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   Table of Contents - Current issue
September-October 2018
Volume 52 | Issue 5
Page Nos. 447-574

Online since Tuesday, September 4, 2018

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Let's give our best to the children: The pediatric trauma symposium Highly accessed article p. 447
Anil Agarwal
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Epidemiology of pediatric musculoskeletal injuries and their pattern in a tertiary care center of North India p. 449
Omeshwar Singh, Sanjeev Gupta, Mohammad Azhar Ud Din Darokhan, Shakeel Ahmad, Sumeet Singh Charak, Anuradha Sen
Background: Trauma is emerging as an epidemic and a leading cause of morbidity and mortality in children. Children <15 years of age comprise about 32.8% or about 1/3rd of the total Indian population. In India, up to one fourth of hospital admissions and approximately 15% of deaths in children are due to injury. This study presents the epidemiology, various causes and pattern of musculoskeletal injuries in pediatric population of North India. Materials and Methods: This is an observational, prospective hospital-based study conducted in a tertiary care center of North India for 6 months from July to December 2016. All pediatric patients in the age group 0-15 years who presented to the orthopedic emergency and out patient department with a history of trauma were included in the study. Results: Children aged 6-15 years (58%) suffered more injuries than children under 5 years of age (42%). Male pediatric population (58.5%) had more musculoskeletal injuries as compared to female pediatric population of the same age group (41.5%) in both the groups. Urban pediatric population (68.78%) suffered more injuries as compared to rural population of the same age group. Right extremities were more commonly involved in both the age groups. Upper limb injuries (50.59% in 0-5 years age group and 47.42% in 6- 15 years age group) were most common followed by lower limb and pelvic injuries. Very few (2.9% in 0- 5 years age group and 4.8% in 6-15 years age group) patients sustained isolated spinal injuries. Out of the 3712 patients 59.40% of patients had a history of fall, followed by road traffic accident related injuries (32%). The most common injuries were superficial injuries i.e., abrasions and bruises. The second most common injury was cut or open wounds mostly seen on hand, forearm and legs. Conclusion: The high incidence of pediatric trauma on roads and falls indicates the need for more supervision during playing and identification of specific risk factors for these injuries in our setting. Injuries in pediatric age group by and large is a preventable condition. Therefore, injury prevention in children should be a priority.
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Management of orthopaedic injuries in multiply injured child p. 454
Om Lahoti, Anand Arya
Multiply injured child is a unique challenge to the medical communities worldwide. It is a leading cause of preventable mortality and morbidity in children. Common skeletal injuries include closed or open fractures of tibia and femur and pelvic injuries. Initial management focuses on saving life and then saving limb as per pediatric advanced life support and advanced trauma life support. Orthopedic management of open fracture includes splinting the limb, administration of prophylactic antibiotic, and surgical debridement of the wound when safe. However, gross contamination, compartment syndrome, and vascular injuries demand urgent attention.
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Growth plate injuries of the lower extremity: Case examples and lessons learned p. 462
Samir Sabharwal, Sanjeev Sabharwal,
Background: The presence of growth plates at the ends of long bones makes fracture management in children unique in terms of the potential risk of developing angular deformities and growth arrest. Materials wand Methods: We discuss three distinct cases depicting various aspects of physeal injury of the lower extremity in children. Results: The case illustrations chosen represent distinct body regions and different physeal injuries: Salter–Harris II fracture of the distal femur, Salter–Harris VI perichondrial injury of the medial aspect of the knee region, and Salter–Harris III fracture of the distal tibia. The clinical presentation, pertinent history and physical findings, imaging studies, management, and subsequent course are presented. Conclusions: Growth plate injuries of the lower extremity require a high index of suspicion and close monitoring during skeletal growth. Early recognition and proper management of these injuries can minimize long term morbidity. The treatment plan should be individualized after a comprehensive analysis of the injury pattern in each patient. Establishing a long term treatment plan and discussing the prognosis of these injuries with the child's caretakers is imperative.
