Naum Simanovsky

Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries.

Background: In some pediatric ankle and wrist injuries, the clinical picture is suggestive of a fracture despite negative standard radiographs. Objective: The goal of this prospective study was to determine the effectiveness of high-resolution ultrasound (US) in differentiating radiographically occult fractures from sprains. Methods: During a period of 3 years children aged 2 to 16 years, who sustained an acute ankle and wrist injury suggestive of being a fracture on clinical examination, but with negative radiograph, were referred for high-resolution US. Follow-up radiographs were obtained at 2 to 3 weeks. Results: Fifty-eight children (41 children with ankle injury and 17 children with wrist injury) were examined. In 41 patients, US did not reveal fractures, and in 15, small fractures were detected. All patients with negative US studies had negative follow-up x-rays. In 13 patients with positive US, the follow-up radiographs demonstrated a periosteal reaction. In 2 children (1 in each group) in whom a fracture line identified by US was in the depth of the metaphyseal bone, the follow-up radiogram demonstrated an area of increased bone density. In 2 children, 1 in each group, US diagnosed fractures that were not confirmed by follow-up radiograms. Conclusion: Ultrasound is effective in the detecting radiographically silent fractures of the pediatric ankle and wrist. Ultrasound may be used as an adjunct to radiography in clinically suspicious but radiographically negative ankle and wrist injuries. Level of evidence: 1

Underreduced supracondylar fracture of the humerus in children : Clinical significance at skeletal maturity

Background: Although supracondylar fractures of the humerus in children are common, the literature is sparse regarding acceptable limits of reduction of these fractures in the sagittal plane. Methods: We retrospectively reviewed 223 pediatric cases of supracondylar fractures of the elbow treated in our hospital between the years 1996 and 2000. Results: In 30 patients, we found some degree of underreduction of the extension component of the fracture. Twenty-two of them were followed and evaluated at or close to skeletal maturity. The mean age at the time of fracture was 5.4 years, the mean follow-up was 8.2 years. Radiographic remodeling, range of elbow motion, and awareness of the patients to the functional limitation were evaluated. At final follow-up, 17 (77%) of the patients had radiographic abnormality of the humerocondylar angle (a difference of 5 degrees or more compared with the uninjured side). Eleven patients (50%) had limited elbow flexion, and 7 (31%) were aware of this deficit. Most of the underreductions occurred when reduction was attempted in the emergency department, when the angulation was not appreciated, and when the cast was applied without any reduction attempt. Patients who were left to heal with some degree of extension developed limited end-elbow flexion and were aware of it. Although only 3 patients felt minor subjective functional disability at the last follow-up, 10 patients had unsatisfactory results according to Flynn criteria for motion restriction. Conclusions: The treating surgeon must be aware of this possible outcome and be more demanding in the reduction of the extension component of the fracture. Otherwise, clinically significant limitation in elbow flexion may occur. Although the reduction of moderately displaced fractures may seem simple, it should be performed under general anesthesia and with radiographic control of reduction and pin placement.

The measurements and standardization of humerocondylar angle in children.

Background: Supracondylar fractures of the humerus in children are very common. However, the literature regarding measurements of normal anatomical relationships of the distal humerus in sagittal plane is sparse. Method: We reviewed the radiographs of normal elbow joints in 142 children treated in our hospital over 2 years. No history of previous trauma of distal humerus was found. The children were separated into 3 age groups (<5, 5-10, and 10-15 years old), and measurement of the humerocondylar angle (HCA) in sagittal plane was performed. Results: The mean age of children in group 1 was 3 years 1 month; in group 2, 7 years 8 months; and in group 3, 12 years. There were 99 boys and 43 girls. The mean HCA was 41.6 degrees (range, 30-70 degrees). No statistically significant influence on HCA by age, sex, or side was found. We found a small number of extreme variants in HCA (down to 30 degrees and up to 70 degrees) in children without any history of previous trauma and having a normal range of elbow motion. Conclusions: We found that HCA is close to the well-accepted figure of 40 degrees. Interestingly, this value remains the same in all age groups. That means that the geometry of the distal humerus in sagittal plane is established very early during the growth and remains constant. Due to significant individual variations of HCA, it alone cannot be sufficient for final decisions in evaluation and treatment of supracondylar fractures.

