Mirror Hand Disorder's Surgical Management with Metacarpal Wedging

Ulnar dimelia, also known as "mirror hand disorder", is a rare developmental disorder affecting the upper limb. Primarily, it involves the duplication of fingers, carpal bones, metacarpals, or ulna along the sagittal axis, and is often accompanied by the absence of the radius or thumb. The anomaly presents challenges in both bone and soft tissue development, impacting limb functionality and affecting a child's quality of life. We present the case of a one-year-old girl with unilateral ulnar dimelia. Surgical intervention was considered to address functional and aesthetic concerns. The surgery involved creating an opposable thumb from preaxial fingers through a carefully tailored approach. Post surgical therapy included physiotherapy and psychotherapy to ensure both physical functionality and psychological adjustment. The surgical procedure successfully provided an adequate grip pattern, and the patient demonstrated age-appropriate use of the modified hand at the six-month follow-up. Comparison with similar cases highlights the diversity in ulnar dimelia presentations and the need for customised surgical solutions. The timing of surgery is typically recommended between one and two years, considering both anatomical readiness and the advantages of cerebral plasticity in young patients.

Management of Juvenile Osteochondral Fractures Utilising Absorbable PLGA Implants

The incidence of articular injury, particularly osteochondral fractures (OCFs), has seen a cinnotable increase in recent years. Regardless of their location, fragments can be overlooked by plain radiographs, which might lead to osteoarthritis in the long run. Diagnostic imaging has a pivotal role in the assessment and classification of the fracture severity, as well as the presence of any associated dislocations. These fractures require surgical intervention for the restoration of joint function and the reduction of long-term complications. This paper aims to present the surgical correction and post-operative treatment of osteochondral fractures with absorbable implants in four children. The following affected areas are discussed: lateral condyle of the femur, patella and radial head. Utilising absorbable implants for the management of OCFs provides numerous advantages, including the elimination of the need for re-anaesthesia and reoperation, reduction of complications and facilitation of early rehabilitation. This approach also minimises the period of hospitalisation and proves effective in pediatric OCF treatment.

A Complex Case of Clino-Syndactyly with Fourth Metacarpal Aplasia

Syndactyly is the most common congenital malformation of the hand, leading to the fusion of the digits and frequently affecting the ring and middle fingers. The incidence is 1 out of 2500 children, predominantly occurring in boys and Caucasians. Clinically, the malformation may present as a soft tissue or bony fusion, resulting in the union of the fingers characterised as complete or incomplete. This fusion may involve the phalanges but may also extend to the carpal/tarsal bones, even to the metacarpal or metatarsal level, rarely to the distal end of the forearm and lower leg. The malformation is mostly isolated but may occur together with other disorders or malformations such as synostosis, acro-syndactyly, cleft hand, clinodactyly, or polydactyly. Syndromic syndactyly can be observed in cases of Apert syndrome, Poland's syndrome, Pfeiffer syndrome, and many others. A girl born in June of 2019 was diagnosed with congenital malformation of the right hand at birth-affecting the right middle, ring, and little fingers, respectively. After X-ray imaging, the fusion of the third and fourth proximal phalanges to a common metacarpal was identified, forming a unique diagnosis of clino-syndactyly with metacarpal aplasia. Surgical intervention was advocated for, including a wedge osteotomy to correct the synchondrosis at the phalangeal base and a dorsal flap to close the interdigital space created during the correction of the III and IV. fingers. A trapezoid flap for the release of the syndactyly of the IV and V. fingers was applied. The paper aims to present this surgical correction and its results regarding an atypical case of syndactyly with clinodactyly and metacarpal aplasia.

Neck-shaft angle measurement in children: accuracy of the conventional radiography-based (2D) methods compared to 3D reconstructions

Aim of this study was to examine the accuracy of widely used conventional radiography-based (2D) neck-shaft angle measurements compared to 3D reconstruction. In our retrospective study, EOS 2D/3D images of 156 patients (312 limbs) were selected from our database (4-16 years old: 6 girls and 6 boys/year), where no pathology was revealed. Using the 2D modality of the EOS method neck-shaft angle was measured using the "biggest diameter" and "circle fitting" techniques to define the femoral neck axis and 1/3, 1/2 and full femur to determine the femoral shaft axis. EOS 3D reconstructions of same images were also performed and a comparison of 2D and 3D results was made. We did not find any significant difference between accuracy of the four examined 2D methods, although the deviation between 2 and 3D results was considerable (average difference: 5.11-5.58°, p < 0,001). In 31% of the cases, difference was more than 10°. Only femoral torsion showed significant influence on the difference (correlation coefficient: 0.380, p < 0.001). We did not find a clinically significant difference between the examined 2D methods, although their accuracy was highly questionable compared to 3D results. We suggest using any 3D imaging method for surgical planning and in uncertain cases.

