Fractures In Children Research Articles

Paediatric Hand Fractures - A Review.

Paediatric hand fractures account for approximately 25% of hand-related emergency department visits, making them the second most common childhood fractures after distal forearm fractures. These injuries are more prevalent in boys and peak ages between 9 and 14 years. Hand fractures in children are primarily caused by crushing injuries and, increasingly in older children, by sports-related activities. The little finger (52%) and thumb (23%) are the most frequently fractured digits, with phalangeal fractures, especially of the proximal phalanx, being common. Metacarpal fractures are more prevalent in adolescents (13-16 years) compared to younger children. Accurate diagnosis in the paediatric population is complicated by difficult clinical examinations and the presence of growth plates, leading to an 8% misdiagnosis rate, mainly due to misinterpretation of the ossification centres and physes. High-quality radiographic evaluation combined with a thorough clinical assessment is critical for correct diagnosis and appropriate management. The robust periosteum and high remodelling potential of paediatric bones allow most hand fractures to be managed non-operatively with splinting or casting. However, fractures with significant angulation, rotation, intra-articular involvement or open wounds may require surgical intervention, such as closed or open reduction and internal fixation with Kirschner wires. Most paediatric hand fractures heal well with excellent functional outcomes due to the high remodelling capacity of paediatric bones. Early mobilisation and appropriate immobilisation are key to preventing stiffness. Despite the generally favourable prognosis, certain fractures remain challenging to diagnose and treat, highlighting the need for specialised care. The aim of this review article is to discuss the epidemiology, fracture patterns, diagnostic challenges and management strategies essential for optimising functional outcomes and minimising long-term complications in treating paediatric hand fractures. Level of Evidence: Level V (Therapeutic).

Comparative study between K-Wires and Cannulated Screws in Fixation of Lateral Condyle Fracture in Children

Comparative study between K-Wires and Cannulated Screws in Fixation of Lateral Condyle Fracture in Children

Comparative Analysis of the Results of Treatment for Metacarpal Neck Fractures in Children with Antegrade and Retrograde Kirschner Wire Fixation

Introduction. Among hand injuries, the proportion of metacarpal fractures is 9.6–40.0 %. Currently, there is no single approach to the treatment of children with such injuries.The aim is to determine the optimal method of surgical treatment of metacarpal fractures in children by comparative analysis of the results of antegrade and retrograde osteosynthesis with Kirchner spokes.Materials and methods. A prospective cohort study included 186 children with closed head fractures of the II–V metacarpal bones. The main group consisted of 103 children (55.38 %) who underwent antegrade osteosynthesis; the control group consisted of 83 children (44.62 %) who had needles retrograde. Local inflammatory changes were assessed on the 3rd and 7th days after surgery. The volume of active movements in the metacarpophalangeal joints was measured after 3, 6 and 12 weeks.Results. At week 3 of follow-up, the median amplitude of movements in the metacarpophalangeal joints in patients of the main group was 18 [13; 26] degrees, in the control group — 7 [4; 9] (p < 0.001); at week 6–59 [49; 72] and 35 [32; 54] (p < 0.001) At week 12–89 [84; 90] and 82 [74; 86], respectively (p < 0.001). Macroscopic assessment of the needle insertion area on the 3rd day after surgery showed the absence of local inflammatory changes in 92 (89.3 %) and 73 patients (88.0 %) of the main and control groups (p = 0.953); on day 7, in 100 (97.1 %) and 76 (92.5 %), respectively (p = 0.497), however, the differences were not statistically significant.Discussion. The optimal way to treat metacarpal fractures in children should be technically simple and low-traumatic. The importance of early rehabilitation for restoring the volume of movement in the joints of the hand is confirmed by many studies.Conclusion. Due to the minimization of damage to the articular surfaces and the early start of rehabilitation, the best functional results were achieved in the antegrade osteosynthesis group.

Melatonin receptor 1A variants as genetic cause of idiopathic osteoporosis.

