Pebam Sudesh

Pediatric Femoral Neck Fractures: Our 10 Years of Experience

Background Femoral neck fractures are rare injuries in children, but the high incidence of long term complications make it an important clinical entity. The aim of this retrospective study was to analyze the clinical outcomes of pediatric femur neck fractures that we managed over a 10 year period. Methods The study included 36 children (20 boys and 16 girls) who sustained femoral neck fractures and completed a minimum follow-up of one year. The children were treated either conservatively, or by open reduction and internal fixation (ORIF), or closed reduction and internal fixation (CRIF). The outcomes were analyzed using Ratliff criteria and a detailed record of complications was kept for all patients. Results The mean age of included patients was 10 years (range, 3 to 16 years) and the average follow-up was 3.2 years (range, 1.1 to 8.5 years). Based on Delbets classification system, there were 0 type I (transepiphyseal), 16 type II, 11 type III, and 9 type IV fractures. There were 8 undisplaced fractures, 4 of which later displaced after being managed initially in a hip spica. A satisfactory outcome was obtained in 27 (75%) children. Avascular necrosis (AVN) was the most common complication. It was seen in 7 of our patients, all of whom had an unsatisfactory outcome. Other complications included three cases each of coxa vara, non-union, and arthritic changes; and one case each of infection, primary screw perforation of head, and premature epiphyseal closure. Complications were lowest in the group treated by ORIF. Only 2 patients managed exclusively by conservative treatment ultimately achieved a satisfactory outcome. Conclusions We believe that internal fixation of pediatric femoral neck fractures is preferred whenever feasible because conservative treatment carries a high risk of failure of reduction. Aggressive operative treatments aimed at anatomical reduction should be the goal and there should be no hesitation in choosing ORIF over CRIF. Outcome of patients is influenced primarily by development of AVN which occurs as an independent entity without much relation to the mode of treatment carried out.

Modified step-cut osteotomy for post-traumatic cubitus varus: Our experience with 14 children

BACKGROUND Lateral closing wedge osteotomy is a commonly described procedure for correcting cosmetically unacceptable post-traumatic cubitus varus deformity in children. However, complications like residual deformity, lateral prominence, loss of fixation and ulnar nerve palsies commonly contribute to poor outcomes with such an osteotomy. PATIENTS AND METHODS Fourteen children (11 boys and three girls) presenting a mal-united extension type supracondylar fracture of the humerus with an average age of 9.07 years (6-14 years) were operated around 3.6 years (1.5-7 years) after the injury using a modified step-cut osteotomy. The average follow-up period was 2.1 years (1-4 years). Objective assessment included measurement of preoperative and postoperative lateral prominence index, carrying angle and range of elbow motion. Results were graded excellent, good or poor as per the Oppenheim criteria. RESULTS There were eight excellent, five good and one poor result. A residual varus of more than 10° was seen in the single patient with poor result. None of the patients showed a prominent lateral humeral condyle or formation of hypertrophic scar. Our results were comparable to the published results of the classical lateral closing wedge osteotomy in terms of elbow motion and correction of deformity. CONCLUSION A modified step-cut osteotomy is a safe and simple procedure which prevents lateral prominence and leads to good or excellent outcomes in most of the patients. The step-cut osteotomy procedure, mentioned here, might be beneficial over the conventional lateral closing wedge osteotomy in certain aspects like the lateral humeral condyle prominence, scar acceptibility and cosmesis. However, the apparent aforementioned advantages of this osteotomy over the conventional lateral closing wedge osteotomy needs to be further evaluated and confirmed on the basis of large, prospective randomised controlled trials.

Comparison of the oswestry disability index and magnetic resonance imaging findings in lumbar canal stenosis: an observational study.

Study Design Cross-sectional study. Purpose The aim of the study was to determine relationship between the degrees of radiologically demonstrated anatomical lumbar canal stenosis using magnetic resonance imaging (MRI) and its correlation with the patients disability level, using the Oswestry Disability Index (ODI). Overview of Literature The relationship between the imaging studies and clinical symptoms has been uncertain in patients suffering from symptomatic lumbar canal stenosis. There is a limited number of studies which correlates the degree of stenosis with simple reproducible scoring methods. Methods Fifty patients were selected from 350 patients who fulfilled the inclusion criteria. The patients answered the national-language translated form of ODI. The ratio of disability was interpreted, and the patients were grouped accordingly. They were subjected to MRI; and the anteroposterior diameters of the lumbar intervertebral disc spaces and the thecal sac cross sectional area were measured. Comparison was performed between the subdivisions of the degree of lumbar canal stenosis, based on the following: anteroposterior diameter (three groups: normal, relative stenosis and absolute stenosis); subdivisions of the degree of central canal stenosis, based on the thecal sac cross-sectional area, measured on axial views (three groups: normal, moderately stenotic and severely stenotic); and the ODI outcome, which was also presented in 20 percentiles. Results No significant correlation was established between the radiologically depicted anatomical lumbar stenosis and the Oswestry Disability scores. Conclusions Magnetic resonance imaging alone should not be considered in isolation when assessing and treating patients diagnosed with lumbar canal stenosis.

