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Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Surgical treatment of toe syndactyly remains controversial. The strong demand from parents for a cosmetic release is increasing in our societies. But is it worth it? The objective was to assess medium-long term outcomes and to identify the risk factors of recurrence, complication and poor clinical outcomes., Methods: Sixty-eight toe syndactylies (38 patients) undergoing surgery between 2008 and 2017 with a follow-up higher than two years were included consecutively and retrospectively. Four children (four syndactylies) were lost to follow-up and excluded. The mean age of the first surgery was 3.9 years old (0.8-16.7) and cohort mean follow-up was 6.9 years (2.8-11.2). In all patients, web release with a commissural dorsal flap was performed and associated a cutaneous resurfacing (spontaneous epithelialization, full-thickness skin graft taken from the popliteal crease, or a hyaluronic acid ester matrix)., Results: Eighteen syndactylies (28.1%) in 14 patients recurred and one syndactyly required revision surgery. An age of surgery above two years was the only risk factor for recurrence found in univariate (OD = 0.27[0.08;0.85];p = 0.02) and multivariate studies (IC 95% = 0.05-0.68;p = 0.02). Seven complications (11.7%) in seven syndactylies (6 patients) were reported with six keloids (9.4%) and one scar retraction (1.6%). Each complication underwent an additional procedure. African ethnicity (N = 15) represents a risk factor (N = 4/15; OD = 0.12[0.009;0.97];p = 0.02) for keloids formation. Withey's average score is 4.9 (1-11), mean OxAFQ-C score was 52/60 (30-60), 67% would repeat the surgery and 69% felt satisfied at last follow-up. The simple syndactyly would appear less satisfied than complex or complicated (p = 0.02)., Conclusions: Surgical treatment of child's congenital syndactyly involves a risk of recurrence (28%) and potential complications (11,7%). Performed surgical procedure over two years old increase the risk of recurrence. African ethnicity is a risk factor in scarring complication. Only half of simple syndactylies are satisfied and prone to repeat the surgery., (Copyright © 2021 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

In children suffering from brachial plexus birth injuries (BPBI), one major difficulty concerns intraoperative selection of the roots to be used for reconstruction. Between November 2018 and August 2020, surgical qualitative evaluations and pathological quantitative analyses were conducted on 52 roots and 29 distal neural stumps (trunks, divisions, cords, and nerves distal to the neuroma) in 17 patients who underwent brachial plexus reconstruction. For each root, surgeons rated stump quality as "good", "fair" or "avulsed". Neural sections were then sent to pathology to determine percentage intraneural fibrosis under microscopy. Mean root intraneural fibrosis rates were 30.5% (SD 24.9; range, 0-80%), 46.3% (SD 32.6; range, 0-90%) and 24.6% (SD 23.5; range, 0-80%) in the "good quality", "fair quality" and "avulsed" groups, respectively, with no significant differences between groups. In distal neural stumps, the mean intraneural fibrosis rate was 30.9% (SD 24.7). These findings raise the question of conducting frozen section biopsy of neural stumps after neuroma resection to determine surgical reconstruction strategy., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Outcomes measurements after pollicization remains difficult due to the lack of a standardized assessment protocol. This study reports our experience of a global assessment of pollicized thumbs that includes a specific questionnaire for subjective evaluation, a detailed clinical assessment focused on functional outcomes incorporating function and usage of the pollicized thumb. Twenty-seven patients completed the questionnaire, and nine hands were clinically evaluated by a multidisciplinary team composed of hand surgeons and occupational therapists. Subjective evaluations revealed that 24 patients would recommend pollicization. Clinical evaluations revealed that only four out of nine patients properly integrated their pollicized thumb during bimanual activities; however, occupational therapy input allowed the children to compensate for the lack of strength and other difficulties. We propose the use of this global assessment package to analyse function and usage at various capacities, which can be useful for the surgeon, child and parents. Level of evidence: IV.

Background: Brachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters., Methods: Kinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated., Findings: The humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters., Interpretation: Using kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Ultrasound shear wave elastography (SWE) is a noninvasive, reliable and reproducible method, used for the qualitative and quantitative evaluation of tissues. The aim of this study was to compare muscle elasticity between the healthy and the involved sides in children with neonatal brachial plexus palsy (NBPP) using the elastography tool and to assess whether the difference was correlated with the Mallet grading system. We repeatedly measured the shear modulus coefficient of several muscles around the shoulder in stretched or passively relaxed positions on 14 patients. We evaluated the abductor muscles (supraspinatus and deltoid), the infraspinatus, the pectoralis major and the latissimus dorsi. We found a mean shear modulus significantly higher in most studied muscles in the pathologic side (P < 0.001), especially in the stretched position (P < 0.001). Moreover, the shear modulus increases with the degradation of the Mallet score for the abduction and external rotation tasks. SWE seems to be a reliable and reproducible tool to assess muscle elasticity in NBPP., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

To assess the practicability (usability and satisfaction) and analytical performances of the VitaPCR™ SARS-CoV-2 Assay (Credo Diagnostics Biomedical Pte. Ltd.), a rapid point-of-care nucleic acid amplification test (NAAT), by reference to real-time reverse-transcription polymerase chain reaction (rRT-PCR) for respiratory viruses. The practicability of the VitaPCR™ Assay and Instrument was assessed from usability evaluation and a satisfaction questionnaire. Nasopharyngeal swabs were collected from 239 patients with coronavirus disease 2019 (COVID-19)-like illness during the second epidemic wave, in Paris, France. Overall, the usability of the VitaPCR™ Instrument was high. The satisfaction questionnaire indicated a high appreciation of the VitaPCR™ NAAT mainly for the short duration of analysis in only 20 min. A total of 140 and 99 samples were positive and negative for SARS-CoV-2 RNA by rRT-PCR, respectively. In the event of significant viral load (i.e., N gene C t values  33), the platform's analytical performances dropped significantly, with lower sensitivity, concordance, and accuracy, while its specificity remained high. The VitaPCR™ SARS-CoV-2 Assay is an accurate rapid point-of-care NAAT, suitable for clinical practice for the rapid diagnosis of COVID-19, especially in patients with COVID-19-suspected symptoms., (© 2021 Wiley Periodicals LLC.)

