J. Lechevallier

Les infections ostéoarticulaires à Kingella kingae chez l'enfant. À propos d'une série récente de huit cas

UNLABELLED Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent. METHODS AND RESULTS We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful. DISCUSSION Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection. CONCLUSION This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.

Infections ostéo-articulaires de l’enfant: Étude de deux séries consécutives et évaluation d’un protocole de diagnostic et de traitement

PURPOSE OF THE STUDY The purpose of this study was to evaluate a diagnostic and management protocol for osteoarticular infection in children which was developed at the Rouen University Hospital in 1993. We studied the technical aspects of the protocol allowing improved certain diagnosis and bacteriological documentation as well as the reduction in intravenous treatments and hospital stay. MATERIAL AND METHODS Two successive series were compared. The first constituted from May 1984 to February 1992 was a retrospective series of 106 children with osteoarticular infections. The second series was prospective an included 104 children with osteoarticular infection treated after institution of the protocol (January 1995 to December 1998). All children were treated in the same unit. Files were reviewed at a minimum follow-up of 18 months following the end of treatment. We analyzed: clinical, biological, and radiological data at admission; elements of the bacteriological study and their contribution to identification of the causal agent; duration of intravenous antibiotic therapy; total duration of antibiotic therapy, and hospital stay; complications and sequelae. RESULTS After institution of the protocol, we observed significant progress: certain diagnosis of acute osteomyelitis improved from 67% to 85% after institution of a more comprehensive diagnostic program; bacteriological identification improved from 37.5% to 72.2% for acute osteomyelitis and from 41.6% to 59.5% for septic arthritis, with a growing number of recognized cases of Kingella kingae infections causing acute osteomyelitis (n=2) or septic arthritis (n=4) due to technical progress in sampling and culturing. Mean duration of intravenous antibiotic therapy (15 days versus 9.95 days), mean duration of total antibiotic therapy (47.3 versus 33.8 d) as well as length of hospital stay (17.5 d versus 12.5 d) were significantly improved. The shorter antibiotic therapy did not led to any supplementary morbidity. CONCLUSIONS A systematic bacteriological diagnostic protocol has enabled an improvement in treatment and hospitalization. The protocol has been further updated and simplified in light of these findings and observations of insufficiencies, taking into account recent data in the literature and epidemiological features of osteoarticular infection in children.Resume L’histoire naturelle des infections osteo-articulaires (IOA) de l’enfant a ete considerablement modifiee par les progres de l’antibiotherapie. Meme si depuis 10 ans la prise en charge pluridisciplinaire tend a se simplifier, le traitement ideal des osteomyelites aigues (OMA) et des arthrites septiques (AS) chez l’enfant, en particulier en termes de choix de l’antibiotique, duree et voie d’administration, reste relativement mal defini. Ce travail a pour objectif principal d’evaluer un protocole de prise en charge des IOA de l’enfant, qui avait ete mis en place en 1993 au CHU de Rouen, par la comparaison et l’etude de 2 series d’un total de 210 patients, d’en tirer les enseignements en termes de progres et d’insuffisances afin d’elaborer de nouvelles recommandations. Ainsi, apres la mise en place du protocole, des progres significatifs ont ete realises : la certitude diagnostique est passee pour les OMA de 67,6 % a 85,7 % grâce a une realisation plus systematique du bilan diagnostique ; la documentation bacteriologique est passee de 37,5 % a 72,2 % pour les OMA et de 41,6 % a 59,5 % pour les AS, avec notamment une reconnaissance croissante des IOA a Kingella kingae (4 AS et 2 OMA) grâce aux progres des techniques de prelevement et de culture ; et les durees moyennes de traitement intraveineux (15 jours versus 9,95 jours), les durees moyennes totales de traitement (47,3 J vs 33,8 J) ainsi que les durees moyennes d’hospitalisation (17,5 J vs 12,5 J) ont ete significativement diminuees. A l’issue de ce travail, en fonction des insuffisances relevees, des particularites epidemiologiques relevees et des donnees recentes de la litterature, le protocole a ete reactualise et simplifie.

