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Abstract Background Epidemiological research on fractures in children under the age of two is of great importance to help understand differences between accidental and abusive trauma. Objective This systematic review aimed to evaluate studies reporting on the incidence of fractures in children under two years of age, excluding birth injuries. Secondary outcome measures included fracture location, mechanisms of injury and fracture characteristics. Methods A systematic literature review (1946 to February 7th 2024), including prospective and retrospective cohort studies and cross-sectional cohort studies, was performed. Studies including children from other age groups were included if the actual measures for those aged 0–2 years could be extracted. We also included studies restricted to infants. Annual incidence rates of fractures were extracted and reported as the main result. Critical appraisal of was performed using the Appraisal tool for Cross-Sectional Studies. Results Twelve moderate to good quality studies met eligibility criteria, of which seven were based on data from medical records and five were registry studies. Studies investigated different aspects of fractures, making comprehensive synthesis challenging. There was an overall annual fracture incidence rate of 5.3 to 9.5 per 1,000 children from 0–2 years of age; with commonest sites being the radius/ulna (25.2–40.0%), followed by tibia/fibula (17.3–27.6%) and the clavicle (14.6–14.8%) (location based on 3 studies with a total of 407 patients). In infants, the reported incidence ranged between 0.7 to 4.6 per 1,000 (based on 3 studies), with involvement of the clavicle in 22.2% and the distal humerus in 22.2% of cases (based on 1 study). Only a single metaphyseal lesion was reported (proximal humerus of an 11-month-old infant). Fracture mechanisms were detailed in four studies, with fall from chair, bed, table, own height or fall following indoor activities causing 50–60% of fractures. Conclusions There is a paucity of good quality data on fracture incidence in children under the age of two. Larger, prospective and unbiased studies would be helpful in determining normal pattern of injuries, so that differences from abusive trauma may be better understood.

Abstract Background Prenatally diagnosed hepatic hilar cysts are a challenging finding for the clinician. They can either be a sign of cystic biliary atresia (BA) or a choledochal cyst (CC), two diagnoses with different postnatal management and prognosis. Based on a case report of four patients, we aim to propose a management algorithm for prenatally diagnosed “hepatic hilar cysts”. Case presentation A hepatic hilar cyst, ranging from 5 to 25 mm, was detected prenatally in all four girls confirmed postnatally along with the presence of a gallbladder. Stool color was normal until two weeks of life at which time the stool color became lighter, and the patients developed cholestasis. All were operated before seven weeks of life: Case 1 had a CC with patent but irregular intrahepatic bile ducts at intraoperative cholangiogram, and no communication with the duodenum. A Roux-en-Y bilioenteric anastomosis was performed. The cyst showed complete epithelial lining loss, and liver pathology showed BA features. Case 2 had the final diagnosis of cystic BA with patent but abnormal intrahepatic bile ducts. She underwent two operations: the first operation at four weeks as described for case 1, since intraoperative findings were similar, as was histology. As cholestasis increased postoperatively, she underwent a Kasai hepato-porto-enterostomy six weeks later, where distinct BA findings were found with complete scarring of the hilar plate. Case 3 had a cystic BA with the cyst located within the common bile duct and atretic bile ducts proximal to the porta hepatis. It exhibited no communication with the liver or duodenum. A Kasai operation was performed, with histology showing complete epithelial loss within the cyst wall and scarring of the hilar plate. Case 4 had a cystic BA presenting a completely obliterated hepatic duct with the cyst lying within the common bile duct. A Kasai procedure was performed. Histology showed a common bile duct with a residual lumen of 0.1 mm. Conclusions The spectrum of disease from CC to BA in the setting of a prenatally discovered hepatic hilar cyst is emphasized. Even if cholangiogram differentiates most patients with BA from those with CC, caution is advised for transitional types.

ObjectivesInflammatory biomarkers, as indicators of biological states, provide a valuable approach for accurate and reproducible measurements, crucial for the effective management of mild traumatic brain injury (mTBI) in pediatric patients. This study aims to assess the diagnostic utility of blood-based inflammatory markers IL6, IL8, and IL10 in children with mTBI, including those who did not undergo computed tomography (CT) scans.MethodsA prospective multicentric cohort study involving 285 pediatric mTBI patients was conducted, stratified into CT-scanned and non-CT-scanned groups within 24 h post-trauma, alongside 74 control subjects. Biomarker levels were quantitatively analyzed using ELISA. Sensitivity and specificity metrics were calculated to determine the diagnostic efficacy of each biomarker.ResultsA total of 223 mTBI patients (78%) did not undergo CT scan examination but were kept in observation for symptoms monitoring at the emergency department (ED) for more than 6 h (in-hospital-observation patients). Among CT-scanned patients (n = 62), 14 (23%) were positive (CT+). Elevated levels of IL6 and IL10 were found in mTBI children compared to controls. Within mTBI patients, IL6 was significantly increased in CT+ patients compared to both CT– and in-hospital-observation patients. No significant differences were observed for IL8 among the compared groups. IL6 yielded a specificity of 48% in identifying CT– and in-hospital-observation patients, with 100% sensitivity in excluding all CT+ cases. These performances were maintained whether IL6 was measured within 6 h or within 24 h after the trauma.ConclusionThe inflammatory marker IL6 emerges as a robust biomarker, showing promising stratification value for pediatric mTBI patients undergoing CT scans or staying in observation in a pediatric ED.