Background: In cases of brachial plexus birth injury with internal rotation contracture of the shoulder, the subscapularis muscle may be released proximally, from the subscapular fossa, or distally, along with periarticular soft tissues arthroscopic to the glenohumeral joint. We hypothesized that the indication for each procedure would rely primarily on patients' bone remodeling potential and periarticular soft-tissue contractures, performing proximal releases in patients aged < 4 years and periarticular distal releases in older patients. The purpose of this study was to analyze the outcomes such a strategy could provide., Methods: All patients presenting with brachial plexus birth injury-related shoulder internal rotation contractures who underwent a subscapularis release were included; in addition, to restore the joint axial balance, the infraspinatus was systematically reanimated with a tendon transfer (ie, latissimus dorsi or lower trapezius) during the same operating time. Chart review yielded preoperative and postoperative clinical and radiographic measurements, including active and passive range of motion of the shoulder in external rotation (ER) with the arm at the side of the body, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process., Results: Between July 2012 and January 2018, 28 children were operated on at our institution. In patients who underwent proximal subscapularis release (n = 13), significant improvements were observed regarding active shoulder ER, passive shoulder ER, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process, averaging 58° ± 32° (P < .0001), 56° ± 20° (P < .0001), 9.7 ± 3.1 points (P = .0006), 15° ± 10° (P = .0034), and 24% ± 20% (P = .0113), respectively, after a mean follow-up period of 4 years. Following distal release procedures (n = 15), these improvements averaged 26° ± 29° (P = .0024), 27° ± 28° (P = .0011), 3.3 ± 4.1 points (P = .0049), 2° ± 17° (P = .4086), and 4% ± 18% (P = .215), respectively, after a mean follow-up period of 3 years., Conclusion: When combined with axial rebalancing of the joint, the proximal release of the subscapularis muscle appears to be sufficient to provide satisfactory functional outcomes in patients with great bone remodeling potential and supple periarticular soft tissues. In older patients, a more comprehensive release of the glenohumeral joint's arthroscopic aspect seems to provide lower but still significant clinical improvements., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

When developing new cosmetics, it is extremely important to consider the safety of consumers. Absence of potential irritancy is generally assessed using an OECD TG439 compliant Reconstructed Human Epidermis (RHE) systems and MTT assays, resulting in an irritant/not irritant classification. To gain insight into the irritancy of molecules/finished cosmetic products and to predict the outcome of irritation tests performed on subjects whatever their nature, we developed a test that uses skin explants and histological analysis. Results showed that this irritation test is sensitive enough to accurately and repeatably detect known irritants. If the diverse origin of the skin explants used led to variability in the histological alterations scored, the overall grading of irritancy is highly reproducible. Finally, when testing 120 non-alcoholic cosmetics of various galenic forms, comparison of data between the ex vivo irritation tests and of a 24-/48-h human patch test revealed a single false negative, very close to the limit, and a 10% false positive rate. It was not possible to calculate the sensitivity of the ex vivo irritation test; however, its specificity was 89.9% and its accuracy was 89.1%. Similar results, with a slightly higher false positive rate, were found when testing 49 alcoholic cosmetics. These values exceed the minimum requirements of OECD TG439., (Copyright © 2020. Published by Elsevier Ltd.)

Introduction: In the pediatric population, fractures of the radial neck account for approximately 1% of all fractures and can have substantial consequences. Given the growing popularity of horse riding and the high-energy traumas that this can entail, we sought to assess prognosis for radial neck fracture sustained in horse riding., Hypothesis: Radial neck fracture sustained in horse riding is more severe and more frequently associated with other ipsilateral osteoarticular lesions which worsen prognosis., Material and Method: We performed a multicenter retrospective comparative study in a continuous series of 39 patients. The inclusion criteria consisted of radius neck fracture in children under the age of 15 years. Endpoints comprised associated lesions at time of trauma, and ranges of elbow motion in pronation/supination and flexion/extension at last follow-up., Results: Compared to other etiologies, radial neck fractures following horse-riding accidents were more frequently associated with other ipsilateral osteoarticular lesions (p=0.0002), and more often required open reduction (p=0.0409) and postoperative rehabilitation (p=0.041). However, there were no significant differences in any ranges of motion at last follow-up (p>0.05)., Conclusion: Radial neck fractures following horse-riding accidents in children were more severe than those caused by other mechanisms. Awareness campaigns in riding clubs and development of specific protective equipment should be considered to reduce occurrence., Level of Evidence: Therapeutic III - Retrospective comparative study., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Introduction: Madelung's deformity is rare. Treatment often consists in radial or ulnar osteotomy, Vickers' ligament resection or ulnar epiphysiodesis. The present multicenter retrospective study reports clinical and radiographic results in various surgeries. The study hypothesis was that early surgery improves outcome., Material and Method: Files were analyzed for 36 children (47 wrists) operated on between 1998 and 2015. Mean age at diagnosis was 12 years (range, 6-15 years). Mean follow-up was 7.2 years (range, 2-17.4 years). Two age groups were distinguished: 6-11 and 12-17 years. Endpoints were esthetic, functional (Mayo Wrist Score: MWS) and radiographic [lunate fossa angle (LFA), radial height (RH), lunatum cover rate (LCR), ulnar head translation (UHT), lunatum ascension (LA)]. Techniques mainly comprised distal radius osteotomy (DRO) with ulnar shortening osteotomy (USO), and Vickers' ligament resection (VR), either isolated or associated to osteotomy., Results: Age at surgery guided choice of technique, but did not impact results. VR gave better functional results when performed in young children; it was mainly performed in the 6-11 years age group, providing very satisfactory results (7 out of 8 wrists) with excellent function (7 out of 8), without improving radiographic parameters; in the 12-17 years age group, even when esthetic results were excellent, functional results were only good-to-acceptable (3 out of 5 wrists) and 1 result was poor. DRO+USO was mainly performed in the 12-17 years age group, with very satisfactory or satisfactory results (8 out of 10 wrists) and excellent function (6 out of 10). DRO+USO appeared to be an option of choice, significantly improving radiographic parameters and correcting the deformity (24.5° improvement in LFA (p=0.0033) and 36.2% improvement in LCR (p=0.0103)). DRO+USO+VR was mainly implemented in the 12-17 years age group, with very satisfactory results (3 out of 4 wrists) and excellent-to-good MWS in most cases (3 out of 4), but without significant radiographic improvement., Discussion: Esthetic and functional results were comparable regardless of age, except for VR, which gave better functional results in the 6-11 years age group, but without significant difference., Conclusion: The present study showed that, regardless of children's age, surgery provided esthetic, functional and radiographic benefit, although no decision-tree could be drawn up., Level of Evidence: IV., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

From 1998 to 2014, we performed primary brachial plexus repair in 260 children with neonatal brachial plexus palsy. Thirty-three presented with a C5-8 palsy and 24 were reviewed for this study. The surgical strategy was to focus on repairing the upper trunk. Secondary surgical procedures were performed in 21 patients, mainly for shoulder external rotation deficit or weak wrist extension. After a mean follow-up of 9.7 years (range 3 to 19), the median Mallet score for the shoulder was 9.5 and the mean Raimondi score for the hand was 3.3. Median active movement scale was 5, 7 and 5.5 for the deltoid, biceps and triceps, respectively. We conclude that primary C5-8 brachial plexus reconstruction provides restoration of elbow flexion and most patients have a sensitive and functional hand. We also found that secondary surgery to improve shoulder and wrist function is often necessary, which should initially be explained to the family. Level of evidence: IV.

