Osteoarticular infections (OAI) are a significant cause of morbidity and mortality. Cultures and serology are some of the gold standards for identifying infection but are often unable to provide a timely diagnosis or a diagnosis at all.
Genetic testing offers capabilities that other modalities lack. Polymerase chain reaction has multiple versions with various costs and turnaround times. This technology has become implemented in multiple pediatric center OAI diagnostic protocols. There is sufficient literature documenting effectiveness in certain clinical situations, especially with fastidious organism diagnosis, but significant limitation still exists.
Metagenomic next-generation sequencing is an unbiased or hypothesis-free modality with the capability to detect the genetic material of bacteria, viruses, parasites, fungi, and humans from a single sample.
Potential benefits include pathogen identification unaffected by antimicrobial administration, detection of fastidious organisms more quickly, delineation of pathogens in polymicrobial infections, antimicrobial susceptibility, and avoidance of invasive procedures.
It is a resource-intensive modality with little standardization of the complex processes. Appropriate use and definitive clinical impact have yet to be determined.
Despite the high incidence of developmental dysplasia of the hip (DDH), treatment is very diverse. Therefore, the Dutch Orthopedic Society developed a clinical practice guideline with recommendations for optimal and uniform treatment of DDH. This article summarizes the guideline on centered DDH (i.e. Graf types 2A–C).
The guideline development followed the criteria of Appraisal of Guidelines for Research and Evaluation II. A systematic literature review was performed to identify randomized controlled trials and comparative cohort studies including children <1 year with centered DDH. Articles were included that compared (1) treatment with observation, (2) different abduction devices, (3) follow-up frequencies, and (4) discontinuation methods. Recommendations were based on Grading Recommendations Assessment, Development, and Evaluation, which included the literature, clinical experience and consensus, patient and parent comfort, and costs.
Out of 430 potentially relevant articles, 5 comparative studies were included. Final guideline recommendations were (1) initially observe 3-month-old patients with centered DDH, start abduction treatment if the hip does not normalize after 6–12 weeks; (2) prescribe a Pavlik harness to children <6 months with persisting DDH on repeated ultrasonography, consider alternative abduction devices for children >6 months; (3) assess patients every 6 weeks; and (4) discontinue the abduction device when the hip has normalized or when the child is 12 months.
This paper presents a summary of part 1 of the first evidence-based guideline for treatment of centered DDH in children <1 year. Part 2 presents the guideline on decentered DDH in a separate article.
The physis of the distal femur contributes to 70% of femoral growth and 37% of the total limb growth; therefore, physeal injury can lead to important alterations of axes and length.
Distal metaphyseal corner-type fracture prior to walking is classically associated with child abuse. In children aged >10 years, sports-related fractures and car accidents are significant contributors.
Imaging includes a two-plane radiographic study of the knee. It is recommended to obtain radiographs that include the entire femur to rule out concomitant injuries. In cases of high suspicion of distal metaphyseal fractures and no radiographic evidence, CT or MRI can show the existence of hidden fractures.
Fractures with physeal involvement are conventionally classified according to the Salter–Harris classification, but the Peterson classification is also recommended as it includes special subgroups.
Conservative and surgical management are valid alternatives for the treatment of these fractures. Choosing between both alternatives depends on factors related to the fracture type.
As there is a high risk of permanent physeal damage, long-term follow-up is essential until skeletal maturity is complete.
Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures.
Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children’s fractures.
The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent- and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend.
It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children’s fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children.
Cite this article: EFORT Open Rev 2020;5:347-353. DOI: 10.1302/2058-5241.5.200012
Fractures of the anterior tibial tuberosity during childhood are an infrequent pathology (around 3% of all proximal tibial fractures), but the incidence of this injury has risen over recent years, likely due to the increased involvement of this age group in sports activities.
This fracture is more commonly seen in children 12–14 years old.
It is vital to identify the anatomical structures associated with this type of fracture, along with the pathophysiological mechanisms involved.
Treatment includes non-operative and operative options, with the goal of achieving articular congruency, restoring the extensor mechanism function, and avoiding damage to the proximal tibial physis.
Understanding the management of this fracture, and the complications that might arise, is critical. The provision of an appropriate clinical management plan and the avoidance of complications are vital in the prevention of disability.
Cite this article: EFORT Open Rev 2020;5:260-267. DOI: 10.1302/2058-5241.5.190026
The optimal management and long-term outcomes of olecranon fractures in the paediatric population is not well understood. This systematic review aims to analyse the literature on the management of paediatric olecranon fractures and the long-term implications.
A systematic review of several databases was conducted according to PRISMA guidelines. English-language studies evaluating the management of isolated paediatric olecranon fractures were included. Data extracted included demographics, classifications, conservative and operative treatment methods and outcomes.
Fifteen articles fitting the inclusion criteria were included. There were 11 case series and four retrospective comparative series. The reported studies included 299 fractures in 280 patients.
The mechanism of injury was predominantly low energy. Fractures displaced < 4 mm were treated non-operatively with almost universally good results, with the majority being treated with cast immobilization. Fractures displaced > 4 mm were commonly treated operatively with generally good results, with tension band wire and suture fixation being the most common treatment modalities. Weight > 50 kg was associated with failure of suture fixation.
In those studies that reported olecranon fractures with associated elbow injuries (e.g. radial head fractures) outcomes were poorer. Forty-six fractures were in patients with osteogenesis imperfecta, who sustained a higher rate of re-fracture after removal of metalwork and contralateral olecranon fracture.
Despite a relatively low evidence base pool of studies, the aggregate data support the non-operative treatment of isolated undisplaced olecranon fractures with good results, and support the operative treatment of fractures displaced ≥ 4 mm.
Cite this article: EFORT Open Rev 2020;5:280-288. DOI: 10.1302/2058-5241.5.190082