Pediatric Neck Research Articles

Percutaneous Fixation of Pediatric Fractures of the Proximal Phalanx Neck: A Novel Technique.

Proximal phalanx neck fractures occur almost exclusively in children. Fractures of the proximal phalanx neck can be difficult to treat nonoperatively given the anatomic location and associated extrinsic forces. A divergent or crossed pin configuration is often utilized for the stabilization of these fractures. We present a surgical technique with a single Kirschner (K-wire) placed axially along the affected finger, with a hyperextension reduction maneuver, to reduce and fixate proximal phalanx neck fractures in children and adolescents. We performed a retrospective review of all pediatric proximal phalanx neck fractures treated by a single surgeon. Demographic data, as well as clinical and radiographic outcomes were recorded. We then directly compared axial pinning [14 patients; average age 6.63 y (9 mo to 17 y)] with nonoperative treatment [28 patients; average age 8.03 y (9 mo to 16 y)], and open treatment [8 patients; average age 8.13 y (1 to 14 y)]. Patients who underwent closed reduction and axial pinning had significantly improved final coronal alignment compared with nonoperative treatment. Compared with fractures which required open reduction, closed reduction with axial pinning resulted in significantly shorter surgical duration and time to radiographic healing. The final range of motion showed no difference between intervention types, as all patients regained full range of motion. We find this axial pinning technique to be simpler and faster than divergent pin fixation, with no significant differences in time to radiographic healing, time to full activity, final proximal interphalangeal active flexion or extension, loss of reduction, or radiographic parameters. Level III-Therapeutic.

The clinical and radiographic characteristics of avascular necrosis after pediatric femoral neck fracture: a systematic review and retrospective study of 115 patients

BackgroundAvascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) showed poor prognosis, but its clinical and radiographic characteristics remained unclear.MethodsA systematic review and a retrospective study were performed to evaluate the clinical and radiographic characteristics of patients with AVN after PFNF.ResultsA total of 686 patients with PFNF and 203 patients with AVN from 21 articles were analyzed. Ratliff’s classification was used in 178 patients, with types I, II, and III AVN accounting for 58.4%, 25.3%, and 16.3%, respectively. Ratliff’s assessment was used in 147 patients, of whom 88.4% had an unsatisfactory prognosis. In retrospective study, 115 patients with a mean age of 13.6 ± 2.0 years were included. The mean interval between AVN and PFNF was 13.7 ± 9.5 months. At the time of diagnosis, 59.1% cases were symptomatic and 65.2% progressed to collapsed stage. Fifty (43.5%), 61 (53.0%), and 4 patients (3.5%) were defined as types I, II, and III , respectively, via Ratliff’s classification. Thirteen (11.3%), 40 (34.8%), and 62 patients (53.9%) showed types A/B, C1, and C2 disease, respectively, via the JIC classification. Multivariate analysis demonstrated a strong relation between collapsed stage and symptomatic cases (OR = 6.25, 95% CI = 2.39–16.36) and JIC classification (OR = 3.41, 95% CI = 1.62–7.17).ConclusionAVN after PFNF showed a tendency toward extensive necrotic lesions, presumably resulting in a rapid progression of femoral head collapse. And the symptoms and the JIC classification are other two risk factors of collapse progression.

Epidemiology and Management of Pediatric Head and Neck Burns: An Institutional Review.

Pediatric head and neck burns (HNBs) require special attention due to the potential for long-term disfigurement, functional impairment, and psychosocial stigma. We performed a retrospective review of patients <18years old admitted to Grady Memorial Hospital with a diagnosis of HNB from 2009-2017. Demographic data, burn characteristics, management, and hospital course were analyzed. Of the 272 patients included, 65.4% were male with a mean age of 63.2months. Burn mechanism was primarily secondary to scalding liquids (70.2%) or flames (23.9%). The average total body surface area involved was 10.3%, and 3.0% for the head/neck. Average length of stay was 5.2days and overall mortality was 1.1%. Twenty-five patients (9.2%) required surgery in the acute setting, and 5 (1.8%) required secondary surgery for hypertrophic scarring or contracture. Pediatric HNBs occur most commonly in males <6years old secondary to scalding liquids or open flames. Most patients can be managed nonoperatively without long-term sequelae.