Radial club hand deformities are commonly treated with arthrolysis to allow centralization of the ulna. In this retrospective cohort study of 31 hands in 28 patients, we aimed to assess the outcomes of correction using progressive distraction and subsequent percutaneous pinning of the wrist with a corrective ulnar osteotomy. Mean follow-up time was 7 years (range 2 to 20). The angulation of the hand-forearm complex was decreased after each step of the procedure. Mean correction of the angulation was 64°, and the residual total forearm-hand angulation was 12° after completion of the surgery. At the time of bony maturity (four patients), all wrists had fused. Fifty-eight reoperations were required in 31 wrists because of pin migration or breakage, and in addition 18 secondary osteotomies of the ulna were performed. From this study we conclude that distraction and pinning provide satisfactory and stable realignment of the wrist to correct the deformity, but this treatment has drawbacks regarding the high number of reoperations and the loss of wrist mobility. Level of evidence: IV.

Introduction: In children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion (ROM) and causing activity limitation. The aim of this multicentre randomised controlled trial is to evaluate the effectiveness of botulinum toxin injections (BTI) in the shoulder internal rotator muscles of 12-month-old babies in limiting the progression of posterior subluxation of the glenohumeral joint, compared with a sham procedure mimicking BTI. The secondary aims are to evaluate the effectiveness of BTI in (1) limiting the progression of glenoid retroversion and three-dimensional (3D) deformity and (2) improving shoulder ROM and upper limb function, as well as to confirm the tolerance of BTI., Methods and Analysis: Sixty-two babies with unilateral BPBI and a risk of posterior humeral head subluxation will be included. Only those with at least 7% posterior subluxation of the humeral head compared with the contralateral shoulder on the MRI will be randomised to one of two groups: 'BTI' and 'Sham'. The BTI group will receive BOTOX injections at the age of 12 months in the internal shoulder rotator muscles (8 UI/kg). The sham group will undergo a sham BTI procedure. Both groups will undergo repeated shoulder MRI at 18 months of age to quantify changes in the percentage of posterior migration of the humeral head (primary outcome), glenoid version and 3D bone deformity. Clinical evaluations (passive shoulder ROM, active movement scale) will be carried out at baseline and 15 and 18 months of age. The mini-assisting hand assessment will be rated between 10 and 11 months and at 18 months of age. Adverse events will be recorded at least monthly for each child., Ethics and Dissemination: Full ethical approval for this study has been obtained. The findings will be disseminated in peer-reviewed publications., Trial Registration Number: EudraCT: 2015-001402-34 in European Clinical Trial database; NCT03198702 in Clinical Trial database; Pre-results., Competing Interests: Competing interests: CP reports non-financial support from Biogen, outside the submitted work. SB reports non-financial support from Allergan, outside the submitted work. GLG reports other from Portola Pharmaceuticals, other from Boehringer-Ingelheim, other from Pfizer, other from Bristol-Myers Squibb, other from LEO Pharma, other from Daiichi Sankyo, other from Bayer, other from Bayer, other from Pfizer, other from LEO Pharma, other from Sanofi, other from bioMérieux, outside the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The objective of this study was to evaluate the results after selective pronator teres (PT) neurectomy in children with spastic hemiplegia. Patients with PT spasticity without contracture and an active supination improvement after PT botulinum toxin injection were included. Hand function and deformities were evaluated with the House score, Gschwind and Tonkin pronation deformity classification and Zancolli's classification. Twenty-two patients (mean age 11.6 years) were included in this study. The average follow-up was 32.6 months. All but one patient improved their supination with a preoperative mean active supination of 5° (range -80-70°) and postoperative of 48° (range 10-90°). Active pronation was always maintained at the last follow-up. PT selective neurectomy appears to improve active and passive forearm supination and should be included in a global strategy of treatments to improve upper limb function in children with cerebral palsy., Level of Evidence: IV.

Congenital muscle hypertrophy of the upper limb is a very rare condition with unknown aetiology. This descriptive observational and retrospective series included eight children followed by a multidisciplinary team from 2005 to 2017. The diagnosis was based on a cluster of clinical and radiological characteristics after elimination of differential diagnoses. Patients were categorized according to: anomalies of the wrist, anomalies of long fingers of intrinsic or extrinsic origin; and anomalies of the thumb with or without first web space contracture. Treatment begins in young children with hand orthoses to limit muscle contraction and joint malposition. The purpose of surgical treatment was to release contractures and to restore muscle balance through, in the main, finger intrinsic releases and first web releases. At the 2-year follow-up, we found that limited surgical procedures improved finger, thumb and wrist positions. We conclude that muscle hypertrophy is the main cause of deformity and that selective releases of contracted musculo-tendinous units and skin lengthening are effective., Level of Evidence: IV.

Study Design This is a retrospective cohort study. Objective The authors report surgical outcome in a series of very young children who underwent finger replantation after traumatic amputation. Methods During a 10-year period, 65 children were treated with replantation for finger amputation in two institutions. This study focused on replantation of 15 fingers in 13 young patients under 6 years of age (mean age: 2.9 years; range: 1.1-5.7 years). Early postoperative complications were categorized into major or minor. At the time of assessment, the authors evaluated everyday life activities, pain and cold tolerance, total active range of motion (TAM) in patients with successful replantation, and growth disturbance. Results The overall success rate for children younger than 6 years was 47% (7 out of 15), and the authors had 67% of major complications, mainly in patients with crush injuries. There was venous ischemia in 13 (86%) fingers treated with controlled bleeding. The hemoglobin level decreased more than 2 g/dL in six patients, and blood transfusion was necessary in two patients. At the last follow-up, patients with successful replantation had a mean TAM of 72%. Conclusion Despite numerous complications mainly in relation with venous congestion, the functional outcome is satisfactory after successful replantation in young children, which should always be attempted. Level of Evidence/Type of Study Level III, case series, therapeutic study.