Idiopathic osteoporosis (IOP) is a rare form of early-onset osteoporosis diagnosed in patients with no known metabolic or hormonal cause of bone loss and unknown pathogenesis. Patients with IOP commonly report both childhood fractures and family history of osteoporosis, raising the possibility of genetic etiologies of IOP. Whole-exome sequencing analyses of different IOP cohorts identified multiple variants in melatonin receptor 1A (MTNR1A) with a potential pathogenic outcome. A rare MTNR1A variant (rs374152717) was found in members of an Ashkenazi Jewish family with IOP, and an MTNR1A variant (rs28383653) was found in a nonrelated female IOP cohort (4%). Both variants occur at a substantially higher frequency in Ashkenazi Jewish individuals than in the general population. We investigated consequences of the heterozygous (rs374152717) variant [MTNR1Ac.184+1G>T (MTNR1Ac.184+1G>T)] on bone physiology. A mouse model of the human rs374152717 variant reproduced the low bone mass (BM) phenotype of young-adult patients with IOP. Low BM occurred because of induction of senescence in mutant osteoblasts followed by compromised differentiation and function. In human cells, introduction of rs374152717 led to translation of a nonfunctional protein and subsequent dysregulation of melatonin signaling. These studies provide evidence that MTNR1A mutations entail a genetic etiology of IOP and establish the rs374152717 variant as a loss-of-function allele that impairs bone turnover by inducing senescence in osteoblasts. The higher prevalence of the MTNR1A variants identified in IOP cohorts versus the general population indicates a greater risk of IOP in those carrying these variants, especially Ashkenazi Jewish individuals bearing the rs374152717 variant.

6874 A Rare Case Of Hereditary 1,25 (OH)2D Resistant Rickets

Abstract Disclosure: G. Umarji: None. F. Thelmo: None. S.A. Jabbour: None. Vitamin D-dependent rickets type 2A (VDDR2A) also known as hereditary 1,25 (OH)2D resistant rickets is due to biallelic loss-of-function mutations in the gene encoding vitamin D receptor on chromosome 12q13.11, thus, it represents a true form of tissue resistance to vitamin D. It is a scarce form of rickets with approximately only 120 cases reported. A 37-year-old male was referred to endocrinology by neurosurgery for evaluation of metabolic bone disease. Seven years ago, he was in a car accident which resulted in a lumbar spine injury causing radiculopathy and severe low back pain leading to lumbar spine decompression/fusion. However, he suffered from nonunion of bones and had to undergo another surgery a year later with recurrent postoperative nonunion of bones. During the operation, the surgeon noticed that his spine seemed demineralized. He had a history of multiple minor fractures in childhood, decreased hearing in left ear for two years, fragile teeth for many years, and some hair loss since age 30. Physical exam showed a height of 1.82 m, weight 89.3 kg with body mass index of 26 kg/m2, broken teeth, no leg bowing and normal stance. Laboratory results showed normal renal function, thyroid function tests and testosterone level, corrected calcium 8.3 mg/dL (8.7-10.2), 25-OH-vitamin D 54 ng/mL (30-100), phosphorus 2.8 mg/dL (2.8-4.1), intact parathyroid hormone 65 pg/mL (15-65), bone-specific alkaline phosphatase 21 mcg/L (4-27), 24-hour urine calcium 156 mg/day (100-300), 24-hour urine phosphorus 1,752 mg/day (390-1,425), FGF-23: 93 RU/mL (44-215) and 1,25 (OH)2D 92 pg/mL (24-81.5). Dual absorptiometry of the lumbar spine and hip showed osteopenia with Z scores of -2.2 and -1.2 respectively. Genetic testing for metabolic bone disease panel showed heterozygous mutation in VDR gene at nucleotide position c.146+9dup associated with autosomal recessive VDDR2A. We present a very rare form of vitamin D resistant rickets. As many patients with VDDR2A are unable to respond to any form of vitamin D, it is suggested that VDDR2 be more appropriately described as hereditary 1,25 (OH)2D resistant rickets (HVDRR), hereditary resistance to 1,25 (OH)2D, or even pseudovitamin D-deficiency type IIA (PDDR IIA). Clinical features include severe rickets, bone pain, hypotonia, dental caries and alopecia. Biochemical features include hypocalcemia, hypophosphatemia, normal to elevated alkaline phosphatase, normal 25(OH)D and importantly, elevated 1,25-(OH)2D levels. Management is with high doses of calcium and vitamin D therapy. While rare, this disease highlights the need for a comprehensive evaluation of metabolic bone diseases and a thorough understanding of calcium and vitamin D metabolism. Presentation: 6/2/2024