Enhanced optimization of volumetric modulated arc therapy plans using Monte Carlo generated beamlets.

A treatment planning system (TPS) produces volumetric modulated arc therapy (VMAT) plans by applying an optimization process to an objective function, followed by an accurate calculation of the final, deliverable dose. However, during the optimization step, a rapid dose calculation algorithm is required, which reduces its accuracy and its representation of the objective function space. Monte Carlo (MC) routines, considered the gold standard in accuracy, are currently too slow for practical comprehensive VMAT optimization. Therefore, we propose a novel approach called enhanced optimization (EO), which employs the TPS VMAT plan as a starting point, and applies small perturbations to nudge the solution closer to a true objective minimum. The perturbations consist of beamlet dose matrices, calculated using MC routines on a distributed-computing framework. DICOM files for clinical VMAT plans files are exported from the TPS and used to generate input files for the EGSnrc MC toolkit. Beamlet doses are calculated using the MC routines, each corresponding to a single multileaf collimator leaf from a single control point traveling 0.5cm in or out of the field. A typical VMAT plan requires 5000 to 10000 beamlets, which may be calculated overnight. This results in a ternary-valued objective function, which may use the same clinical objectives as the original VMAT plan. A simple greedy search algorithm is applied to minimize this function and determine the optimal set of ternary variables. The resulting modified control point parameters are imported into the TPS to calculate the final, deliverable dose, and to compare the EO plan with the original. EO was evaluated retrospectively on seven VMAT plans (two adult brain, one pediatric brain, two head and neck, and two prostate). Additionally, the use of stricter objectives was investigated for two of the cases: the left cochlea planning organ at risk (OAR) volume objective for the pediatric brain case, and the rectum objective for a prostate case. EO produced improved objective scores (by 6% to 60%) and dose-volume histograms (DVH) for the brain plans and the head and neck plans. For each of these plans, the target dose minimum and homogeneity were preserved, while one or more of the OAR DVH's was reduced. Although EO also reduced the objective scores for the prostate plans (by 46% and 79%), their absolute score and DVH improvements were not substantial. The stricter objective on the pediatric brain case resulted in lower dose to the OAR without compromising the target dose. However, the rectum dose in the prostate case could not be improved without reducing dose homogeneity to the planning target volume, suggesting that VMAT prostate cases may already be highly optimized by the TPS. We have developed a novel approach to improving the dose distribution of VMAT plans, which relies on MC calculations to provide small modifications to the control points. This method may be particularly useful for complex treatments in which a certain OAR is of concern and it is difficult for the treatment planner to obtain an acceptable solution with the TPS. Further development will reduce the beamlet computation time and result in more sophisticated EO treatment planning methods.

The current outcomes and future challenges in pediatric vascularized composite allotransplantation.

We review the outcomes and future challenges associated with pediatric vascularized composite allotransplantation, including follow-up data from our bilateral pediatric hand-forearm transplantation. In 2015, the first heterologous pediatric upper extremity hand-forearm transplant was performed at the Children's Hospital of Philadelphia, and in 2019, the first pediatric neck reconstructive transplantation was performed in Poland. The 5-year follow-up of the pediatric upper extremity recipient demonstrates similar growth rates bilaterally, an increase in bone age parallel to chronologic age, and perhaps similar overall growth to nontransplant norms. The pediatric upper extremity recipient continues to make gains in functional independence. He excels academically and participates in various extracurricular activities. Future challenges unique to the pediatric population include ethical issues of informed consent, psychosocial implications, limited donor pool, posttransplant compliance issues, and greater life expectancy and therefore time to inherit the many complications of immunosuppression. Currently, we recommend pediatric vascularized composite allotransplantation (VCA) for bilateral upper extremity amputees, preferably on immunosuppression already, and those patients who would have the most potential gain not available through standard reconstructive techniques while being able to comply with postoperative immunosuppression protocols, surveillance, rehabilitation, and follow-up.