Purpose: Obstetric brachial plexus palsy (OBPP) may result in a severe impairment of upper limb function, especially when major motor functions do not recover with or without early microsurgical reconstruction. Various methods to restore elbow flexion have been described. The aim of this study was to report the results after pectoralis minor transfer for elbow flexion restoration in late OBPP., Methods: Nineteen patients were included. Mean age at surgery was six years (range, 2.3-12.8). The mean follow-up period was four years (range, 1-15). Shoulder function was evaluated by the Mallet classification and hand function by the Raimondi scale. We used the "active movement scale" (AMS) to evaluate elbow flexion function., Results: Eighteen of the 19 patients had improvement in their elbow active flexion. There was significant improvement in biceps muscle power according to the BMRC grading system, from an average grading of 1.7 (range, 1-3) pre-operatively to 3 (range, 1-4) post-operatively (P < 0.05). The average active elbow flexion was significantly improved from a mean of 81° (range, 0-120; SD = 44) pre-operatively, most of them gravity eliminated, to a mean of 111° (range, 0-140; SD = 33) post-operatively (P < 0.05). According to the AMS, 12 patients (63%) had a good result, 4 (21%) a fair result and 5 (26%) a poor result. Poor results were significantly correlated with a low pre-operative AMS score (P < 0.05)., Conclusions: The pectoral minor transfer can be a reliable technique for elbow flexion improvement in late OBPP by strengthening an already existing but inadequate active flexion., Level of Evidence: IV.

Background: The physical signs of obstetrical brachial plexus palsy range from temporary upper-limb dysfunction to a lifelong impairment and deformity in one arm. The aim of this study was to analyze the kinematics of the upper limb and to evaluate the contribution of glenohumeral and scapulothoracic joints of obstetrical brachial plexus palsy children., Methods: Six children participated in this study: 2 males and 4 females with a mean age of 11.7years. Three patients had a C5, C6 lesion and 3 had a C5, C6, C7 lesion. They were asked to perform five tasks based on the Mallet scale and the kinematic data were collected using the Fastrak electromagnetic tracking device., Findings: The scapulothoracic protraction and posterior tilt were significantly increased in the involved limb during the hand to mouth task (p=0.006 and p=0.015 respectively). The scapulothoracic Protraction/glenohumeral Elevation ratio was significantly increased in the involved limb during the hand to neck task (p=0.041) and the elevation task (p=0.015). The ratios of scapulothoracic Tilt on the three glenohumeral excursion angles were significantly increased during the hand to mouth task (p≤0.041). The scapulothoracic Mediolateral/glenohumeral Elevation ratio was significantly increased in the involved limb during the elevation task (p=0.038). The glenohumeral elevation excursion was significantly decreased in the involved limb during the hand to neck task (p<0.001) and the elevation task (p=0.0003)., Interpretation: This study gives us information about the greater contribution of the scapulothoracic joint to shoulder motion for affected arm of obstetrical brachial plexus palsy patients compared to their unaffected arm. Kinematic analysis could be useful in shoulder motion evaluation during the Mallet score and to evaluate outcomes after surgery., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Metaphyseal and physeal fractures of the distal radius are common in children. Most cases are best treated with closed reduction and cast immobilization. Long-term outcomes of these injuries are excellent when specific treatment principles of reduction and casting are followed. Surgical indications are limited and include open fractures, intra-articular fractures, non-reducible fractures, unstable fractures, and the presence of associated nerve injury. Closed reduction and percutaneous pin fixation is the most commonly used surgical option. The clinician should be aware of delayed complications such as growth disturbance of the distal radius, and understand how to manage these problems to ensure successful long-term outcomes. Epiphysiodesis is uncommon but growth plate injuries need to be followed for one year., (Copyright © 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Unlabelled: Twenty adolescents with severe spastic deformities of the wrist (Zancolli type 3) and poor function on the House score were operated on between 2009 and 2014, and included in this retrospective cohort study. All were treated by wrist arthrodesis combining a proximal row carpectomy, curetting of the distal radius in order to imbed the capitate and a dorsal locking plate. The primary endpoint was improvement in the House score. Secondary endpoints included pre- and postoperative wrist flexion deformity, bone union, patient satisfaction regarding appearance and complications. The mean follow-up was 22 months. The mean age at the time of surgery was 16.2 years. Additional soft-tissue release was necessary in eight wrists. The mean House score improved significantly from 0.9 to 2.7. Average flexion deformity improved significantly from 66° to 10°. Bony union was achieved in all patients within 6 months. Four of the 20 patients required hardware removal because of fixed extension of the middle metacarpal. Wrist arthrodesis combining proximal row carpectomy with the use of a dorsal locking plate is a safe and reliable technique to improve function and appearance., Level of Evidence: IV., (© The Author(s) 2016.)

Traumatic trapeziometacarpal joint dislocation of the thumb accounts for less than 1% of all hand injuries. This injury is even less common in children. Optimal treatment strategies for this injury are still the subject of debate for both children and adults. We report a case of recurrent posttraumatic trapeziometacarpal joint dislocation in an eight-year-old girl. We believe our case is the first report of recurrent acute dislocation leading to chronic dislocation in the English medical literature. Restoring the anatomy and biomechanics of the trapeziometacarpal joint is essential when treating these injuries; for this reason, surgical treatment is usually indicated. Overall, the prognosis of trapeziometacarpal dislocation treated acutely is favorable and stable over time. However, the role of open surgery and ligament reconstruction remains controversial, especially in children., (Copyright © 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: Coverage of soft-tissue defects of the ankle and foot is often challenging. The distally based sural fascio-cutaneous flap is useful for reconstructing the lower leg, ankle, heel, and foot but has rarely been evaluated in paediatric patients. The objectives of this study were to assess the reliability of this flap in paediatric patients, to describe the complications associated with its use, and to define its indications in paediatric patients with soft-tissue defects of the ankle and foot., Hypothesis: We hypothesised that the sural flap was reliable for covering soft-tissue defects at the ankle and foot in paediatric patients., Material and Methods: A distally based sural fascio-cutaneous flap was used to cover soft-tissue defects of the ankle and foot in 20 paediatric patients between 1997 and 2013. The evaluation at last follow-up included a physical examination and determination of the modified functional Kitaoka score. Mean follow-up was 50.6 months (range, 10-192 months) and mean patient age at surgery was 8.8 years (range, 1.5-17 years). Trauma was the most common cause of soft-tissue defect (n=12); other causes were surgical-site infections (n=2), tumours (n=3), chronic ulcer (n=1), burn injury (n=1), and infusion fluid extravasation (n=1)., Results: Of the 20 flaps, 16 (80%) remained fully viable, whereas 4 developed partial necrosis requiring excision and skin grafting, which consistently ensured a good outcome. Other complications consisted of marginal necrosis (n=4), unsightly donor-site scars (n=5), and infection (n=2). Abnormal flap sensation was noted in 11 patients. The mean modified Kitaoka score was 65/80 (range, 0-80), and the score value indicated that function was excellent in 9 (45%) patients, good in 9 (45%) patients, and poor in 2 (10%) patients., Discussion: The distally based sural fascio-cutaneous flap is a method of choice for covering soft-tissue defects of the ankle and foot in paediatric patients. This reliable flap spares the major blood vessels and has a strong blood supply. Its best indication is coverage of an acute traumatic soft-tissue defect with exposure of a vital structure. In patients requiring late reconstruction, caution is in order when considering the use of a distally based sural fascio-cutaneous flap, which can induce delayed complications, most notably at the donor site., Level of Evidence: IV, retrospective case-series study., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5-C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5-C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5-C6 nerve root avulsion., (© The Author(s) 2015.)