7336 Decades In The Dark: The Long Road To Diagnosing And Treating Hypophosphatasia

Abstract Disclosure: V.A. Mendpara: None. G. Madrigal Loria: None. L.Z. Khan: None. Background: Hypophosphatasia (HPP) is a rare bone disorder that results from deficient activity of the tissue non-specific isoenzyme alkaline phosphatase (ALP).[1] This case highlights a patient whose diagnosis of this treatable genetic condition was significantly delayed for almost two decades, despite receiving care at a prominent academic institution. The patient's persistently low ALP levels in routine lab tests were overlooked by multiple clinicians, leading to a delay in her care and eventual treatment. Case presentation: A 61-year-old Caucasian woman presented at the endocrinology clinic with complaints of severe fatigue, generalized pain, multiple childhood fractures, and ongoing dental issues. The rheumatology clinic to which she was referred for polyarthralgia diagnosed her with Hypophosphatasia (HPP) after noting chronically low alkaline phosphatase (ALP) levels from her previous charts ranging from 15 to 24 U/L (normal range: 34 to 123 U/L) over two decades. Her serum calcium, parathyroid hormone (PTH), and 25-hydroxy vitamin D levels were within normal ranges. A DEXA scan revealed normal bone density, effectively ruling out osteoporosis. Further investigation showed elevated Vitamin B6 levels at 219.6 nmol/L (normal range: 20.0 to 125.0 nmol/L), raising suspicion for HPP. The patient's family history provided additional insight, with her mother having a history of short stature and fractures and her son experiencing premature tooth loss at the age of 2. A genetic evaluation identified a heterozygous pathogenic variant in the ALPL gene (c.881A>C, p.Asp294Ala), confirming the diagnosis of autosomal dominant HPP. Initiating treatment with Asfotase alfa, a medication targeting HPP, resulted in a marked improvement in the patient's symptoms. Discussion: This case shows the diagnostic complexities of HPP, stressing the significance of actively screening for this condition via ALP levels in routine laboratory testing or during osteoporosis evaluations. The diagnostic process is critical to distinguish HPP from primary osteoporosis, as treatment and potential risks differ significantly. Inadvertent use of bisphosphonates can worsen hypomineralization and lead to atypical femoral fractures in HPP patients. Asfotase alfa enzyme replacement therapy, available since 2015, offers a targeted approach by replacing the enzyme defect, thereby mitigating symptoms. Heightened awareness among healthcare providers of HPP in adults holds the potential to enhance diagnosis rates and facilitate improved treatment outcomes for this highly treatable condition.[1] Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, Eighth Edition. ASBMR. Presentation: 6/2/2024

Association of fluoride exposure with disease burden and neurodevelopment outcomes in children in South Korea.

Community water fluoridation is an effective public health strategy for preventing dental caries, yet. Concerns exist about potential health problems. This study explores associations between tap water fluoride levels and pediatric disease burden, as well as neurodevelopmental outcomes at 6years of age. This nationwide population-based cohort study included children born in Korean cities with and without tap water fluoridation projects, between 2006 and 2012, aiming for a fluoride concentration of 0.8 ± 0.2mg/L in treated tap water. Data from the National Health Insurance Service were used, spanning from birth to 2018. The relationship between exposure to fluoridated tap water and incidence of 16 childhood diseases that were previously identified as potentially linked to fluoride exposure were examined. Additionally, we evaluated the neurodevelopmental outcomes across various domains, including gross motor, fine motor, cognition, language, social skills, and self-help functions. These assessments were performed using data from a comprehensive national health screening program for children aged six years. A fluoride-unexposed group included 22,881 children, whereas a fluoride-exposed group comprised 29,991 children (52% males). Children in the fluoride-exposed group had a decreased risk of dental caries and bone fractures [hazard ratio (95% confidence interval, CI), 0.76 (0.63-0.93) and 0.89 (0.82-0.93), respectively] and increased risk of hepatic failures [1.85, (1.14-2.98)] compared to those in the unexposed group. Additionally, the risk ratio of abnormal neurodevelopmental screening outcomes increased by 9%, but this was statistically uncertain (95% CI, 0.95-1.26). Fluoridated tap water was associated with an increased risk of hepatic failure but a decreased risk of bone fractures in children. The association between fluoridated tap water and neurodevelopmental screening outcomes at 6years remains unclear, highlighting the need for further studies to clarify this association.