Pediatric medial humeral epicondyle fracture in children: Are biodegradable pins with tension band absorbable sutures efficient?

Medial humeral epicondyle fractures account for 10% to 20% of elbow injuries in children. We hypothesized that in the fixation of medial humeral epicondyle fractures, safety and efficiency of bioabsorbable poly(l-lactide-co-glycolic acid) implant are comparable to traditional metallic and other novel approaches. A retrospective cohort study was performed between 2016 and 2019, analyzing 24 children who had medial humeral epicondyle fractures. Every fracture was stabilized with biodegradable poly(l-lactide-co-glycolic acid) implants (Bioretec® ActivaPin®) and tension band polydioxanone sutures. Indications for surgery included closed fractures with >1 cm dislocation and incarcerated fractures. Postoperatively, the degree of anatomic reduction and the presence or absence of nonunion or fragmentation were confirmed with X-rays. In this clinical study, we evaluated the operation time, age, and gender distribution. The mean age at the time of injury was 12.3 (8-16 years). In the fourth week, every patient's X-ray showed callus formation, and the range of motion of the elbow after 6 months of the operation was almost complete in all children. Transient ulnar nerve palsy was developed in 1 patient, which was spontaneously resolved in the fourth postoperative month. No other complications were observed during the average follow-up period of 34 months (16-60 months). Bioabsorbable pins with absorbable sutures are a good alternative treatment of medial epicondyle humeral fracture. No permanent complications were noted while using this technique. We suggest this method because it does not require a secondary (metal removal) operation.

Bioresorbable implants vs. Kirschner-wires in the treatment of severely displaced distal paediatric radius and forearm fractures - a retrospective multicentre study

BACKGROUND

Distal radius fractures are very common in paediatric patients. Severely displaced fractures may require surgical intervention. The gold standard surgical method is percutaneous K-wire osteosynthesis followed by immobilisation. Metal implants can be removed with a second intervention; however, these extra procedures can cause further complications. Several studies confirm the benefits of bioabsorbable implants for paediatric patients. The aim of this retrospective study was to compare the complication rates of displaced distal metaphyseal radius (AO 23r-M/3.1) and forearm (AO 23-M/3.1) fractures in children operated on with K-wires versus a novel technique with bioresorbable implants.

METHODS

We retrospectively reviewed 94 patients in three paediatric trauma centres who underwent operations due to severely displaced distal forearm or metaphyseal radial fractures between January 2019 and January 2020. The mean age was 8.23 (ranging from 5-12). 30 patients (bioresorbable group, BR-group) were treated with biodegradable PLGA implants (Bioretec®, ActivaPin®), 40 patients with one or two stainless steel Kirschner-wires (K-wires, Sanatmetal®) which were buried under the skin (KW I-group) and 24 children with K-wires left outside the skin. (KWII. Group). We examined the number of minor and major complications as well as the need for repeated interventions. Follow-up was at least one and half year.

RESULTS

There was no significant difference between the complication rates at the two KW groups (p = 0.241; Cramer's V = 0.211), while the complication rate of the BR group was significantly lower. (p = 0.049; Cramer's V = 0.293 and p = 0.002; Cramer's V = 0.418 respectively). No later than half a year after the injury, no difference was observed between the functional outcomes of the patients in each group. One and a half years after the injury, no signs of growth disturbance were found in any of the children. No second surgical intervention was required in the BR group.

CONCLUSIONS

Surgeries with bioresorbable intramedullary implants may have fewer complications than K- wire osteosynthesis in the treatment of severely displaced distal forearm fractures. The benefits are most pronounced in the first six weeks after surgery, reducing the number of outpatient visits and increasing the child's sense of comfort. As no second intervention is required, this can lead to significant cost savings. After half a year, there is no difference in the outcomes between the different surgical treatment strategies.

Gyermekkori, áramégés okozta kézujjsérülések ellátásáról és késői szövődményeiről