Pediatric Radial Neck Fractures: Which Ones Can Be Successfully Closed Reduced in the Emergency Department?

The purpose of this study is to examine pediatric patients with a radial neck fracture and determine the factors associated with a failed closed reduction (CR) in the emergency department (ED). A total of 70 patients with acute radial neck fractures were retrospectively reviewed. Inclusion criteria were: age 18 years or younger at time of injury, diagnosis of radial neck fracture without other associated elbow fractures, an attempt at CR with manipulation in the ED or immediate surgery, open proximal radial physis, and appropriate imaging to categorize the injury. Charts were reviewed and demographic data was obtained. Initial injury films were reviewed and the Judet classification was used to define fracture types/categories. CR was attempted on 41 patients. Twenty-nine patients went straight to surgery without a CR attempt. Compared with patients that had an attempted CR in the ED, patients that went straight to surgery had longer mean time from injury to ED presentation (5.6 d; P=0.0001), greater mean fracture angulation (55.0 degrees; P=0.001), and greater fracture translation (46.2%; P=0.001). When analyzing the patients that had a CR attempted in the ED, univariate statistical analysis demonstrated that ≥Judet 4 classification (P=0.03), greater amounts of fracture angulation (P=0.003), and a treatment delayed >24 hours from injury (P=0.007) were significant risk factors for failure of CR in the ED. Zero (0/10) patients with fracture angulation ≥60 degrees had a successful CR. Only 1/14 patients presenting >24 hours after injury had a successful CR in the ED. Circumventing sedation in the ED, and instead splinting for a planned surgical intervention may be a more efficient treatment method for pediatric radial neck fractures that present to the ED>24 hours after injury and/or have angulations ≥60 degrees. Adopting this new strategy may save time, reduce costs, and avoid possible harm/complications associated with sedation in the ED. Level III-prognostic.

The current state and future prospects of the fundamental research on pediatric otorhinolaryngology: an analysis of application and funding data of the National Natural Science Foundation of China from 2009 to 2019.

BackgroundThis study aimed to summarize the current situation and deficiencies of the fundamental research on pediatric otolaryngology-head and neck science. It is hoped that the results can provide support for the long-term development of the basic research on this subject.MethodsInformation concerning the applications to and funding from the National Natural Science Foundation of China (NSFC) for otolaryngology-head and neck from 2009 to 2019 was collected and analyzed.ResultsIn the past 10 years, pediatric otolaryngology-head and neck science received 150 applications, accounting for 2.92% of all applications for otolaryngology-head and neck science. Ultimately, 20 projects were funded, accounting for 2.17% of all the funded projects. There were 88 applications for children’s ear science and hearing-related research, accounting for 58.67% of the applications for pediatric otolaryngology-head and neck science. Furthermore, 14 approved grants focused on cochlear implants and the genetics and mechanisms of deafness. There were 25 applications related to children’s nasal science, particularly allergic rhinitis, accounting for 16.67% of the total applications. Of these, 4 applications were funded, and these mainly focused on the disease regulation and pathogenesis of allergic rhinitis. A total of 30 applications related to children’s laryngopharyngeal diseases, accounting for 20% of the applications, mainly focused on obstructive sleep apnea syndrome (OSAS), adenoid hypertrophy, and tonsil hypertrophy, with only 1 application being funded. The scientific research on children’s head and neck was mainly related to laryngeal papilloma and lymphatic vascular malformation, with 7 projects being applied for and 2 being funded.ConclusionsThe fundamental research of pediatric otolaryngology-head and neck science in China is at a relatively weak level and lags behind the average level of the discipline. There are relatively few basic researchers engaged in pediatric otolaryngology-head and neck science, and the dominant research units are relatively concentrated. The basic research of children’s ear science is relatively advanced in each subspecialty, so the basic research on children’s unique congenital and hereditary diseases should be further strengthened.