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Optimizing management of open fractures in children p. 470
Akshat Sharma, Vikas Gupta, Kumar Shashikant
Open fractures in children differ from adults owing to their better healing potential. Management strategies for open fracture in children are changing with improvement in our understanding of soft-tissue reconstruction and fracture fixation. A literature review was performed for articles covering management of open fractures in children. The cornerstones of management include prevention of infection, debridement, and skeletal stabilization with soft-tissue coverage. The injury should be categorized according to the established trauma classification systems. Timely administration of appropriate antibiotics is important for preventing infections. Soft-tissue management includes copious irrigation and debridement of the wound. Fractures can be stabilized by a variety of nonoperative and operative means, taking into consideration the special needs of the growing skeleton and the role of a thick and active periosteum in the healing of fractures. The soft-tissue coverage required depends on the grade of injury.
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Foreign body-related extremity trauma in children: A single-center experience p. 481
Anil Agarwal
The extremity foreign body in a child has propensity of getting missed or mistaken diagnosis. We report our experience of extremity foreign body trauma in order to increase awareness of this disease entity. The retrospective series of 24 retained foreign bodies was based on a 10-year chart review of emergency data (ICD code Z18). Patients with both upper and lower limb affections were included. Patients with ocular, otolaryngeal, tracheobronchial, gastrointestinal, and axial foreign bodies were excluded from the study. Male predominance (M:F = 20:4), young patient age (mean 6.8 years), variable lag period for consultation (range 3 h–8 years), and majority lower limb affection (58%; foot [7; 29%] and knee [5; 20.8%]) were some characteristics of extremity foreign bodies trauma. The foreign bodies reported were metallic needle (7; 29%), rubber band (3; 12.5%), pellets (3; 12.5%), bangle glass (2; 8%), glass pieces (2; 8%) “dhaga,” wooden twig, wooden thorn, ceramic earthen pot pieces, stapler pin, broomstick, and cracker piece in one case each (1; 4%). Postremoval, the wound healing was uneventful in all patients. Foreign body-related extremity trauma in children is a rare event. It has its own set of characteristics and differential diagnosis. Familiarity with the regional practices and customs is must to establish the circumstances/nature of the foreign body injury. The foreign body should preferably be removed in a well-equipped setting.
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Cervical spine evaluation in pediatric trauma: A review and an update of current concepts p. 489
Nirmal Raj Gopinathan, Vibhu Krishnan Viswanathan, Alvin H Crawford
The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords “paediatric cervical spine injuries” or “paediatric cervical spine trauma.” Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%–80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.
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Femoral neck fractures in children: A review p. 501
Thomas Palocaren
Paediatric femoral neck fractures are uncommon injuries and are usually caused by high-energy trauma. Low-energy trauma can result in pathologic neck fractures and stress fractures of the neck, due to repetitive activity. Surgical options can vary based on age, Delbet classification and displacement of the fracture. Treatment for displaced fractures is by closed or open reduction and smooth/cancellous screw fixation. Compression screw and side plate fixation is indicated for basal fractures. Fixation should be supplemented by spica cast immobilization in younger children. The high rate of complications occurs due to the vascular anatomy of the hip and proximal femur. Avascular necrosis, coxa vara, premature physeal closure, and nonunion are the most common and these often result in poor outcome.
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Titanium elastic nailing with temporary external fixator versus bridge plating in comminuted pediatric femoral shaft fractures: A comparative study p. 507
Sukalyan Dey, Kartikey Mishra, Taral Vishanji Nagda, Jaideep Dhamele, Chasanal Rathod, Dipa Dey
Background: High-velocity trauma, associated injuries, risk of iatrogenic devascularization of fragments and need for maintaining alignment upto union make comminuted fracture in pediatric femur a formidable fracture to treat. This comparative study was conducted to evaluate the outcomes of two modes of management in such cases: titanium elastic nailing supplemented with external fixator and submuscular bridge plating (BP). Materials and Methods: Thirty eight children (aged 6–12 years) with comminuted fracture shaft femur who were randomized into two groups underwent systematic evaluation. One group was operated with titanium nailing with temporary external stabilization by fixators (titanium nailing with external [TNE] group) for 4 weeks. The other underwent submuscular BP with locked plates (BP group). Clinical and radiological outcomes, operative time, blood loss, radiation exposure, difficulties in removal and complications were evaluated. Results: Both groups achieved union (10.7 ± 1.9 weeks BP, 11 ± 1.6 weeks TNE), satisfactory knee flexion (138.2 ± 6.4° BP, 136 ± 7.3° TNE), and painless weight bearing (7.3 ± 0.9 weeks vs. 7.3 ± 1.4 weeks) in acceptable alignment. Functional outcomes were excellent in majority of both BP (15 of 19) and nail external fixator groups (15 of 18). Operating time and radiation exposure (69.5 ± 14.5 s vs. 50.9 ± 12.9 s) were more in TNE than in BP (P < 0.01). However, implant removal was more difficult in BP (56.4 ± 12.4 min in BP vs. 30.1 ± 8.8 min TNE). Pin-tract infections (n = 3) and hardware prominence (n = 2) in TNE group and deep infections (n = 2) in BP group were notable complications. Conclusion: Two groups were similar in radiological and functional outcomes. Inserting elastic nails and external fixator was a more exacting surgery, while removal was more difficult in BP group. Both techniques had acceptable success and complication rates.