Features of the state of bone tissue in children with cerebral palsy. Part 1. Etiological aspects. A literature review

BACKGROUND: The growth of the human body is the most significant period of development of the bone tissue, because it is during this period that the size, shape, and architectonics of bone are formed against the background of increasing body weight and increasing physical exertion. Considering a number of pathological factors of the underlying disease (alimentary, neurological, hormonal, stress, and physical), bone tissue in children with cerebral palsy grows and develops with deviations from the norm. АIM: To present up-to-date generalized information about the features of bone tissue in children with cerebral palsy to orthopedic traumatologists, neurologists, and physical therapy specialists. MATERIALS AND METHODS: Studies on the problem of bone tissue condition in patients with cerebral palsy were analyzed. Data published over the past 20 years were searched in the scientific databases PubMed, Google Scholar, Cochrane Library, Crossref, and eLibrary without language restrictions. RESULTS: In the last 20 years, the number of studies about pediatric osteoporosis has increased. The gold standard for determining the level of bone mineral density is dual-energy X-ray absorptiometry. However, its use in children has presented some difficulties and limitations. In children, the relationship between bone mineral density values and the risk of fractures has not been well studied, which does not allow us to discuss about osteoporosis based on densitometric bone mineral density data alone. In patients with cerebral palsy, a decrease in bone mineral density and bone mass during growth was found. Previous studies showed that the main factors associated with a decrease in bone mineral density in this group of patients include neuroendocrine causes due to growth retardation against the background of CNS damage, alimentary factors, decreased calcium and vitamin D concentrations, systemic use of glucocorticoids, intake of antiepileptic drugs, decreased motor activity, and low muscle mass. Increasing serum vitamin D concentrations does not have a positive effect on bone mass, although increasing serum calcium concentrations is associated with an increase in bone mineral density. CONCLUSIONS: Identifying and correcting factors leading to decreased bone mineral density in children with cerebral palsy can improve bone health in this group of patients. The absence of a relationship between bone mineral density values and the risk of fractures in children with cerebral palsy does not allow us to discuss about osteoporosis based only on bone mineral density densitometric data. There may be more factors leading to an increased risk of bone fractures in children with cerebral palsy that require further study.

Orthodontic-Orthognathic Management of a Patient With Severe Mandibular Deficiency Due to Bicondylar Fracture: A Case Report

This case report is about a 30-year-old Iranian female. The patient’s chief complaint was the backwardness of the lower jaw. The patient reported a history of condylar fractures in childhood. There was crowding in the maxillary and mandibular arch, and the midline in the mandible was 2 mm deviated to the left. The canine and first premolar on the left side of the maxilla were extracted, and the canine on the left side of the mandible was impacted. Clinical examinations and paraclinical documents revealed that the patient was a skeletal class II case with mandibular deficiency, complicated by a vertical maxillary excess. Virtual surgery planning was used to plan the patient’s treatment. The amount of adhesion of soft tissue to hard tissue was also taken into consideration. According to the measurements of the patient and the class II, vertical maxillary excess of the patient, the shortness of the ramus, and the large angle of the occlusal plane, our chosen orthognathic surgery included bilateral sagittal split osteotomy, advancement genioplasty, and maxillary impaction.

Strategies for Managing Pediatric Fracture Pain: Assessment, Pharmacological, and Non-Pharmacological Interventions.

Fractures are prevalent among the pediatric population, with approximately 1 in 3 children experiencing at least 1 fracture during childhood. Children are not just little adults; they have unique needs in pain management. With a lack of knowledge in pediatric pain management, medical staff primarily focus on the fractures, often overlooking and inadequately addressing pain. There is a scarcity of literature on acute fracture pain for children, while a wealth of literature summarizes chronic and tumor-related pain in children, which is not suitable for addressing pain caused by fractures. Therefore, a pain management literature review grounded in clinical experience is essential to provide guidance to doctors and parents on safely and effectively reducing the pain associated with children's fractures. We conducted a thorough review of existing literature and summarized treatment experiences into the 3 areas of pain assessment, non-pharmacological treatments, and pharmacological treatments. First, we evaluated and analyzed existing pain assessment methods, identifying the most suitable tools for different age groups. Second, we explored non-pharmacological treatments suitable for children with fractures to alleviate mild to moderate pain and reduce the need for analgesics. Lastly, we reviewed pharmacological treatments. For moderate pain, we recommend administering non-steroidal anti-inflammatory drugs. For severe pain, we suggest opioid medications, providing detailed information on usage and contraindications for different age groups. Therefore, this article aimed to review the evaluation and management of pain in children with bone fracture, and covers aspects of pediatric pain characteristics, pain assessment tools, pharmacological therapy, and non-pharmacologic therapy.