Characterization of pediatric head and neck masses with quantitative analysis of diffusion-weighted imaging and measurement of apparent diffusion coefficients

Purpose:Our objective was to investigate the accuracy of quantitative diffusion-weighted imaging (DWI) to determine the histopathologic diagnosis of pediatric head and neck lesions.Materials and Methods:This retrospective study included 100 pediatric patients recently diagnosed with head and neck tumors. All patients underwent preoperative conventional magnetic resonance imaging (MRI) and DWI. Each lesion was evaluated according to signal characteristics, enhancement pattern, and diffusivity. The average apparent diffusion coefficient (ADC) obtained from each tumor was compared to the histological diagnosis of benign, locally malignant, or malignant categories.Results:Our retrospective study showed a significant negative correlation between average ADC and tumor histopathologic diagnosis (P < 0.001, r = -0.54). The mean ADC values of benign, locally malignant lesions, and malignant tumors were 1.65 ± 0.58 × 10–3, 1.43 ± 0.17 × 10–3, and 0.83 ± 0.23 × 10–3 mm2 s-1, respectively. The ADC values of benign and locally malignant lesions were overlapped. We found a cut-off value of ≥1.19 × 10–3 mm2s-1 to differentiate benign from malignant pediatric head and neck masses with a sensitivity of 97.3%, specificity of 80.0%, positive predictive value of 94.7%, and negative predictive value of 88.9%.Conclusion:Diffusion-weighted MRI study is an accurate, fast, noninvasive, and nonenhanced technique that can be used to characterize head and neck lesions. DWI helps to differentiate malignant from benign lesions based on calculated ADC values. Additionally, DWI is helpful to guide biopsy target sites and decrease the rate of unnecessary invasive procedures.

Pediatric head and neck rhabdomyosarcoma: An analysis of treatment and survival in the United States (1975–2016)

IntroductionRhabdomyosarcoma (RMS) is the most common soft tissue head and neck sarcoma in children. Stringent analysis of survival data is imperative to optimize treatment. MethodsThe National Cancer Database (NCDB, 2004–2016) and the Surveillance, Epidemiology, and End Results Program (SEER, 1975–2016) were queried for patients ages 0–19 with RMS of the head and neck. Survival trends were analyzed using univariable logistic regression and Chi-square pairwise comparisons. Survival by treatment was analyzed using log-rank tests, Kaplan Meier, and multivariable Cox-proportional hazards regression. Results1147 (63.3% age <10 years, 54.3% male) and 459 (71.4% age <10 years, 53.6% male) patients were identified in NCDB and SEER, respectively. In NCDB, embryonal (n = 625, 54.5%) and alveolar (n = 300, 26.2%) were the most common histology and nonparameningeal/non-orbital (n = 634, 55.3%), followed by parameningeal (n = 303, 26.4%) and orbital (n = 210, 18.3%) the most common location. Five-year overall survival (OS) was 70.3% with lower mortality risk for embryonal histology (adjusted HR [aHR] = 0.69, p = 0.0038). Orbital tumors had greatest survival (5-year OS = 92.4%) of all sites, and their mortality risk was higher with chemotherapy and radiation compared to surgery and radiation (aHR = 6.27, p = 0.0302). SEER analysis showed average increased survival by 4% per year (p < 0.0001), but no significant 5-year OS difference when comparing 1976–1980 and 2006–2010 (p = 0.0843). ConclusionsMajor prognostic factors for survival in childhood RMS of the head and neck were embryonal histology, orbital site, extent of disease, and use of SRT for orbital tumors. Larger population studies are required to demonstrate survival differences between treatment modalities for other sites.

Closed Reduction and Immobilization of Pediatric Fifth Metacarpal Neck Fractures.