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Intrasubstance anterior cruciate ligament injuries in the pediatric population p. 513
Alexandr Aylyarov, Mikhail Tretiakov, Sarah E Walker, Claude B Scott, Khalid Hesham, Aditya V Maheshwari
Pediatric intrasubstance anterior cruciate ligament (ACL) tears have a significant epidemiologic impact as their numbers continue to grow globally. This review focuses on true pediatric intrasubstance ACL tears, which occur >400,000 times annually. Modifiable and non-modifiable risk factors include intercondylar notch width, ACL size, gender, landing mechanisms, and hormonal variations. The proposed mechanisms of injury include anterior tibial shear and dynamic valgus collapse. ACL tears can be associated with soft tissue and chondral defects. History and physical examination are the most important parts of evaluation, including the Lachman test, which is considered the most accurate physical examination maneuver. Imaging studies should begin with AP and lateral radiographs, but magnetic resonance imaging is very useful in confirming the diagnosis and preoperative planning. ACL injury prevention programs targeting high risk populations have been proven to reduce the risk of injury, but lack uniformity across programs. Pediatric ACL injuries were conventionally treated nonoperatively, but recent data suggest that early operative intervention produces best long term outcomes pertaining to knee stability, meniscal tear risk, and return to previous level of play. Current techniques in ACL reconstruction, including more vertically oriented tunnels and physeal sparing techniques, have been described to reduce the risk of physeal arrest and limb angulation or deformity. Data consistently show that autograft is superior to allograft regarding failure rate. Mean durations of postoperative therapy and return to sport were 7 ± 3 and 10 ± 3 months, respectively. These patients have good functional outcomes compared to the general population yet are at increased risk of additional ACL injury. Attempts at primary ACL repair using biological scaffolds are under investigation.
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Pediatric tibial shaft fractures p. 522
Nirav K Patel, Joanna Horstman, Victoria Kuester, Senthil Sambandam, Varatharaj Mounasamy
Tibial shaft fractures are one of the most common pediatric fractures. They require appropriate diagnosis and treatment to minimize complications and optimize outcomes. Diagnosis is clinical and radiological, which can be difficult in a young child or with minimal clinical findings. In addition to acute fracture, Toddler's and stress fractures are important entities. Child abuse must always be considered in a nonambulatory child presenting with an inconsistent history or suspicious concomitant injuries. Treatment is predominantly nonoperative with closed reduction and casting, requiring close clinical and radiological followup until union. Although there is potential for remodeling, this may not be adequate with more significant deformities, thus requiring remanipulation or rarely, operative intervention. This includes flexible intramedullary nailing, Kirschner wire fixation, external fixation, locked intramedullary nailing, and plating. Complications are uncommon but include deformity, growth arrest, nonunion, and compartment syndrome.
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Single bone fixation versus both bone fixation for pediatric unstable forearm fractures: A systematic review and metaanalysis p. 529
Bicheng Yong, Zhe Yuan, Jingchun Li, Yiqiang Li, Edward P Southern, Federico Canavese, Hongwen Xu
Background: It is uncertain whether single bone fixation is comparable to both bone fixation in the treatment of unstable both bone forearm fractures in children. Materials and Methods: A systematic review using PubMed, Embase, and Cochrane Library database searches was performed on October 1, 2015 on English language scientific literature only. Clinical study designs comparing single bone fixation with both bone fixation of pediatric both bone forearm fractures were included. Studies of only one treatment modality were excluded from the study. Studies eligible for inclusion were assessed using the risk of bias tool for nonrandomized studies. Results: Metaanalysis points to no significant differences in re-angulation, loss of rotation, union time and complications between single bone and both bone fixation. However, the published research lacks quality. Conclusions: Despite scattered evidence and small sample sizes, the metaanalysis suggests single bone fixation can be considered a suitable alternative for both bone forearm fractures in children, as it carries less time in surgery and less cost without compromise in final functional outcome compared to double-bone fixation.