A Short-Term Study of 18 Cases of Distal Femur Fractures Managed By Locking Compression Plate [Lcp] Using A Less Invasive Skeletal Stabilisation System [LISS

Distal femur fractures have traditionally been the most challenging to treat. Restoring full motion and function to the knee may be challenging due to these fractures' proximity to the knee joint. Regardless of the treatment method, comminution, damage of soft tissue, fracture extension into the knee joint, and related injury to the quadriceps mechanism frequently concludes in suboptimal outcomes. The early surgical fixation notion, increased implant availability, early postoperative knee joint immobilization, and a better understanding of damage patterns have all significantly improved the patient's functional result. Our study focuses on distal femur fractures managed by LCP [locking compression plate] using a less invasive skeletal stabilization system [LISS]. This is a retrospective research of 18 cases of distal femur fractures in adults who had LCP treatment with the LISS. The operation at Saveetha Medical College and Hospital in Chennai runs from January 2021 to January 2022. All types of intercondylar and supracondylar fractures are included. Children's fractures and pathological fractures were not included. Age distribution, side of injury, sex distribution, anatomy of injury, mechanism of injury, damage grading, subtype of fracture, concomitant injuries, and open fractures were the parameters used to assess the cases. AP and lateral views of the X-ray were taken. A thorough preoperative workup was completed. Every case was scheduled for surgery as soon as feasible. External fixators were used in the initial treatment of complicated cases. Patients underwent locking compression plate (LCP) fixation with the LISS. Radiological examination immediately following surgery, four weeks, six weeks, eight weeks, twelve weeks, four months, and every six months for a maximum of one year.The age range of the patients was 21 to 70 years, with a mean age of 30 years. A maximum incidence of fractures was noted in individuals aged 40 to 60. Males accounted for the majority of the 18 cases, with a female-to-male ratio of 3:5. Our series was predominantly right-sided. The most frequent cause of injury has been traffic accidents. Throughout the research period, no patients were lost to follow-up. Of the eighteen cases, the majority involved distal femur fractures, with intercondylar extension accounting for a higher number of cases, and isolated supracondylar fractures following. A head injury was present in one case, and acetabular fracture in another, a Boxer’s fracturein a third case, and 2 open fractures (1 compound grade III A, the other compound grade II). The fractures took an average of 13.3 weeks to heal. It required an average of 15.3 weeks longer in cases of compound fractures. Less than six degrees of malalignment (varus, valgus) were present. Every patient exhibited optimal articular alignment.Excellent outcomes were obtained with the LISS, which combines appropriate physiotherapy with an LCP (angle stable build). In principle, an LCP implant is the best option for fractured and osteoporotic bones. In summary, the use of LCPs in the LISS appears to yield superior outcomes when managing distal femur fractures.

Diagnosis and Treatment of Cervical Spine Fractures in Children

Background. Cervical spine injuries in children are relatively uncommon and account for approximately 1.5% of trauma admissions. The aim of our study was to determine the incidence and patterns of pediatric cervical spine fractures in a single Trauma Center over the last decade.Material and methods. The hospital’s medical database was queried for data from the period between January 2014 and December 2023. An initial search revealed that 511 patients had been hospitalized with neck injuries in that time frame. Among these records, we identified 24 patients with a fracture of the cervical spine. The inclusion criteria were: (1) age under 18 yo, (2) fracture of the cervical spine (3) follow-up of at least 6 months. A thorough analysis was performed, including injury mechanism, diagnosis, medical procedures and final outcome., A Neck Disability Index (NDI) was assessed for all patients at the six months’ follow-up visit to evaluate treatment outcomes.Results. The study group consisted of 14 boys and 10 girls aged 4.6 to 18 years (average age 14.2). We diagnosed one case of an isolated C1 fracture, six C2 fractures, two C4 fractures, two C5 fractures, two C7 fractures, and nine cases of multiple spinal fractures. Additionally, we diagnosed two cases of cervical spine dislocation: one of right-sided rotational dislocation of C6/C7 and one of complete dislocation of C2/C3. Eight patients were treated surgically by open reduction combined with anterior plate fixation. Four patients were treated using a halo vest. Eleven patients were treated conservatively: six using a Minerva orthosis, four with a cervical-thoracic orthosis, and one with a rigid cervical collar. The highest NDI values were encountered in the group of patients with concomitant intracerebral injury, where the mean value was 18.6/45 (12-26/45). The mean NDI score for the remaining patients was 4/45 (0 - 9/45).Conclusions. 1. The incidence of cervical spine fractures in children is low. 2. Most cervical spine injuries in children are treated conservatively with good outcomes. 3. Both conservative and surgical treatment of cervical spine fractures in children produces good results 4. Computed Tomography remains the gold standard for diagnosing cervical spine fractures in children. 5. The halo-vest in pediatric patients suffering from C2 fractures was well tolerated and provided good outcomes. 6. Surgical treatment of lower cervical fractures by open reduction with anterior fusion is efficient in terms of fusion status and patient satisfaction. 7. Prospective, randomized, multicenter studies are required to assess the epidemiology, methodology, and treatment effects of cervical spine fractures in children.