Introduction: Treatment of severe radial club hand is difficult. Several authors have emphasized the importance of preliminary soft-tissue distraction before centralization., Hypothesis: Treatment of severe radial club hand by articulated mini-rail allowing prior soft-tissue distraction improves results., Material and Methods: Thirteen patients were treated sequentially, with an initial step of distraction and a second step of centralization. The first step consisted in fitting 2 mini-fixators, one in the concavity and the other in the convexity of the deformity. Four transfixing wires through the ulna and metacarpal bone connected the 2 fixators. After this preliminary distraction, the fixator was removed and a centralization wire was introduced percutaneously, with ulnar osteotomy if necessary. Sagittal and coronal correction was measured on the angle between forearm and hand., Results: Mean age at treatment was 37.5 months (range, 9-120 months). Mean distraction time was 53.2 days (26-90 days). Ulnar osteotomy was required in 8 cases (61%). There were no major complications requiring interruption of distraction. Sagittal and coronal correction after centralization reduced mean residual forearm/hand angulation to<12°., Discussion: Soft-tissue distraction in the concavity ahead of centralization is essential to good correction, avoiding extensive soft-tissue release and hyperpressure on the distal ulnar growth plate. There have been several studies of distraction; the present technique, associating 2 mini-fixators connected by threaded K-wires, provided sufficient distraction in the concavity of the deformity to allow satisfactory correction in all cases. Subsequent complications (breakage or displacement of the centralization wires) testify to the complexity of long-term management., Conclusion: The present study confirms the interest of a preliminary soft-tissue distraction step in treating severe radial club hand., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Resection of primary malignant tumors often creates large bony defects. In children, this creates reconstructive challenges, and many options have been described for limb salvage in this setting. Studies have supported the use of an induced-membrane technique after placement of a cement spacer to aid in restoration of bone anatomy., Questions/purposes: We asked: (1) What complications are associated with the induced-membrane technique? (2) How often is bone healing achieved after resection greater than 15 cm using this technique? (3) What is the functional outcome of patients treated with this technique?, Methods: We performed a retrospective evaluation of eight patients with a mean age of 13.3 years (range, 11-17 years) treated for a malignant bone tumor between 2002 and 2012 at our centers. The primary malignant tumors involved the proximal humerus, femur, and tibia. All patients were treated using the induced-membrane technique after a resection with mean bone loss of 18 cm (range, 16-23 cm). The general indication for using the induced-membrane technique during this time was a large diaphyseal defect after resection of the tumor. In addition to using cancellous graft as with the original technique, in the current patients an autogenous nonvascularized fibula was used to enhance stability. The patients were assessed at the last followup using the Musculoskeletal Tumor Society (MSTS) scoring system. Mean followup was 47.1 months (range, 24-120 months), and none of the patients were lost to followup before 2 years., Results: A total of four unplanned reoperations were performed in these eight patients. A fracture of the reconstruction occurred in three patients and all were treated successfully, two with surgery and one with immobilization. Bone fusion was obtained in all patients within 4 to 8 months (mean, 5.6 months) after the reconstruction. The mean healing index was 0.31 month/cm of reconstruction (range, 0.23-0.5 month/cm). At last followup, the mean MSTS score was 74% (range, 67%-80%)., Conclusions: Our findings suggest that the modified induced-membrane technique is a reasonable alternative to other limb reconstruction techniques for bone tumors in children and has the advantage of not requiring a bone bank or an expensive metal prosthesis. Although more patients will be needed to substantiate our findings, it has become a standard part of our arsenal in the treatment of large bone defects after resection of pediatric primitive bone tumors., Level of Evidence: Level IV, therapeutic study.

Tendon lengthening and transfer are usually indicated for certain neuromuscular disorders, peripheral or central nerve injury, congenital disorder or direct traumatic or degenerative musculotendinous lesion. In musculotendinous lengthening, technique depends on muscle anatomy, degree of correction required, and the need to avoid excessive loss of force. Lengthening within the muscle or aponeurosis is stable. In the tendon, however, it may provide greater gain but is not stable and requires postoperative immobilization to avoid excessive lengthening. Tendon transfer consists in displacing a muscle's tendon insertion in order to restore function. The muscle to be transferred is chosen according to strength, architecture and course, contraction timing, intended direction, synergy and the joint moment arm to be restored. Functions to be restored have to be prioritized, and alternatives to transfer should be identified. The principles of tendon transfer require preoperative assessment of the quality of the tissue through which the transfer is to pass and of the suppleness of the joints concerned. During the procedure, transfer tension should be optimized and the neurovascular bundle should be protected. The method of fixation, whether tendon-to-bone or tendon-to-tendon suture, should be planned according to local conditions and the surgeon's experience., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Recent limping in children aged between 1 and 4 years old are often a diagnostic problem because the young child may not be able to show the area of pain. Dominated by the traumatic causes like hairline fracture, the physician should eliminate the most severe, including infectious etiologies that require urgent treatment. The clinical examination is fundamental and simple complementary investigations like standard X-rays and biology (blood count cell, C reactive protein) looking for increased inflammatory parameters will help to find the cause in the majority of cases. The persistence of a limp beyond a week involves the realization of bone scan or MRI imaging., (Copyright © 2014. Published by Elsevier SAS.)

Background: Hematogenous osteoarticular infections of the hand and the wrist in children with sickle cell anemia are rare and no specific studies for this location have been published., Methods: This retrospective and comparative study reviewed 34 children who carry the diagnosis of osteoarticular infections of the wrist and the hand at our institution during a 10-year period extending from January 2000 to December 2010. The first group included 8 patients with sickle cell anemia (Hg SS). The second group or control group included 26 children without sickle cell disease or any immune deficiency. Differences between groups were established by χ tests., Results: The most common site of osteomyelitis for the sickle cell group was the metacarpals and the fingers phalanx (87.5%) whereas the most common site for the control group was the wrist and the carpus (96.2%; P<0.005).The most common pathogens responsible for osteomyelitis was Salmonella sp. (37.5%) for children with SCD, whereas it was Staphylococcus aureus (70%) for the nonsicklers. There was a significant difference between both groups regarding the treatment. Indeed, a surgical procedure was needed for the sickle cell group in all cases (100%) whereas a surgical debridement was needed in only 19.2% patients in the control group (P<0.001). At long-term follow-up, there were more long-term complications in the sickle cell group (62.5%) with epiphysiodesis of the metacarpals and metacarpophalangeal joint destruction whereas only 11.5% cases with complications were present in the control group including distal ulna epiphysiodesis, proximal interphalangeal joint stiffness, and a central radius epiphysiodesis (P<0.004)., Conclusions: Our results confirm the severity of hand osteomyelitis in patients with sickle cell disease. A systematic approach is needed to perform early diagnosis and treatment. Identification of the causative organism is required (blood culture, bone aspiration). With antibiotic therapy, surgical treatment is the rule. Parents have to be advised about frequent complications like shortening or deformation due to premature fusion., Level of Evidence: Level III.