Maladie des brides amniotiques : étiopathogénie, diagnostic anténatal et prise en charge néonatale

Resume La maladie des brides amniotiques (MBA) est un ensemble de malformations congenitales complexes, interessant principalement les membres, mais aussi la region cranio-faciale et l’axe thoraco-abdominal. 2 theories principales physiopathologiques s’opposent : la rupture precoce de l’amnios (theorie exogene) conduirait a la formation des brides fibreuses, qui seraient elles-memes responsables par strangulation des malformations observees ; la theorie endogene privilegie une origine vasculaire, les brides n’ayant alors aucun role causal. Le pronostic de la maladie depend de la gravite des malformations. Une interruption medicale de grossesse est generalement proposee en presence de severes malformations cranio-faciales et viscerales, alors que les malformations isolees de membres sont accessibles a un traitement chirurgical a la naissance. En cas de bride amniotique associee a une constriction isolee de membre, une resection antenatale de la bride peut etre proposee pour eviter la survenue d’une amputation in utero. Cependant, l’etiologie exacte de la maladie etant inconnue et son evolution naturelle imprevisible, le traitement antenatal reste aujourd’hui controverse. L’etude du flux vasculaire par Doppler au sein du membre etrangle pourrait etre un interessant parametre predictif d’une amputation in utero, et ainsi aider a preciser les indications de la chirurgie antenatale dans la MBA.

Rib displacement threatening the spinal cord in a scoliotic child with neurofibromatosis

About 30% of children with neurofibromatosis are affected by scoliosis usually due to bony dysplasia and/or neurogenic tumors. We report the case of a scoliotic girl with type 1 neurofibromatosis presenting with a costovertebral dislocation at the apex of the spinal curvature.

Surgery for slipped capital femoral epiphysis in adolescents

The treatment of slipped capital femoral epiphysis (SCFE) in adolescents remains controversial. The goal of initial treatment is to prevent further slippage of the epiphysis. In mild forms, both stable and unstable, in situ fixation is widely accepted as the reference treatment. In contrast, several techniques are available for stable moderate-to-severe SCFE. In unstable moderate-to-severe SCFE, emergent reduction with decompression and internal fixation is currently the preferred method. Selection of the surgical technique rests on an appraisal of advantages versus drawbacks. The goal of this review is to discuss the various surgical methods available for SCFE in adolescents.

Prévisibilité des résultats de l'épreuve classante nationale 2004

OBJECTIVE To assess the individual predictability of success for undergraduate medical students taking the French national-ranking examination (examen classant national [NRE]) in June 2004. METHODS In total, 86 students in Rouen were classified according to RNE scores. We used the Spearman rank test [rs] to correlate to the RNE score each students previous test results during the medical curriculum: written exams (first two years of medical classes), clinical skill tests (third- and fourth-year) and the clinical and therapeutic synthesis certificate (CSCT), and the northwest region official RNE practice test. Each students ECN rank was then predicted by a regression formula. RESULTS Written exam (r5 = 0.35), third- and fourth-year clinical skill (r(s) = 0.62), CSCT (r(s) = 0.49) and regional practice test (r(s) = 0.56) scores were strongly and significantly associated with the RNE classification. Of the 59 students who took all tests, 12 students (20.3%) diverged from the regression model: three students obtained a national classification substantially better than expected, nine ranked substantially lower than expected. CONCLUSION Test results during the undergraduate medical curriculum in a cohort of undergraduate medical students were strongly predictive of the RNE results. An identifiable group of students with unstable results could benefit from targeted teaching and individual support. The effect of knowledge of their individual position before the RNE remains to be assessed.Resume Objectif Etudier la previsibilite de la reussite individuelle des etudiants a l’epreuve classante nationale (ECN) en juin 2004. Methodes La totalite des resultats aux examens de la cohorte des 86 etudiants rouennais classes lors de l’ECN a ete relevee. Pour chaque etudiant, les examens ont ete regroupes par cycle d’etude : epreuves redactionnelles (1er cycle), dossiers cliniques (2e cycle), dossiers du certificat de synthese clinique et therapeutique (CSCT) et examen blanc de preparation a l’ECN de l’inter-region Nord Ouest (G4). Les rangs aux differents examens ont ete correles aux classement obtenus a l’ECN (coefficient de correlation de Spearman [rs]). Une esperance individuelle de rang a ete calculee a partir de l’equation de la droite de regression. Resultats Les rangs obtenus aux epreuves redactionnelles (rs = 0,35), aux dossiers cliniques (rs = 0,62), aux dossiers du CSCT (rs = 0,49) et a l’examen du G4 (rs = 0,56) etaient fortement et de facon significative associes aux rangs obtenus a l’ECN. Parmi les 59 etudiants presents a toutes les epreuves, 12 (20,3%) ont diverge du modele : 3 ont obtenu un rang national meilleur que leur esperance calculee d’apres leurs resultats locaux, 9 ont ete plus mal classes qu’espere. Conclusion A l’echelle d’une promotion d’etudiants, les agregats de notes obtenues au cours du cursus sont fortement correles entre eux et sont tres predictifs du resultat a l’ECN. Il semble toutefois exister une population identifiable d’etudiants aux resultats instables, pouvant justifier d’efforts pedagogiques cibles, voire personnalises. L’impact sur la preparation des etudiants de la connaissance de leur propre position reste a evaluer.