Factors Affecting Lateral Overgrowth in Operatively Treated Lateral Condyle Fractures in Children.

The most frequent sequelae of pediatric lateral condyle fractures is lateral condyle overgrowth (LCO). The purpose of our study was to investigate LCO in relation to age, quality of reduction, type of fixation, and fracture displacement. We retrospectively analyzed operatively treated lateral condyle fractures in children. The percent change in interepicondylar width (IEW) ((final - initial)/ initial x 100) was used to quantify LCO. IEW was measured from the medial and lateral epicondyles of the distal humerus, using the AP radiographs taken at admission (initial) and follow-up visits (final). The Song classification was used to classify fractures. Fixation was classified as pins, screws or both. The quality of reduction was defined as anatomic or nonanatomic (>2mm of displacement). Patients were stratified into mild (0% to 10% overgrowth), moderate (10% to 20% overgrowth), and severe (>20% overgrowth) subgroups for further analysis. Two hundred one patients were included in the study with an average time between initial and final radiograph measurements of 11.32 weeks. There was an average 11.84 %LCO. Using multivariable analysis, three variables demonstrated significant, independent associations with %LCO: age, race, and quality of reduction. Increasing age remained inversely associated with %LCO. Compared with White patients, Black and Asian patients had significantly greater %LCO. Patients with nonanatomic reductions had a significantly greater %LCO compared with anatomic reductions. When patients were stratified into mild, moderate, and severe groups, age in the mild group, nonanatomic reduction in the moderate group, and race in the severe group were found to be independently associated with increased %LCO using multivariable analysis. The amount of LCO was found to be related to nonanatomic reduction, younger age, and Black and Asian race. Interestingly, it was not related to the amount of initial displacement or type of hardware used. To date, this is the largest study investigating LCO in surgically treated lateral condyle fractures. Level III-retrospective cohort study.

Childhood pancreatic neuroendocrine neoplasms: A national experience.

National multicenter retrospective study of all patients, aged from 0 to 17 years at diagnosis, treated from 2011 to 2020 for a pNEN and registered in the French National Registry of Childhood Cancers or FRACTURE database. Fifteen patients, 13 well-differentiated pancreatic neuroendocrine tumors (pNETs) and two neuroendocrine carcinomas (pNECs), were selected. Median age at diagnosis was 14 years (range, 7-17). Eight patients, all with localized disease, had a cancer predisposition syndrome (CPS), including five cases diagnosed during systematic screening. Five (31%) had metastatic disease at diagnosis: three grade 2 pNETs and two pNECs. First line therapy included exclusive pancreatectomy (seven cases, all M0), active surveillance (three cases, all M0), medical therapies (somatostatin analogues, chemotherapy; four cases, all M1), and surgery with medical therapy (one M1 case). Three-year progression-free survival was 57% (confidence interval [CI] 95%: 27-78) and was significantly better for patients with low-grade well differentiated (73vs. 0%; p<10-4) and localized (76vs. 20%; p=.02) tumors. The two patients with pNECs died. Three-year overall survival was 92% (CI95%: 59-99) and was significantly better in patients with low-grade tumor (100vs. 50%; p=10-4). Childhood pNENs occur more frequently in adolescents with CPS. Localized low-grade pNETs in children have a very good prognosis, whereas the treatment of high-grade and metastatic pNETs/pNECs should be better defined.