Background: Acetabular fractures are rare in children and can be complicated by premature fusion of the triradiate cartilage resulting in secondary acetabular dysplasia. Early recognition and treatment of a physeal bar in this location can be difficult. The purpose of this case report was to investigate whether early intervention could restore acetabular growth and prevent secondary acetabular dysplasia as measured on plain radiographs., Case Description: We report a series of three patients (3, 4, and 5 years old) who underwent physeal bridge resection and methylmethacrylate or fat interposition through an extended Pfannenstiel approach. The mean followup was 6 years. After resection of the osseous bridge the physis initially remained open with evident acetabular growth in all three patients. In one patient, the bridge reformed 6 years after the procedure. All patients had a slight increase in the thickness of the acetabular wall relative to the contralateral side but no radiographic evidence of acetabular dysplasia., Literature Review: To our knowledge, there are only two reports of physeal arrest resection of triradiate cartilage with one successful result., Clinical Relevance: Posttraumatic, partial physeal arrest of the triradiate cartilage may be treated with resection of the bone bridge resection through an extended Pfannenstiel approach. The potential benefits of this treatment must be weighed against the risks.

The hand is a commonly inljured location of a child. Fractures are the most frequent lesions with two specific locations. In the young child, the fracture is usually a crush injury, such as occurs when a hand gets caught in a door, with lesion of the distal phalanx. Soft tissue associated injuries are the main problem in this location. In the older child, the fracture is usually secondary to recreational sports, with lesion on the proximal phalanx of the second and fifth digits. Dislocations or sprains are less common. A metacarpophalangeal joint dislocation is more likely to be irreducible secondary to volar plate entrapment. Open reduction is often necessary Most hand injuries in children are treated nonoperatively with a favorable outcome. The treating physician should however identify those cinical situations that require surgery, as complications are most commonly due to a failure to identify and treat an injury requiring an operation acutely. These injuries include intra-articular fractures, displaced phalangeal neck fractures and malrotated fractures. Malrotation or intra articular malunion have no remodeling capacity.

The hand is one of the most commonly injured locations in children. In the young child, the ignorance of dangers may explain this frequency. In the older child, hand trauma is usually secondary to recreational sports. Most hand injuries in children are treated nonoperatively because of high remodeling potential. Surgical treatments are mandatory in case of open or unstable fracture, displaced intraarticular fractures and displaced phalangeal neck fractures. In phalangeal neck fractures, percutaneous treatment should be preferred. Finger stiffness and non-union are uncommon and are usually in relation with skin or vascular involvement. In case of physis fracture, clinical and radiological follow-up should monitor any growth problems., (Copyright © 2013. Published by Elsevier SAS.)

The hand is the most commonly injured location of a child. Fractures of the digits are the most frequent lesions with two specific locations: 1) in the young child, the fracture is usually a crush injury, such as occurs when a hand gets caught in a door, with lesion of the distal phalanx; soft tissue associated injuries are the main problem in this location; 2) in the older child, the fracture is usually secondary to recreational sports, with lesion on the proximal phalanx of the second and fifth digits. Dislocations or sprains are less common. Most interphalangeal joint injuries occur at the proximal interphalangeal joint and are secondary to hyperextension with as results a volar plate injury. Most fingers injuries in children are treated non operatively with a favorable outcome. The treating physician should however identify those clinical situations that require surgery, as complications are most commonly due to a failure to identify and treat an injury requiring an operation acutely. These injuries include intra-articular fractures, displaced phalangeal neck fractures, and malrotated fractures. Malrotation or intra-articular malunion have no remodeling capacity. Non-union and stiff digits are uncommon but a significant trauma or a high-energy mechanism with severe soft tissues injuries appears to be a factor of risk., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Metacarpal fractures and dislocations in the fingers are common injuries in children's hands. Most of these can be treated successfully non-operatively, although a subset requires more aggressive treatment. Results following appropriate care in children are generally good. Twenty percent of them need a reduction, need for surgical stabilization is rare. Each injury is presented, including diagnostic, therapeutic principles, pitfalls to prevent and potential complications., (Copyright © 2013. Published by Elsevier SAS.)

Introduction: The present study sought to assess the interest of inter-tibiofibular graft (ITFG), alternatively called posterolateral bone graft, in traumatic segmental tibial bone defect., Material and Methods: Twenty-eight ITFGs were performed in 125 tibial reconstructions for traumatic bone defect. Patient's records were reviewed retrospectively in a multicenter study. Tibial reconstruction with and without ITFG was compared for bone healing and patient's return to full weight-bearing status., Results: There were no failures of bone healing in the ITFG group, versus 14 (14%) in the non-ITFG group. Graft-to-consolidation delays were shorter with first-line ITFG, at a mean 10 months (range, 3-20 months) versus 16.5 months (range, 3-63 months) in the non-ITFG group (P<0.05). Weight-bearing was likewise more quickly resumed, with full weight-bearing at a mean 9 months (range, 3-19 months) versus 15 months (range, 1-34 moths) respectively (P<0.05). Return to work was also quicker, at a mean 15 months (range, 4-28 months) versus 27 months (range, 8-56 months) respectively (P<0.05)., Discussion: This study confirmed the interest of ITFG in tibial bone defect reconstruction. ITFG may singly be used for small defects less than 4 cm, or in conjunction with another tibial reconstruction technique; ITFG in the present series achieved consolidation in all cases and significantly shortened the times to return to full weight-bearing status and to work., Level of Evidence: III: retrospective case-control study., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Traumatic bone defects (BD) are rare in children. There are no pediatric series in the literature on this topic. The aim of this first pediatric series was to determine the epidemiological characteristics and evaluate the results of different treatments in this entity., Material and Methods: This retrospective multicenter study evaluated diaphyseal bone defects in cases in which bone reconstruction was performed. BD was either initial and associated with trauma or secondary, resulting from infected non-union., Results: The series included 27 patients (17 boys and 10 girls), mean age 11.4 years old (3-16) (20 traffic accidents). At the outset of all patients' history was an open fracture (one stage 1, seven stage 2, 11 stage 3A and seven stage 3B, 1 NR). BD involved 13 tibias, 9 femurs, three humerus, one radius and one ulna. Bone defects were initial in 20 cases and secondary in seven cases. They were less than 2 cm in two cases, between 2 and 5 cm in 9 cases, between 5 and 10 cm in 10 cases and more than 10 cm in six cases. Treatment of BD was immediate in one case and delayed in 26 cases. Techniques used included: induced membrane in 10 cases, bone transport in seven cases, bone autograft in eight cases, vascularized fibular transfer in one case, no bone reconstruction in one case. Union was obtained in 27 patients. Union was obtained within a mean 12.3 months BD (3-62). Fifteen patients presented with sequellae., Discussion: Traumatic bone defects have a better prognosis in children than in adults. The thicker, more active and richly vascularized periosteum in children is an important prognostic factor. Treatment of BD requires good initial bone stabilization. Reconstruction depends on the integrity of the periosteum. In case of an intact periosteum, bone reconstruction does not seem necessary in young children. If one part of the periosteum is intact, a simple autograft seems sufficient even with extensive bone defects. In the absence of the periosteum or especially in case of infection, the induced membrane technique seems preferable, with bone transport or a vascularized bone transfer., Level of Evidence: IV: retrospective study., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Partial closure of the growth plate is an uncommon complication in the distal radius even though distal radial fractures are among the most common injuries in children. We report two cases of resection of a bony bridge in the distal radial growth plate in boys aged 8 and 9 years with a description of the operative technique.

