of three treatment approaches

Introduction. Closed reduction and percutaneous pinning are the most widely used treatment options for displaced supracondylar humerus fractures in children, but there is still no consensus concerning the most preferred technique in injuries of the extension type. Objective. The aim of this study was to compare three common orthopaedic procedures in the treatment of displaced extension type supracondylar humerus fractures in children. Methods. Total of 93 consecutive patients (66 boys and 27 girls) referred to our hospital with Gartland type II or III extension supracondylar humeral fractures were prospectively included in the study over a six-year period. At initial presentation 48 patients were classified as Gartland type II and 45 as Gartland type III fractures. The patients were subdivided into three groups based on the following treatment modality: closed reduction with percutaneous pinning, open reduction with Kirschner wires (K-wires) fixation, and closed reduction with cast immobilisation. The treatment outcome and clinical characteristics were compared among groups, as well as evaluated using Flynn’s criteria. Results. Excellent clinical outcome was reported in 70.3% of patients treated with closed reduction with percutaneous pinning and in 64.7% of patients treated with open reduction with K-wire fixation. The outcome was significantly worse in children treated with closed reduction and cast immobilisation alone, as excellent outcome is achieved in just 36.4% of cases (p=0.011). Conclusion. Closed reduction with percutaneous pinning is the method of choice in the treatment of displaced pediatric supracondylar humeral fracture, while open reduction with K-wire fixation is as a good alternative in cases with clear indications. [Projekat Ministarstva nauke Republike Srbije, br. 175095

Comparison of Negative Pressure Wound Therapy (NPWT) and Classical Wet to Moist Dressing (WtM) in the Treatment of Complicated Extremity Wounds in Children

Treating complicated wounds in the pediatric population using traditional wet to moist wound dressing methods is not always appropriate due to the frequent need to change dressings daily or even a number of times a day, causing distress to the patient. Topical negative pressure is a method that allows for fewer dressings and provides localized benefits, thus accelerating wound healing. The merits of this therapy have been proven in studies on adults, but research on the pediatric population is scarce. Here we intend to present the results of negative pressure wound therapy (NPWT) on 34 pediatric patients (study group) and compare them with 24 patients (control group) treated with the traditional wet to moist dressing for complicated wounds. The results show that topical negative pressure wound therapy is a safe method that downgrades a wound from a complicated to a simple one and allows definitive coverage using a simpler technique with fewer wound dressings. The scars of the patients in the study group exhibited a better result on a visual scar scale. The patients in the control group had a shorter hospital stay. Based on the recorded results, we were able to make treatment recommendations