Összefoglaló. Elektromos áram okozta égési sérülések gyermekkorban ritkán fordulnak elő, az összes égés mindössze 2-10%-át teszik ki. Nehézséget okozhat a sérülés valódi súlyosságának meghatározása a kicsiny ki- és bemeneti sebek miatt. Áramégések során a legtöbb esetben mély necrosis alakul ki. Ilyen sérülések esetén a bőr, a lágy részek, a csontok, illetve fiatal életkorban a növekedési zóna sérülésével is számolni kell, ami növekedési zavart és ezáltal másodlagos deformitásokat okozhat. Jelen esettanulmányunk célja az áramégés során létrejött gyermekkori kézujjsérülések ellátásának és késői szövődményeinek bemutatása. Egy 15 éves fiúgyermek izzócsere közben ráfogott egy vezetékre, ami a jobb mutatóujján égési sérülést okozott. Distalis interphalangealis ízülete felett volarisan 25 × 14 milliméter nagyságú bemeneti, dorsalisan a körömágy lateralis szélén 8 × 7 milliméteres kimeneti áramjegy volt látható fehér, necroticus sebalappal, mely III . fokú égési sérülésnek bizonyult. A mély égési sérülés miatt necrectomia, keresztlebeny-plasztika és az adóterület teljes vastagságú bőrrel végzett transzplantálása történt. A primer rekonstrukciót követően három héttel a lebeny leválasztására került sor. A nyomon követés során a mutatóujj körömperc-deviációja volt észlelhető. A röntgenvizsgálat a körömpercbázis ízfelszínét is érintő csonthiányt igazolt. Egy 2 éves leánygyermek szöggel nyúlt a konnektorba, emiatt hüvelykujján és tenyerén keletkezett égési sérülés. Interphalangealis ízülete felett dorsalisan és volarisan, valamint a hypothenar területén III. fokú égési sérülés volt látható. Necrectomiát követően a hüvelykujj ventralis bőrdefektusának zárása elforgatott lebennyel, a donorterület és a dorsalis bőrdefektus fedése teljes vastagságú bőrrel történt. A gyermek nyomon követése jelenleg is zajlik, rövid távon a csontérintettség okozta végperc-deviáció látható. A gyermekek hosszú távú nyomon követése szükséges a késői szövődmények felismerése és kezelése céljából. Orv Hetil. 2022; 163(14): 564-568. Summary. Pediatric electrical injuries are rare; they only constitute 2-10% of all burn causes. Determination of their actual severity may be challenging due to their small entry and exit wounds. Deep necrosis develops during electrical burns in most cases. These injuries can damage the skin, soft and bone tissues, and in children, the growth plate, which may cause secondary deformities. The objective of these case reports was the presentation of paediatric electrical finger injuries' management and late-onset complications. A 15-year-old boy touched an electric wire while changing a lightbulb, which caused a burn injury on his right index finger. During the physical examination, a 25 × 14 mm, third-degree burn was identified volarly, above the distal interphalangeal joint as an entry wound, and an 8 × 7 mm exit site occurred dorsally at the nailbed's lateral edge. Necrectomy and cross finger flap surgery were performed. The cross flap was separated three weeks after the primary reconstruction. Throughout the follow-up examinations, the ulnar deviation of the distal digit was observed. X-ray confirmed the bone atrophy of the distal phalanx base. A 2-year-old girl inserted a nail into the power outlet, causing third-degree burns on her thumb around the interphalangeal joint and hypothenar region. After necrectomy, the thumb's skin defect was reconstructed with a rotated flap, while the donor site received full-thickness skin graft transplantation. The follow-up of the child is still ongoing. Long term follow-up of these patients is necessary to identify and treat late-onset complications. Orv Hetil. 2022; 163(14): 564-568.

Tenodesis yields better functional results than tenotomy in long head of the biceps tendon operations-a systematic review and meta-analysis

Background

Pathology of the long head of the biceps tendon (LHBT) is a common disorder affecting muscle function and causing considerable pain for the patient. The literature on the two surgical treatment methods (tenotomy and tenodesis) is controversial; therefore, our aim was to compare the results of these interventions.

Methods

We performed a meta-analysis using the following strategy: (P) patients with LHBT pathology, (I) tenodesis, (C) tenotomy, (O) elbow flexion and forearm supination strength, pain assessed on the ten-point Visual Analog Scale (VAS), bicipital cramping pain, Constant, ASES, and SST score, Popeye deformity, and operative time. We included only randomized clinical trials. We searched five databases. During statistical analysis, odds ratios (OR) and weighted mean differences (WMD) were calculated for dichotomous and continuous outcomes, respectively, using the Bayesian method with random effect model.

Results

We included 11 studies in the systematic review, nine of these were eligible for the meta-analysis, containing data about 572 patients (279 in the tenodesis, 293 in the tenotomy group). Our analysis concluded that tenodesis is more beneficial considering 12-month elbow flexion strength (WMD: 3.67 kg; p = 0.006), 12-month forearm supination strength (WMD: 0.36 kg; p = 0.012), and 24-month Popeye deformity (OR: 0.19; p < 0.001), whereas tenotomy was associated with decreased 3-month pain scores on VAS (WMD: 0.99; p < 0.001). We did not find significant difference among the other outcomes.

Conclusion

Tenodesis yields better results in terms of biceps function and is non-inferior regarding long-term pain, while tenotomy is associated with earlier pain relief.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-022-05338-9.