Giant osteochondroma of axis in a child with multiple hereditary exostoses: case report and review of literature.

Though osteochondromas are the most common benign bone tumour, their spinal involvement is less frequent. We report a case of osteochondroma in a 5-year-old female child with multiple hereditary exostoses that originated from posterior elements of C2 vertebra, not involving spinal canal and caused restriction of neck movement. It was excised from its base without disturbing the continuity of lamina. Two years later she had normal neck movements without any recurrence. The rarity of this tumour at this location, with such a large size at an early age, makes this article unique.

Regeneration of the Achilles tendon after percutaneous tenotomy in infants: a clinical and MRI study.

We aimed to study the regeneration potential of tendo-achilles after percutaneous tenotomy in 34 clubfeet treated by Ponsetis technique. Clinical and MRI evaluation was done after 6 weeks and 6 months of tenotomy to assess the regeneration of the tendon. At the follow-up, Achilles tendon was palpated like a cord in all the feet. MRI study revealed continuity of the tendon in all cases at the end of 6 weeks and 6 months of the tenotomy. Thus, it could be concluded that tendo-achilles does regenerate following percutaneous tenotomy, used in the correction of clubfoot using Ponsetis technique.

Bilateral pathological dislocation of the hip secondary to tuberculous arthritis following disseminated tuberculosis: a case report and review of the literature.

Pathological dislocation of the hip has been reported as a complication in various hip disorders. Several pathomechanisms including capsular laxity, synovial hypertrophy, and acetabular and proximal femur destruction have been described. We report a case of bilateral pathological dislocation of the hip in a 6-year-old girl secondary to tuberculous arthritis following disseminated tuberculosis, which we managed operatively. At the 18-month follow-up, the child had a clinically stable left hip despite radiological subluxation. Bilateral pathological dislocation of the hip associated with tuberculous arthritis is a rare condition and has never been reported in the literature.

Pseudoaneurysm of the popliteal artery in a child with multiple hereditary exostosis: a rare case report and literature review.

Multiple hereditary exostosis (MHE) is a rare condition that tends to be overlooked because of its benign nature. The formation of pseudoaneurysm is a rare complication in association with osteochondromatosis. An 8-year-child with MHE presented with a mass behind her left thigh. Imaging confirmed pseudoaneurysm of the popliteal artery. The patient was operated for closure of rent in the arterial wall with a polytetrafluroethylene graft and excision of osteochondroma. At 2 years of follow-up, circulation was normal and the patient was symptom free, without any growth disturbance. This case report highlights the rare possibility of pseudoaneurysm with osteochondroma and focuses on thorough evaluation and proper management of these patients.

T-condylar fracture delayed for 10 days in a 5-year-old boy: a case report and review of the literature

T‐condylar fracture is rare in paediatric age group, especially in skeletally immature children less than 9 years old, with very few cases reported in available literature. We present such a case in a 5 year old child that was initially managed as a supracondylar fracture at another centre before referral to us, 10 days after the injury. The child was diagnosed as having a displaced T‐condylar fracture on plain radiograph. Open reduction and internal fixation with K‐wires was performed. At 2 years follow‐up, the child had good range of motion at elbow with 5° of cubitus varus. With this background we discuss the pertinent principles of management of T‐condylar fractures in skeletally immature children.

Congenital mesenchymoma of tibia: case report and review of literature.

Fibrocartilaginous mesenchymoma is a rare bone tumor arising from long bones in children and adolescents. With only 21 cases reported in the literature, it is often not included in the differential diagnosis in patients with a bone tumor. Previously, the youngest case reported was in a 19-month-old boy, and a congenital variant had not been reported. We describe a case of congenital fibrocartilaginous mesenchymoma of the proximal tibia that presented shortly after birth. Biopsy of a suspected malignancy on imaging confirmed the diagnosis. The child was temporarily lost to follow up and presented again with genu varum and limb shortening but surprisingly, the tumor had completely resolved without surgical intervention.

Mirror foot and our surgical experience: A case report and literature review

Preaxial mirror polydactyly of foot is a rare congenital anomaly with even fewer documentations for definitive treatment. To provide a sensate, near normal foot with ability to wear shoes is difficult to achieve in this variant with fibular dimelia and calcaneal duplication, with a delayed presentation at 6 years. Our case obtained satisfactory cosmetic and functional outcome upon excision of accessory calcaneum and the medial three toes along with covering the defect with local full thickness skin flap: a first of its kind mentioned in literature. We report this case because of its rarity and to share our surgical experience and its acceptable outcome.