Iatrogenic Intraoperative Fracture in Patients With Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is a genetic defect in collagen type I, phenotypically characterized by bony fragility and a propensity to high rates of childhood fracture. Fragility fractures in patients with OI have been reported with routine hospital care. In addition, there is a nonzero rate of iatrogenic fracture during orthopaedic surgery directly related to the technical steps of the procedure itself. The rate of this latter has never been explicitly investigated. A review of all patients at a single OI referral center was conducted, including all patients with a diagnosis of OI seen between 2013 and 2023, inclusive. All patients who underwent orthopaedic surgery of any kind were reviewed, and clinical and radiographic details of all procedures were extracted. Among the details examined were the OI subtype, surgery details, any implants used, intraoperative and hospital stay complications, modified Clavien-Dindo classification of complications, and ultimate outcome. Eleven of 60 patients experienced an unplanned, iatrogenic intraoperative fracture during orthopaedic surgery (11/60 = 18.3%). This comprised 15 fractures among 356 total orthopaedic surgical episodes (15/356 = 4.2%). All but one fracture occurred on the operative long bone segment, all were a direct result of surgical steps, and 11 of 15 fractures occurred in the femur. Most fractures were secondary to the removal, insertion, or exchange of intramedullary implants in the lower extremity (11 of 15 fractures), most often the femur. Thirteen of 15 injuries were classified as modified Clavien-Dindo II or III, requiring modification of postop rehabilitation, additional treatments, or surgical intervention (87%). Overall, iatrogenic fracture was the most common intraoperative complication experienced in the cohort. Iatrogenic fracture during orthopaedic surgery for patients with OI is not uncommon. A sizeable minority of patients with OI undergoing orthopaedic surgery will experience unplanned fractures, most commonly in the femur, and care is altered in most instances. The risk of intraoperative fracture can be discussed with families of children with OI as part of informed consent and shared decision-making. Level IV-retrospective cohort series.

Management of closed diaphyseal fractures in children in two black African countries: Preliminary results and epidemiological profile

Objectives: The objective of this study was to describe the clinical evolution and the epidemiological profile of long bone fractures in children in two African countries. Methods: This was a five-year retrospective study of closed fractures of long bones in children aged 9.7 years (Ranging 4–16). Seventy-two fractures were treated by elastic stable intramedullary nailing and plate osteosynthesis. The results were evaluated according to Oestern and Tscherne criteria, and parental satisfaction was assessed using an individual investigation form. Results: The treatment of closed fractures of long bones in children is marked by complications such as infection (16.6%), implant migration (19.4%), non-union (11.1%), and malunion (2.7%). According to the assessment criteria, 33.3% were excellent, 45.8% were good, and 20.8% were poor. Twenty percentages of parents were very satisfied, 61% were satisfied, and 18% were disappointed with the outcome. Conclusion: Osteosynthesis is only indicated in common pediatric trauma if the capabilities of remodeling a callous are insufficient. It should not be the first choice in children’s fracture therapeutic options.

Outcome of Flexible Intramedullary Nailing versus Plating in Treatment of Diaphyseal Femur Fractures in Paediatrics: Systematic Review and Meta-analysis

Abstract Background Pediatric femoral fractures are the most the common long bone fracture in children, with one third of these occurring between ages 5 to 12. These injuries are usually the result of road traffic accidents, sports and non-accidental injury. Different modalities exist for managing these fractures, often stratified according to the age of the patient. Aim of the Work The aim of this work is to provide a complete overview of the optimal surgical treatment of diaphyseal femur fractures in children by evaluating and comparing the clinical and functional outcomes of flexible intramedullary nailing versus plating for such fractures. Patients and Methods This review followed the Cochrane Handbook's standard methodology and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta- analyses (PRISMA) statement guidelines. Result In patients undergoing flexible nailing, the surgical variable data found this treatment modality to be superior in terms of certain operative features: shorter operative duration times (p = 0.00001), smaller volumes of estimated blood loss (p = 0.00001). There was no difference regarding length of hostital stay (p = 0.59). This suggests that flexible nailing may offer increased safety to patients in terms of duration of anesthesia, volume of blood loss, and cost of surgery when compared to plating. However, Secondary outcome analysis also found a statistically significant increased risk of malunion (p = 0.002) and metalwork irritation (p = 0.00001) when using FIN compared to plating techniques. There was no difference regarding risk of infection (p = 0.53) and developing leg length discrepancy (p = 0.44). Conclusion Options for stabilization and fixation in this age group include flexible nailing, plating (open or sub-muscular), external fixation, or hybrid techniques.