There is no clear consensus for the criteria for closed treatment of metacarpal neck fractures. Our objective was to determine whether closed reduction of pediatric fifth metacarpal neck fractures results in a clinically meaningful improvement in radiographic angulation. We performed a retrospective cohort study of pediatric patients with fifth metacarpal neck fractures treated with closed reduction. Radiographs were examined for sagittal fracture angulation measured post-reduction, 2 to 14 days post-reduction, and 21 to 35 days post-reduction. We compared the angulation for open versus closed physes, initial fracture angulation greater than or less than 50°, and immobilization in extension versus intrinsic-plus position. Fifty-four subjects were included with an average age of 14.8 years at the time of injury and a mean initial fracture angulation of 42.7°. The improvement in fracture angulation was 8.3° (90% confidence interval [CI], 5.9-10.7) on post-reduction radiographs, 8.5° (90% CI, 6.1-10.9) at 2 to 14 days post-reduction, and 4.3° (90% CI, 1.4-7.2) at 21 to 35 days post-reduction. Subgroup analysis showed that patients with injury angle greater than or equal to 50° had significantly higher mean reductions than those with injury angle less than 50°. In this group, angulation improved 15.6° (90% CI, 8.5-22.7) post-reduction, 15.1° (90% CI, 10.1-20.1) at 2 to 14 days post-reduction, and 16.5° (90% CI, 10.4-22.6) at 21 to 35 days post-reduction. Closed reduction of pediatric fifth metacarpal neck fractures with initial fracture angulation less than 50° may not meaningfully improve sagittal alignment. For fractures with initial angulation greater than or equal to 50°, closed reduction resulted in clinically important, statistically significant, and lasting improvements of 16.5°.

Impact of ultrasound in diagnosis of pediatric superficial masses in head and neck.

Background: Neck masses are frequently encountered in pediatric medicine, and can present a diagnostic dilemma for the clinicians involved. Aim: to determine the impact of ultrasound in diagnosis of superficial masses in head and neck in pediatric. Methods: This is a review article. The search was performed using MEDLINE, Embase, Pubmed and CINAHL Plus in the same date range with the following medical terms: “Ultrasound; Pediatric; mass; head; neck”, including articles from 2000 to 2019. Results: In this review, the US findings are described for a variety of common and uncommon pediatric head and neck masses diagnosed in our practice. Specifically, the entities covered include neonatal scalp hematoma, craniosynostosis, dermoid and epidermoid cysts, Langerhans cell histiocytosis, lymph nodes and their complications, fibromatosis colli, thyroglossal duct cyst, branchial cleft cyst, cervical thymus, congenital goiter, thyroid papillary carcinoma, parathyroid adenoma, hemangioma, lymphangioma, jugular vein phlebectasia, acute parotitis, leukemia and/or lymphoma, neurogenic tumor, and rhabdomyosarcoma. Conclusion: Duplex US has emerged as the first-line imaging modality for the evaluation of superficial pediatric masses. Without the use of ionizing radiation, iodinated contrast material, or sedation and/or anesthesia, this safe, quick, and cost-effective imaging modality allows rapid evaluation and characterization of masses.