Segmental defects of the tibia are challenging therapeutic problems for both the physician and the patient. These defects may be caused by severe trauma, infection, tumors and congenital processes. Several different techniques have been described for treatment of these defects including the Papineau technique, allograft reconstruction, bone transport using the Ilizarov frame, free vascularized fibular graft, tibiofibular synostosis and medial transport of the fibula with Tuli's technique, use of the Ilizarov frame and Huntington's procedure. All of these techniques have their specific advantages as well as disadvantages. Some of these techniques are used rarely i.e. the Papineau technique. The procedure of choice for most large tibial defects is bone transport with Ilizarov's technique; but in some cases the tibial remnant is inadequate for lengthening and we must use alternative treatments. In the three aforementioned techniques, the fibula is transferred with peroneal and anterior tibial muscles on a pedicle of peroneal vessels. This transfer retains a biological component of vital bone that allows for a shorter time for consolidation, increased remodeling potential and resistance to infection. It also has better long-term mechanical properties. Hypertrophy of the centralized fibula is described as attaining twice its original diameter or twice the size of the contralateral tibia. Hypertrophy has been seen in nearly all cases of the fibular centralization. Maximum hypertrophy is seen in children and besides patient age, is related to bony union and weight bearing. The reported time for hypertrophy of fibula varies from one to four years. No significant change in the diameter of the fibula was observed after five years. Fracture of tibialized fibula was not reported in many studies of fibular centralization with different techniques. In the reviewed articles, there were no cases of valgus deformity of the ankle. Either the patients were satisfied with the final results despite appearance of the lower extremity and the presence of some angular deformities, although in most cases, the deformities were mild. In this review we conclude that tibialisation of the fibula in selected cases is a reasonable alternative for the treatment of massive tibial defects.

Purpose: The purpose of this study is to describe the kinematic changes in children with cerebral palsy (CP) after treatments performed on the forearm, wrist or thumb, with specific attention to the changes around the trunk, shoulder and elbow kinematics., Methods: With the use of a specific kinematic protocol, we first described the upper limb kinematics in a group of 27 hemiplegic patients during two simple daily tasks. Eight of these children were treated with botulinum toxin (Botox(®), Allergan) injection or surgery and were, thereafter, evaluated with another kinematic analysis in order to compare the pre- and post-therapeutic condition. The target muscles were the pronator teres, flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis, flexor pollicis longus and the adductor pollicis., Results: Significant kinematic changes were found after treatment. Patients increased forearm supination (P < 0.05) and wrist extension (P < 0.05) during both tasks. Patients also decreased trunk flexion/extension range of motion (ROM) (P < 0.05), improved elbow ROM (P < 0.05) and improved internal shoulder rotation (P < 0.05)., Conclusions: Dynamic shoulder or elbow limitations in children with mild hemiplegia involvement could be related to a compensatory movement strategy and/or co-contractions. As these proximal kinematics anomalies are improved after treatments performed at the forearm, wrist and thumb, they should not be treated first but should be reconsidered after the treatment of more distal problems.

Purpose: The spontaneous recovery rate for locked pediatric trigger thumb (PTT) has recently been reported at between 24% and 66%; these studies concluded that a conservative approach for this condition could be adopted. The aims of this study were to review our results of surgical release of the PTT and to survey pediatric hand surgeons regarding their practice patterns for treatment of the PTT., Methods: After institutional review board approval, we retrospectively reviewed 173 consecutive patients with 217 thumbs treated surgically at our institution. An e-mail survey of 27 pediatric hand surgeons questioned treatment of a 2-year-old child with a 6-month history of a locked trigger thumb and of an intermittently triggering thumb., Results: The retrospective review demonstrated that preoperative range of motion averaged 36° loss of extension (range, 0° to 90°; SD, 22°); postoperative range of motion averaged 1° loss of extension (range, 0° to 30°; SD, 7°) at 27-day follow-up. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or recurrences identified. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries. The practice pattern survey demonstrated that 85% of pediatric hand surgeons would treat a locked PTT in a 2-year-old with surgical release and 52% would treat an intermittently triggering thumb in a 2-year-old with continued observation if the triggering thumb was not painful., Conclusions: The surgical results reported in this study, along with the practice pattern survey, confirm that surgical release is a short, safe, and effective procedure when performed by specialty trained hand surgeons, and it is the treatment of choice for a locked PTT., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients., Methods: This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required., Results: Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases., Conclusions: This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation., Level of Evidence: IV.