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Factors responsible for redisplacement of pediatric forearm fractures treated by closed reduction and cast: Role of casting indices and three point index p. 536
Rajesh Arora, Puneet Mishra, Aditya Nath Aggarwal, Rahul Anshuman, Ravi Sreenivasan
Background: Pediatric forearm fractures are still considered an enigma in view of their propensity to redisplace in cast. The redisplacement may be a potential cause for malalignment. We prospectively analyzed the role of risk factors and above casting indices in predicting significant redisplacement of pediatric forearm fractures treated by closed reduction and cast. Materials and Methods: 113 patients of age range 2–13 years with displaced forearm fractures, treated by closed reduction and cast were included in this prospective study. Prereduction and postreduction angulation, translation, and shortening were noted. In addition, for distal metaphyseal fractures, obliquity angle was noted. In postreduction X-ray, apart from fracture variables, casting indices were also noted (cast index [CI] for all patients with three-point index [TPI] and second metacarpal radius angle in addition for distal metaphyseal fractures). In 2nd week, X-rays were again obtained to check for significant redisplacement. These patients were managed with remanipulation and casting or were operated if remanipulation failed. Comparison of various risk factors was made between patients with significant redisplacement and those which were acceptably reduced. A subgroup analysis of patients with distal metaphyseal fractures was done. Results: Thirteen (11.5%) patients had significant redisplacement; all of them required remanipulation. No association with respect to age, sex, level of fracture, side of injury, surgeon's experience, number of bones fractured, and injury to definitive cast interval was seen. The presence of complete displacement in any of the plane in either of the bones was seen to be highly significant predictor of redisplacement (P < 0.001). Postreduction angulation more than 10° in any plane in either of the bone and fracture obliquity angle in distal metaphyseal fracture also had a highly significant association with redisplacement. There was a significant difference in the mean values of all three casting indices assessed. TPI was the most sensitive casting index (87.5%). Conclusions: Conservative management with aim of anatomical reduction, especially in patients with complete displacement, should be the approach of choice in closed pediatric forearm fractures. Casting indices are good markers of quality of cast.
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Exposed versus buried kirschner wires used in displaced pediatric fractures of lateral condyle of humerus p. 548
Avijeet Prasad, Puneet Mishra, Aditya N Aggarwal, Manish Chadha, Rohit Pandey, Rahul Anshuman
Background: Comparision of results and complications of exposed versus buried Kirschner wires (K-wires) after open reduction of lateral condyle fractures is scarce and mainly from western population; hence, we envisaged to study the safety and efficacy of exposed and buried K-wires used for fixation of displaced pediatric fracture of the lateral condyle of humerus in Indian setup. Materials and Methods: A prospective, nonrandomized, comparative study was conducted in 50 patients with age <12 years, presenting with displaced fracture of lateral condyle of humerus of <2 weeks duration, without associated ipsilateral upper limb injury, who were treated by open reduction and internal fixation with either exposed or buried K-wires (n = 25 in each group). At a minimum followup of 3 months, status of fracture reduction, union, evidence of osteomyelitis, carrying angle at the elbow, and elbow range of motion (ROM) were assessed clinicoradiologically. Results: Four (16%) patients in exposed group and 1 (4%) in buried group had superficial infection, while 3 (12%) patients in exposed group and 2 (8%) in buried group had deep infection. All the patients with infection responded well to oral antibiotics and regular dressings. Buried group had higher incidence of secondary skin and wire-related complications. Conclusion: There was no statistical difference between the two groups but exposed K wires are easy to remove so are preferred over buried K wires.