Posterior arch bifocal fracture of the atlas vertebra: a variant of Jefferson fracture.

Fracture of the atlas vertebra is rare in children. We report two paediatric cases of bifocal pedicular fracture of the posterior arch of C1. Evaluation was performed by nonenhanced computed tomography scan, which successively confirmed both diagnosis and healing. In both cases, nonoperative management was successful.

Legg-Calvé-Perthes Disease

Current knowledge of the causes and risk factors of Legg-Calvé-Perthesdisease (LCPD) does not allow effective preventive strategies. The outcome in adulthood is usually good. Hip osteoarthritis rarely develops before 50 years of age. The risk of osteoarthrosis depends chiefly on the final degree of joint incongruence. Age at onset and the lateral pillar classification are the two main outcome predictors and serve to guide the surgical indications based on the studies by Herrings group. Non-operative treatment is not effective. In contrast, femoral varus osteotomy and Salters innominate osteotomy provide good outcomes. In severe forms, however, combining these two techniques or performing a triple pelvic osteotomy seem preferable. Surgery is now performed considerably less often than in the past, as it is effective only in patients with lateral pillar group B or B/C disease with onset after eight years of age. In other situations, therapeutic abstention is recommended.

Embolie gazeuse iatrogène due à l’utilisation peropératoire d’eau oxygénée : un accident facilement évitable ?: À propos d’un cas

Air embolism is a rare complication of intraoperative use of hydrogen peroxide. We present the case of a young girl who underwent surgery for septic nonunion of the femur and developed this complication postoperatively. Outcome was fortunately favorable. A review of the surgery and anesthesia literature revealed the pathogenic mechanism of this type of accident together with the appropriate diagnostic and therapeutic practices. We propose here a series of preventive measures based on our experience and data in the literature: inform the anesthetist before using hydrogen peroxide, use a cup instead of a syringe for administrating hydrogen peroxide and avoid use in deep highly vascularized cavities.

Patología adquirida del esqueleto del niño

El proposito de este articulo es trazar las grandes lineas del diagnostico, de la clasificacion y de los principios terapeuticos de las patologias ortopedicas adquiridas del nino. Por definicion, se excluyen todas las patologias congenitas o las malformaciones (luxacion de cadera, deformaciones congenitas del pie, etc.). En cambio, se consideran las patologias congenitas o las malformaciones cuyo diagnostico puede establecerse de forma secundaria durante el desarrollo, en el marco de la evaluacion etiologica de una anomalia aparentemente adquirida (escoliosis, desigualdad de longitud de los miembros inferiores, etc.). Ademas, la clasificacion de los epigrafes se ha de basar, en la medida de lo posible, mas en las circunstancias de aparicion de las patologias (signos) que en dichas patologias. Asi se veran, de forma sucesiva, el diagnostico de las cojeras y otros trastornos de la marcha, los dolores de la rodilla, las deformaciones adquiridas del pie, las infecciones osteoarticulares y, por ultimo, las deformaciones de la columna vertebral y del torax.