Positron Emission Tomography and Molecular Imaging of Head and Neck Malignancies

Metabolic reprogramming and avid fluorodeoxyglucose (FDG) uptake in locally advanced head and neck squamous cell carcinomas and other cancers of the upper aerodigestive tract lead to favorable sensitivity and diagnostic accuracy of FDG PET/CT or PET/MR compared to conventional imaging. Meanwhile, the role of non-FDG PET in head and neck malignancies is rapidly expanding. Accurate staging, identifying a clinically occult primary, or detection of distant metastasis or a synchronous malignancy on FDG PET significantly impacts management. FDG uptake after definitive therapy is an invaluable biomarker for surveillance. Patients with metabolic resolution can be spared from neck dissection, whereas FDG avid refractory disease or distant metastasis could necessitate surgical or systemic therapy. PET tracers targeting amino acid transport or fibroblast activation hold promise for improved specificity and better delineation of tumor prior to radiation therapy given their low physiologic or inflammatory uptake in head and neck compared to FDG. Tracers for hypoxia or cellular proliferation provide complementary information to FDG after radiation therapy for assessment of residual malignant cells that could lead to treatment failure. FDG remains the primary tracer for imaging lymphoma and other pediatric head and neck malignancies. Several other PET tracers such as gallium-68-labeled somatostatin receptor analogs and fluorodopa are being increasingly used for detection and characterization of head and neck paragangliomas and certain other cancers. FDG and other PET radiopharmaceuticals are increasingly being exploited in guiding clinical management of various head and neck malignancies and significantly impact patient outcomes.

Automatic Detection of Inadequate Pediatric Lateral Neck Radiographs of the Airway and Soft Tissues using Deep Learning.

To develop and validate a deep learning (DL) algorithm to identify poor-quality lateral airway radiographs. A total of 1200 lateral airway radiographs obtained in emergency department patients between January 1, 2000, and July 1, 2019, were retrospectively queried from the picture archiving and communication system. Two radiologists classified each radiograph as adequate or inadequate. Disagreements were adjudicated by a third radiologist. The radiographs were used to train and test the DL classifiers. Three technologists and three different radiologists classified the images in the test dataset, and their performance was compared with that of the DL classifiers. The training set had 961 radiographs and the test set had 239. The best DL classifier (ResNet-50) achieved sensitivity, specificity, and area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI]: 0.86, 0.94), 0.82 (95% CI: 0.76, 0.90), and 0.86 (95% CI: 0.81, 0.91), respectively. Interrater agreement for technologists was fair (Fleiss κ, 0.36 [95% CI: 0.29, 0.43]), while that for radiologists was moderate (Fleiss κ, 0.59 [95% CI: 0.52, 0.66]). Cohen κ value comparing the consensus rating of ResNet-50 iterations from fivefold cross-validation, consensus technologists' rating, and consensus radiologists' rating to the ground truth were 0.76 (95% CI: 0.63, 0.89), 0.49 (95% CI: 0.37, 0.61), and 0.66 (95% CI: 0.54, 0.78), respectively. The development and validation of DL classifiers to distinguish between adequate and inadequate lateral airway radiographs is reported. The classifiers performed significantly better than a group of technologists and as well as the radiologists.© RSNA, 2020.

Neoplasms of the head and neck in Iranian children and adolescents

Abstract Introduction: Head and neck neoplasms afflict all age groups including children. They manifest with various histological features and clinical behaviors. This study's aim was to provide data and analysis of the prevalence of head and neck neoplasms among the Iranian children and adolescents to help pathologists and clinicians make informed diagnosis and treatment decisions. Materials and Methods: This retrospective study was based on medical records of children and adolescents (≤18 years) documented at a prestigious children's medical center stationed in Tehran, Iran. Cases diagnosed with head and neck tumors recorded from 2005 to 2016 were selected. Patients' age and sex, tumors' sites, and microscopic types were assessed. Data analysis was performed using descriptive statistics. Results: Of the 41,409 available pediatric patients' records documented over 12 years, 418 cases (1.01%) recorded head and neck tumors. Of these 418 cases, 15 recorded metastatic tumors (3.58%) and 403 recorded primary tumors. Of the primary tumors, 386 were found in the soft tissue (95.78%) and 17 in the bone (4.22%). The primary tumor patients' mean age was 5.46 years, including boys (59.8%) and girls (40.2%). The neck was the most common primary tumors' location (57.32%). Of all the primary tumors, 54.6% were benign neoplasms and 45.4% malignant. The commonest benign tumors were hemangioma/lymphangioma, and the most common malignancy was lymphoma. Mesenchymal neoplasms were the most common microscopic group followed by hematopoietic tumors. Conclusions: The analysis of these data indicates that the prevalence of pediatric head and neck tumors in the Iranian population is similar to other countries.