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Outcome analysis of lateral pinning for displaced supracondylar fractures in children using three kirschner wires in parallel and divergent configuration p. 554
Nirmal Raj Gopinathan, Mohammad Sajid, Pebam Sudesh, Prateek Behera
Background: Supracondylar humerus fracture is the most common fracture around elbow in children. Closed reduction and percutaneous Kirschner wire (pin) fixation is the standard method of managing displaced extension type (Gartland Type II and Type III) supracondylar humerus fractures. The configuration of wires is debatable. Although two crossed K-wires are mechanically stable, there is an inherent risk of ulnar nerve injury. Lateral K-wires – parallel or divergent – are good alternative. This study was aimed at identifying the best configuration for the lateral wires. Materials and Methods: Patients with Gartland type 3 supracondylar humerus fractures were randomized by envelope method to receive closed reduction and K-wire fixation in either a parallel or divergent fashion. The patients were followed up at 3 weeks for wire removal and at 6 weeks and 3 months after surgery. Baumann's angle, functional outcome as per Flynn's criteria, and range of motion were recorded in each visit. Effect of delay in surgery was also evaluated as a secondary outcome. Results: Nineteen patients received fixation with parallel wires and 11 patients had divergent fixation. No loss of reduction was seen in any patient at 3 months. No statistically significant difference was seen in the Baumann's angles and outcome according to Flynn's criteria irrespective of the wire configuration (divergent or parallel). Furthermore, the delay in surgery was also found not to have a significant effect on the functional outcome. Conclusions: Both parallel and divergent K-wire configurations provide satisfactory stability when accurate reduction and adequate fixation of the fracture has been done. Based on the limited number of patients in this study, one configuration cannot be judged to be superior to the other.
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Clinical and radiographic outcomes of pediatric radial head fractures p. 561
Seung Min Ryu, Doo Hyung Yoon, Sam-Guk Park
Background: The treatment of pediatric radial head fracture (RHF) is controversial, and the outcome is unpredictable. We aimed to evaluate the long term clinical and radiographic outcomes of patients with pediatric RHF. Materials and Methods: 24 patients with pediatric RHFs operated between January 2004 and 2012 were included in this retrospective study. 17 patients had extra articular radial head (EARH) fractures and 7 had intraarticular radial head (IARH) fractures. The Mayo Elbow Performance Score (MEPS), Tibone and Stoltz classification, range of motion (ROM), and carrying angle (CA) were evaluated. The radial head diameter (RHD) and radial head height (RHH), neck shaft angle (NSA), and distance from the radial head to the radial tuberosity (RHRT) were measured and compared with the other side in simple anteroposterior views of elbow radiographs. Results: At the last followup, the mean MEPS was 100 and 97.9 in groups EARH and IARH, respectively. There were no clinically and radiographically significant differences between the groups. The injured elbows showed smaller ROMs than the uninjured elbows in flexion, supination, and pronation with statistically significant differences. However, the injured elbows showed larger extension ranges than the uninjured elbows with a statistical significance (all P = 0.000). CA, RHD, and RHH were higher in the injured elbows than in the uninjured elbows with statistically significant differences (P = 0.006, 0.000, and 0.011) However, NSA and RHRT of both elbows were similar, with no statistically significant difference (P = 0.810 and 0.752). Conclusion: All patients with pediatric RHF were satisfied with the long term clinical results. The injured elbows showed restricted ROMs compared with the uninjured elbows; however, the extension range increased.
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Arthroscopic excision of osteoid osteoma of the femoral neck p. 568
Arun Govindraj Ramaswamy, Vinay Kumaraswamy, Neelanagowda Patil, Veeresh Pattanshetti
Osteoid osteoma (OO) is a benign, solitary bone tumor of the long bones of the lower limbs and accounts for 10% to 12% of all benign bone. However, an OO of the femoral neck is extremely rare and difficult to treat. Arthroscopic excision of OO of the femoral neck has many advantages. We report a 15-year-old patient with OO of the femoral neck which was treated with arthroscopic excision. The clinical and radiographic findings along with the surgical management of the lesion are presented. The pain disappeared immediately after the operation. At the 14 months' followup, the patient was pain free, and there was no evidence of recurrence.
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Minimally invasive spine surgery p. 572
Saumyajit Basu
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Legends of Indian orthopedics: Dr. Verghese Chacko p. 573
Thomas Kishen, Bhavuk Garg
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Corrigendum: Results of crowe Type IV developmental dysplasia of hip treated by subtrochantric osteotomy and total hip arthroplasty p. 574

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