Study Design: Retrospective study of prospectively collected data., Objective: Compare Universal Clamps (UCs) and hooks for the thoracic correction of adolescent idiopathic scoliosis (AIS)., Summary of Background Data: In scoliosis surgery, sagittal correction is as important as frontal correction due to the risk of junctional kyphosis. Compared to all-screw constructs, hybrid constructs with lumbar pedicle screws and thoracic hooks or sublaminar wires have been shown to achieve similar coronal correction while providing superior postoperative thoracic kyphosis. The authors used a novel sublaminar thoracic implant, the UC with improvements over sublaminar wires. Hybrid constructs using thoracic UCs were compared to those with thoracic hooks., Methods: This series involved 150 patients treated for AIS with hybrid constructs. A total of 75 consecutive patients operated from 2001 to 2003, who had thoracic hooks with in situ contouring, distraction, and compression (Group 1), were compared to 75 consecutive patients operated from 2004 to 2006, who had thoracic UCs with posteromedial translation (Group 2). All had intraoperative somatosensory/motor-evoked potential monitoring and at least 2-years follow-up., Results: Except for follow-up (longer in Group 1), the 2 groups were similar before surgery. The UCs achieved better thoracic coronal correction (P < 0.001), Cincinnati index (P < 0.001), kyphosis (P = 0.02), and apical rotation (P < 0.001). In normokyphotic or hypokyphotic patients, the UC corrected thoracic kyphosis by 11.2 degrees (55%) versus 0.4 degrees (2%) achieved by hooks (P < 0.0001). These differences were stable at last follow-up. There were no intraoperative complications or changes in somatosensory/motor-evoked potentials. UC reduced operative time by 20% (60 minutes; P < 0.001) and blood loss by 23% (250 mL; P < 0.001)., Conclusion: Although both of these hybrid constructs efficaciously corrected the coronal and axial deformities in AIS, the results of the UC technique were superior to those achieved with hooks in all 3 planes, especially the sagittal plane. Moreover, the UC technique is straightforward and safe, reducing both operative duration and blood loss.

Purpose: The development of claw toe deformity following fracture of the tibia in children has not been described in our review of the literature. We report on the management of the acquired claw toe deformity after tibia fracture in five children., Methods: We report on five patients, between 5 and 15 years of age, who developed clawing of the hallux following a fracture of the tibia. In two patients, the lesser toes were involved. On examination, when the ankle was passively plantar flexed, a flexion contracture of the interphalangeal joint of the hallux became fully flexible. When the ankle was dorsiflexed, the clawing became more obvious and fixed. A magnetic resonance imaging (MRI) study in two cases demonstrated fibrosis under or just proximal to the tarsal tunnel., Results: The contractures were relieved by performing a tenolysis proximal to the medial malleolus. The operative findings demonstrated that the etiology could be possibly associated with a localized subclinical compartment syndrome., Conclusions: We described five patients with a claw toe deformity following a tibia fracture associated with adhesions of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles to the surrounding structures under or just proximal to the flexor retinaculum. It is the authors' opinion that this condition may be related to a subclinical compartment syndrome localized in the distal part of the deep posterior compartment. Soft-tissue release without tendon lengthening allowed recovery in all patients.

Inoculation of blood culture vials with joint fluid samples has revealed the important pathogenic role of Kingella kingae in pediatric arthritis. However, recent studies based on broad-range 16S ribosomal DNA PCR and real-time PCR without a probe suggest that conventional methods remain suboptimal. We developed a new real-time PCR method with a probe that is highly specific for K. kingae and applied it to joint fluid samples collected from 89 children with suspected arthritis admitted to our institution during a 2-year period. Real-time PCR was also applied to blood samples obtained before surgery and to joint drainage fluid samples obtained during several days after surgery. Thirty-six (40%) of the 89 cases of suspected septic arthritis had positive culture. Staphylococcus aureus was the main isolate (n = 19/36, 53%), followed by K. kingae (n = 7/36, 19%). Specific real-time PCR identified K. kingae in 24 of the 53 culture-negative cases. Thus, K. kingae was present in 31 (52%) of the 60 documented cases, making it the leading pathogen. Real-time PCR on all 15 blood DNA extracts from patients with K. kingae infection was negative, demonstrating that joint fluid positivity did not result from DNA circulating in blood. Real-time PCR amplification of drainage fluid samples showed that the pathogen could be detected for up to 6 days after antibiotic initiation. K. kingae real-time PCR applied to DNA extracted from joint fluid samples, but not from blood samples, markedly improved the etiological diagnosis of septic arthritis in children. Retrospective diagnosis is feasible for up to 6 days after treatment initiation.

Correction of adolescent idiopathic scoliosis (AIS) has been reported with various systems. All-screw constructs are currently the most popular, but they have been associated with a significant decrease in thoracic kyphosis, with a potential risk of junctional kyphosis, not observed with hybrid constructs in the literature. In addition, it is important to weigh potential advantages of pedicle screw fixation against risks specific to its use. Because hybrid constructs are associated with a lower risk of complications and better sagittal correction than all-screw constructs, at present we use lumbar pedicle screws combined with a new sublaminar connection to the spine (Universal Clamps) at thoracic levels. The purpose of this study was to determine the efficacy and safety of the Universal Clamp (UC) posteromedial translation technique for correction of AIS. Seventy-five consecutive patients underwent posterior spinal fusion and hybrid instrumentation for progressive AIS. Correction was performed at the thoracic level using posteromedial translation. At the lumbar level, correction was performed using in situ contouring and compression/distractions maneuvers. A minimum 2-year follow-up was required. Medical data and radiographs were prospectively analyzed and compared using a paired t test. The average age at surgery was 15 years and 4 months (+/-19 months). The average number of levels fused was 12+/-1.6. The mean follow-up was 30+/-5 months. The average preoperative Cobb angle of the major curve was 60 degrees+/-20 degrees. The immediate postoperative major curve correction averaged 66+/-13%. The average loss of correction of the major curve between the early postoperative assessment and latest follow-up was 3.5 degrees+/-1.4 degrees . The mean Cincinnati correction index was 1.7+/-0.8 postoperatively, and 1.57+/-1 at last follow up. The mean rotation of the apical vertebra was corrected from 23.3 degrees+/-9 degrees preoperatively to 7.3 degrees+/-5 degrees at last follow up (69% improvement, P<0.0001). In the sagittal plane, the mean thoracic kyphosis improved from 23.8 degrees+/-14.2 degrees preoperatively to 32.3 degrees+/-7.3 degrees at last follow up. For the 68 patients who had a normokyphotic or a hypokyphotic sagittal modifier, thoracic kyphosis increased from 20.5 degrees+/-9.9 degrees to 31.8 degrees+/-7.4 degrees, corresponding to a mean kyphosis correction of 55% at last follow up. No intraoperative complication occurred and none of the patients developed proximal junctional kyphosis during the follow up. The principal limitation of the UC technique was the rate of proximal posterior prominence (14.6%), leading us to recommend the use of conventional claws at the upper extremity of the construct. The technique was safe, and reduced operative time, radiation exposure, and blood loss. While achieving correction of deformity in the coronal and axial planes equivalent to the best reported results of all-screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome in all three planes was maintained at 2 year follow up.

We report the first case of cutaneous mucormycosis after a scorpion sting in Tunisia. Histopathology showed broad aseptate hyphae suggestive of a Zygomycete. Saksenaea vasiformis was identified by PCR amplification and sequencing of the fungal DNA on a cutaneous biopsy. Successful treatment was obtained by surgery and liposomal amphotericin B.