A New Method in Dealing With Children's Condylar Fracture by Botulinum Toxin A Injection in Lateral Pterygoid Muscle.

Condylar is one of the most vulnerable sites to be traumatized in pediatric mandible fracture, while temporomandibular joint ankylosis might be the most severe complication of condylar fracture in children. There exists a long-time controversy on the treatment of condylar fractures in children. Considering the risk of facial nerve injury and a certain probability of absorption or even ankylosis after open reduction and internal fixation (ORIF) of condylar fractures, a series of nonsurgical approaches are preferred in cases without severe malocclusion or shortening of the ramus. Our treatment plan was carried out through combining procedures of Botulinum toxin A injection in lateral pterygoid muscle with ORIF of para symphyseal fracture; subsequently, a conservative way of the occlusal splint with elastic traction was performed. Three patients of bilateral or unilateral condylar fractures, aged between 2y and 6y, were involved in this treatment. After more than 1 year's follow-up, the occlusion was satisfactory in all patients. Condylar remodeling was approximately complete in 3 months, and no unwanted complications were observed. We may expect this method to offer a new idea when dealing with children's condylar fracture.

Reliability of a Modified Watson-Jones Classification for Tibial Tubercle Fractures in Children.

The first case report describing a pediatric fracture of the tibial tubercle was published in 1852 in the Medical Times and Gazette, a Journal of Medical Science, literature, criticism, and news. A century later, in 1955, Sir Watson-Jones introduced the first classification system for this fracture. Despite the existence of several classification systems for pediatric tibial tubercle fractures in the medical literature, a crucial aspect of their validation-reliability and reproducibility-has not yet been systematically evaluated. In this study, a modified Watson-Jones (mWJ) classification system of tibial tubercle fractures in children was assessed for intraobserver and interobserver variability. Using the mWJ classification, 3 board-certified pediatric orthopaedic surgeons and 3 orthopaedic surgery residents, classified thirty tibial tubercle fractures based on anteroposterior and lateral radiographs on 2 separate occasions in a 2-week duration. Further comparison was made to evaluate the impact of advanced imaging, specifically computed tomography or magnetic resonance imaging, on diagnostic reliability and reproducibility. The study found substantial intraobserver reliability of the mWJ classification based on radiographs alone, with a Cohen weighted kappa (κ w ) coefficient of 0.733. When advanced imaging was utilized, the reliability of the classification improved to κ w = 0.783. Similarly, interobserver reliability demonstrated substantial consistency among observers when using radiographs alone (κ w = 0.69) and improved agreement with advanced imaging (κ w = 0.75). Notably, there was no significant difference in reliability scores between senior-level attendings and residents when analyzed as separate groups. Fracture classification systems are clinically relevant tools that help organize and transfer knowledge efficiently, provide treatment guidance, propose prognostic expectations, and improve communication in academic literature. The present study demonstrated substantial reproducibility of an mWJ fracture classification system both between and within individual surgeon raters. Level III-diagnostic.

The Role of Orthodontics in the Management of Maxillofacial Fractures in Children: A Review on Contemporary Approaches.

Maxillofacial fractures present complex challenges requiring effective orthodontic management to restore function and aesthetics. This review explores various orthodontic techniques, including fixed braces, maxillomandibular fixation (MMF), functional orthodontic therapy (FOT), and acrylic splints, emphasizing their roles in stabilizing fractures and promoting healing. The management of condylar fractures is discussed, highlighting the benefits of early intervention with functional appliances to facilitate condylar remodeling in children and adolescents. Additionally, the review covers splinting methods for dental and dentoalveolar fractures and the use of open reduction internal fixation (ORIF) for maxillary fractures. It addresses the complications and challenges of fracture management, the need for a multidisciplinary approach, and the limitations of current studies. Future directions include the use of advanced technologies such as virtual surgical planning (VSP) and 3D printing to enhance treatment precision and outcomes. This review provides a comprehensive overview of orthodontic strategies for maxillofacial fractures, offering insights into clinical applications and future advancements.