Use of Proximal Humerus Locking Plates for Fixation of Pediatric Femoral Neck Fractures: Technical Trick.

Displaced pediatric femoral neck fractures are uncommon and complex injuries which require urgent operative fixation. Owing to the small and variable size of the pediatric femur, implant selection and availability can be difficult. We present a novel technique for the stabilization of these fractures with commonly available implants which provides physeal sparing, fixed angle, and stable fixation.

Lateral Pinning of the Pediatric Phalangeal Neck Fracture.

Closed reduction and percutaneous pinning is the treatment of choice for displaced pediatric phalangeal neck fractures. Multiple techniques have been described to address challenges in managing these unstable fractures. We describe our technique of closed reduction and percutaneous pinning, which avoids the physis and increases the wire insertion accuracy, minimizing the number of attempts and wire passes made at percutaneous pinning.

Close Reduction Technique for Severely Displaced Radial Neck Fractures in Children.

Radial neck fractures account for 5-10% of paediatric elbow trauma. Radial neck fractures have been classified by Judet into five types (I-IVb). There is a global agreement to reduce radial neck fractures with angulation more than 30° (Type III, IVa and IVb). Various maneuvers have been described but none of them uniformly achieved complete reduction in severely displaced radial neck fractures (Type IVa and Type IVb Judet). In this case series, we are presenting our experience with close reduction of ten severely displaced paediatric radial neck fractures to achieve complete anatomical reduction. We attempted close reduction in ten consecutive children with average age of 8.59 ± 1.68years (range, 6-12years) who presented with severely displaced radial neck fracture (Type IVa and IVb Judet). There were five girls. All patients had close injuries and presented to us within 24-48h. One of the patients had associated undisplaced lateral condyle fracture. We have excluded two patients with associated elbow dislocation. Close reduction was performed within 48h of initial injury. We were able to obtain complete anatomical reduction in all of our patients with this technique. None of the patients required fixation of fracture. At 1year of follow-up, (12 ± 2.07months, range 9-16months) all patients demonstrated almost full range of elbow and forearm motion. Final radiographs revealed complete union without any evidence of avascular necrosis. This technique offers an option of close reduction for the most severely displaced radial neck fractures, which were otherwise being treated by surgical intervention. The online version of this article (10.1007/s43465-020-00168-6) contains supplementary material, which is available to authorized users.

Practice Patterns and Outcomes of Pediatric Thyroid Surgery: An NSQIP Analysis

BackgroundPediatric thyroid cancer rates are rising. The aim of this study was to determine the state of current practice and outcomes for pediatric thyroidectomies using the pediatric National Surgical Quality Improvement Program (NSQIP-P) with specific attention to differences based on surgeon type/specialty. MethodsAll cases of pediatric thyroidectomies and neck dissections within the NSQIP-P database were identified from 2015 to 2017. Patient, disease, and treatment-related factors affecting 30-day outcomes were analyzed using univariate and multivariate analyses. ResultsA total of 1300 cases were identified. Mean age at time of surgery was 14.0 (SD 3.5) years. The majority of patients were female (78%) and Caucasian (72%). Pediatric general surgeons performed the largest proportion of cases (42%) followed by pediatric otolaryngologists (33%). Malignancies were present in 29% of cases. The overall rate of complications was 3.0%. On multivariate analysis, non-pediatric surgeons were more likely to operate on Caucasian children, malignant pathology, and perform modified radical neck dissections. Pediatric surgeons were more likely to have longer operative times, have specialized in otolaryngology, and operate on sicker children (ASA>2). There were no differences in length of stay or overall complications rates. ConclusionsThis study shows that pediatric surgeons currently perform the majority of thyroid surgeries in children. While unable to assess surgeon volume, our data show that thyroid surgery is being safely performed at NSQIP-affiliated hospitals by both non-pediatric and pediatric surgeons. Further studies are needed to determine if there are differences in specific procedure-related complications and long-term outcomes between surgeon types.