Transphyseal hematogenous osteomyelitis (THO) is a serious condition that can affect the growing physis, yet it is insufficiently recognized in children. The aim of this study was to explore the prevalence and epidemiology of pediatric THO, and to discuss the underlying pathophysiology. All consecutive cases of acute and subacute osteomyelitis admitted to our institution over 17 years were retrospectively studied. Medical records were examined for patient characteristics, bacteriological etiology, and medical and surgical management. Magnetic resonance imaging was reviewed for all patients to identify those with transphyseal spread of infection. For positive cases, the surface area of the transphyseal lesion was estimated relative to the total physeal cross-sectional area. Fifty-four (25.7%) of the 210 patients admitted for acute or subacute osteomyelitis were diagnosed with THO. The study population’s ages ranged from 1 month to 14 years old (median age 5.8 years, interquartile range 1–167 months). Fourteen (25.9%) patients were younger than 18 months old; the remaining 40 (74.1%) had a mean age of 8.5 years old. The most common sites of THO were the distal tibia (29.1%), the proximal tibia (16.4%), and the distal fibula (14.5%). Transphyseal lesions were due to acute infection in 41 cases and to subacute osteomyelitis in 14 cases. The two most frequently identified pathogens were Staphylococcus aureus (49.1%) and Kingella kingae (20.0%). An average transphyseal lesion represented 8.9% of the total physeal surface, and lesions comprised more than 7% of the physeal cross-sectional area in 51% of cases. Our study revealed that pediatric THO was more frequent than commonly thought. Transphyseal lesions were frequently above this 7% cut-off, which is of paramount importance since subsequent growth is more likely to be disturbed when more than 7% of the physeal cross-sectional area is injured. THO also affected children older than 18 months, an age at which transphyseal arterial blood supply to the epiphysis is believed to have disconnected. This finding suggests another pathophysiological reason for the transphyseal diffusion of infection, a topic deserving further studies and greater understanding.

Distal patellar tendon avulsions are rare injuries in healthy individuals, and to date, no case affecting skeletally mature teenagers and adolescents has been reported. In the majority of cases, distal patellar tendon avulsions are associated with severe intra-articular knee lesions, signifying a high-energy trauma. We present the case of a 15.5-year-old female who was admitted to the emergency department after a knee injury. The mechanism of injury was a combination of landing after a jump off a scooter and sudden deceleration with a fixed foot. Lateral radiographs revealed a distal patellar tendon avulsion. An MRI was conducted to accurately diagnose concomitant lesions. The MRI revealed a complete tear of the ACL, and associated bone bruises on the lateral femoral condyle, and also on the posterolateral tibial plateau. A knee joint exam under general anesthesia demonstrated good stability during valgus stress testing and only a grade 1 positive Lachman test. Therefore, we decided to only reconstruct the extensor mechanism and to abstain from a primary ACL reconstruction. The presented case and review of the literature demonstrate the clinical relevance of this atypical lesion. In fact, a distal patellar tendon avulsion after physeal fusion of the proximal tibia should raise a strong suspicion of severe associated intra-articular knee lesions and requires prompt MRI investigation. However, controversy still exists regarding the management of these injuries, in particular concerning the question of whether to address both injuries in a single stage or in 2 stages.

Abstract Complications following lung transplantation may impede allograft function and threaten patient survival. The five main complications after lung transplantation are primary graft dysfunction, post-surgical complications, alloimmune responses, infections, and malignancy. Primary graft dysfunction, a transient ischemic/reperfusion injury, appears as a pulmonary edema in almost every patient during the first three days post-surgery. Post-surgical dysfunction could be depicted on computed tomography (CT), such as bronchial anastomosis dehiscence, bronchial stenosis and bronchomalacia, pulmonary artery stenosis, and size mismatch. Alloimmune responses represent acute rejection or chronic lung allograft dysfunction (CLAD). CLAD has three different forms (bronchiolitis obliterans syndrome, restrictive allograft syndrome, acute fibrinoid organizing pneumonia) that could be differentiated on CT. Infections are different depending on their time of occurrence. The first post-operative month is mostly associated with bacterial and fungal pathogens. From the second to sixth months, viral pneumonias and fungal and parasitic opportunistic infections are more frequent. Different patterns according to the type of infection exist on CT. Malignancy should be depicted and corresponded principally to post-transplantation lymphoproliferative disease (PTLD). In this review, we describe specific CT signs of these five main lung transplantation complications and their time of occurrence to improve diagnosis, follow-up, medical management, and to correlate these findings with pathology results. Key Points • The five main complications are primary graft dysfunction, surgical, alloimmune, infectious, and malignancy complications. • CT identifies anomalies in the setting of unspecific symptoms of lung transplantation complications. • Knowledge of the specific CT signs can allow a prompt diagnosis. • CT signs maximize the yield of bronchoscopy, transbronchial biopsy, and bronchoalveolar lavage. • Radiopathological correlation helps to understand CT signs after lung transplantation complications.