Close reduction and intramedullary flexible titanium nails fixation of femoral shaft fractures in children under 5 years of age.

We retrospectively reviewed 13 cases of diaphyseal femoral fractures treated with close reduction and intramedullary flexible titanium nails, in children aged 3–5 years. The mean follow-up time was 11.5 months (range 3–29). No cases of nonunion or malunion were noted. Minor complications were observed in two children. Loss of initially restored femoral lengthening had occurred in one child, with nail protrusion and related focal cellulites. Mild postoperative leg-length discrepancy occurred in another child. The healed fractures usually exhibited abundant callus, which allowed an early ambulation. Although the operative approach to simple diaphyseal fractures of the femur at such a young age is not routinely recommended, it can be a valuable option as an initial treatment, or when a conventional treatment with a spica cast has failed. In our group of patients, the parents chose this type of treatment as an alternative to the conventional spica cast.

Divergent elbow dislocation in the very young child: easily treated if correctly diagnosed.

We report a case of a 3-year-old boy that sustained a divergent elbow dislocation and was treated appropriately once the diagnosis was established. The purpose of this report is to bring attention to this rare injury.

The outcome of early revision of malaligned pediatric supracondylar humerus fractures

BACKGROUND Supracondylar humerus fractures (SCHF) are the most common elbow fractures requiring surgical treatment in the pediatric age group. Most fractures are reduced and stabilised adequately. Yet, post-surgical malunion may occur. The purpose of this study is to evaluate our results of early revision surgery in 21 surgically treated pediatric SCHF with immediate postoperative loss of alignment and compare them with previous reports of late corrective osteotomies. METHODS Twenty-one pediatric SCHF patients that underwent revision surgery for malalignment within 3 weeks of the initial reduction and fixation consisted the study group. Indications for revision were unacceptable radiographic alignment diagnosed within the first 3 weeks after the index surgery. Clinical outcome included pain, range of motion (ROM) and appearance of the elbow. Radiographic outcome was defined as fracture healing and final alignment, assessed in both coronal and sagittal planes. RESULTS The average time interval between index and revision surgery was 7.6 days (range 3-18). In revision surgery, closed reduction was performed in 17 out of 21 patients, and open reduction was required in four. In one patient, an external fixator was added. In the most recent follow up, all patients but three regained full ROM. The remaining three had a deficit of 10° or less. Two patients had cubitus varus of 10° or less. All patients had a marked radiographic improvement after revision, especially in the sagittal plane increasing the humero-capitaller flexion angle by an average of 20°. DISCUSSION Malunion after reduction and Kirschner wires (KW) fixation of SCHF is an uncommonly reported phenomenon. When malunion is recognised after fracture healing, corrective osteotomies may carry a significant complications rate. We describe our favourable experience with early diagnosis and revision surgery of malaligned SCHF.

Computerized Navigation for Treatment of Slipped Femoral Capital Epiphysis

In situ pinning with a single screw is the treatment of choice for symptomatic slipped capital femoral epiphysis (SCFE). Some technical features are critical and include proper screw entry point, screw direction in relation to the epiphysis, and the length of screw. These are complicated by the deformity created as a result of the posterior slip of the epiphysis. Fluoroscopic based computerized navigation system can increase precision in screw placement while performing the surgical task, and markedly reduce radiation. By using real fluoroscopy-based navigation, the screw can be placed with only two fluoroscopic images. Entry point, length, and precise direction can all be easily determined through this technique.

Partial duplication of the scapula

We report an extremely rare case of partial scapular duplication. Mild shoulder area deformity in a newborn prompted further evaluation that included radiography, ultrasonography and spiral CT. These revealed an additional bone in the area of the left shoulder, above the humerus and lateral to the scapula. The accessory bone articulated with the upper part of the glenoid and caused caudal displacement of the humeral head. However, it did not restrict the normal range of motion in the shoulder joint.