Current controversies in management of fracture neck femur in children: A review

Paediatric femur neck fracture is an uncommon injury and is known for high rate of complications. This in turn, can have significant impact on development of hip and overall function of the child. Controversy prevails in many areas of management and it still remains a difficult injury to manage. Through this paper, an attempt has been made to summarize the current concepts in management and suggest current recommendations regarding the controversies so that these injuries can be managed judiciously. A systematic review was done as per PRISMA guidelines using pre-defined inclusion and exclusion criteria. 18 studies with better scientific evidence after quality assessment were included in the systematic review. Current trends and Controversial issues in management were then identified and discussed. It was observed that existing literature is inconclusive regarding several aspects of management of this injury with no clear guideline available. However, certain recommendations useful for decision making could be made. These injuries should be managed aggressively with operative fixation at the earliest and one should not hesitate to open reduce if acceptable alignment is not obtained after one or two gentle closed manipulations. Choice of implant and their configuration in neck can vary depending on age and weight of patient, type of injury and surgeon’s preference. Initial fracture displacement could be considered to be most predictive for development of osteonecrosis of the femoral head, whereas, role of surgical decompression, type of fixation and timing of surgery is still debatable. Functional outcome is primarily affected by osteonecrosis of the femoral head, nonunion and severe coxa vara, whereas mild coxa vara, shortening, and premature closure of physis when considered alone, don’t have significant influence on functional outcome in short term. Treatment of fracture neck femur in children is still controversial in many aspects and needs further research. It should be understood that complications can occur regardless of the method of treatment and might reveal their full impact many years after injury. Hence, a guarded prognosis should be explained to the parents and care-givers at the time of injury.

Radiation therapy is an important factor to improve survival in pediatric patients with head and neck rhabdomyosarcoma by enhancing local control: a historical cohort study from a single center

BackgroundThe purpose of this study is to analyze the influence of radiation therapy on survival in a historical cohort of 56 pediatric patients with head and neck rhabdomyosarcoma.MethodsA historical cohort of 56 pediatric patients with head and neck rhabdomyosarcoma from June 1st, 2013 to June 30th, 2019 was chosen. Clinical data and follow up results were collected including all diagnosis, treatment and prognosis information. Overall survival (OS) and event free survival (EFS) as time-to-event distributions were estimated with Kaplan-Meier method, and univariate analysis was performed with log rank test to detect differences between groups. Multivariate analysis was performed to explore the risk factors for survival with Cox proportional hazard model.ResultsThe media follow up time of all 56 patients was 31.8 months (range 3.5–74.6 months). There were 26 events during follow up, including 14 disease progressions and 12 relapses. The estimated 5-year OS of all patients was 69.9%, and the estimated 5-year EFS was 48.8%. Patients with radiation therapy as a component of the initial treatment plan had better 5-year OS and EFS compared with those without radiation therapy (OS 80.3% vs. 49.7%, p = 0.003 and EFS 63.9% vs. 21.9%, p < 0.001). In patients with events, those who received salvage radiation therapy had better 5-year OS compared with those who didn’t (OS 66.0% vs. 31.2%, p = 0.033). On multivariate analysis, tumor size > 5 cm and non-initial radiation therapy were independent risk factors for OS in all patients, non-initial radiation therapy was an independent risk factor for EFS in all patients, and tumor size > 5 cm was an independent risk factor for OS in patients with events.ConclusionsRadiation therapy as a component of initial treatment can improve the OS and EFS in pediatric head and neck rhabdomyosarcoma patients by enhancing local control, and non-initial radiation therapy is an independent risk factor for OS and EFS. Salvage radiation therapy still can improve OS in patients with disease progression and relapse. Tumor size > 5 cm is an independent risk factor for OS in pediatric HNRMS patients with or without disease progression/relapse.