Development of a Novel X-ray Compatible 3D-Printed Bone Model to Characterize Different K-Wire Fixation Methods in Support of the Treatment of Pediatric Radius Fractures

Additive manufacturing technologies are essential in biomedical modeling and prototyping. Polymer-based bone models are widely used in simulating surgical interventions and procedures. Distal forearm fractures are the most common pediatric fractures, in which the Kirschner wire fixation is the most widely used operative method. However, there is still lingering controversy throughout the published literature regarding the number of wires and sites of insertion. This study aims to critically compare the biomechanical stability of different K-wire fixation techniques. Different osteosyntheses were reconstructed on 189 novel standardized bone models, which were created using 3D printing and molding techniques, using PLA and polyurethane materials, and it has been characterized in terms of mechanical behavior and structure. X-ray imaging has also been performed. The validation of the model was successful: the relative standard deviations (RSD = 100 × SD × mean-1, where RSD is relative standard deviation, SD is the standard deviation) of the mechanical parameters varied between 1.1% (10° torsion; 6.52 Nm ± 0.07 Nm) and 5.3% (5° torsion; 4.33 Nm ± 0.23 Nm). The simulated fractures were fixed using two K-wires inserted from radial and dorsal directions (crossed wire fixation) or both from the radial direction, in parallel (parallel wire fixation). Single-wire fixations with shifted exit points were also included. Additionally, three-point bending tests with dorsal and radial load and torsion tests were performed. We measured the maximum force required for a 5 mm displacement of the probe under dorsal and radial loads (means for crossed wire fixation: 249.5 N and 355.9 N; parallel wire fixation: 246.4 N and 308.3 N; single wire fixation: 115.9 N and 166.5 N). We also measured the torque required for 5° and 10° torsion (which varied between 0.15 Nm for 5° and 0.36 Nm for 10° torsion). The crossed wire fixation provided the most stability during the three-point bending tests. Against torsion, both the crossed and parallel wire fixation were superior to the single-wire fixations. The 3D printed model is found to be a reliable, cost-effective tool that can be used to characterize the different fixation methods, and it can be used in further pre-clinical investigations.

Pediatric deep burn management after split-thickness autologous skin transplantation: A comparative study

Treatment of pediatric deep burns remains a challenge for healthcare personnel. After skin grafting, several treatment options are available, but comparative studies of the different options are scarce. Here, we compared the effectiveness of 2 postoperative dressings used to treat deep pediatric burns after split-thickness skin grafting.At the Department of Paediatrics, University of Pécs, 16 children received skin transplantation after the deep second and third-degree injuries between January 1, 2012 and December 31, 2020 whose results have been analyzed, in this cohort study. We compared the traditionally used Grassolind or Mepitel net and Betadine solution (comparison group) with Aquacel Ag foam and Curiosa gel (intervention group).Seven children were included in the comparison and 9 children in the intervention group. In the control group, the average number of anesthesia was 6.29, while the number of dressing changes was 4.29. After complete wound closure, the dressing's final removal was on the 13th day, while the mean length of hospitalization was 21.89 days. On average, in the intervention group, 3.56 anesthesia was induced, and 0.66 dressing changes were needed after transplantation. Complete healing (dressing removal) was on the 10th day, and the mean length of hospitalization was 12.38 days.In the intervention group, the need for anesthesia significantly decreased by 43% (P = .004), and they required 84% fewer dressing changes after transplantation (P = .001). Moreover, the dressing could be removed 3 days earlier, and the length of hospitalization was reduced by 45% on average.

Signalling Alterations in Bones of Pituitary Adenylate Cyclase Activating Polypeptide (PACAP) Gene Deficient Mice

Pituitary adenylate cyclase activating polypeptide (PACAP) is a neuropeptide with diverse developmental roles, including differentiation of skeletal elements. It is a positive regulatory factor of chondrogenesis and osteogenic differentiation in vitro, but little is known about its in vivo role in bone formation. In our experiments, diaphyses of long bones from hind limbs of PACAP gene-deficient mice showed changes in thickness and increased staining intensity. Our main goal was to perform a detailed morphological and molecular biological analysis of femurs from PACAP knockout (KO) and wild type (WT) mice. Transverse diameter and anterior cortical bone thickness of KO femurs showed significant alterations with disturbed Ca²⁺ accumulation and collagen type I expression. Higher expression and activity of alkaline phosphatase were also observed, accompanied by increased fragility PACAP KO femurs. Increased expression of the elements of bone morphogenic protein (BMP) and hedgehog signalling was also observed, and are possibly responsible for the compensation mechanism accounting for the slight morphological changes. In summary, our results show that lack of PACAP influences molecular and biomechanical properties of bone matrix, activating various signalling cascade changes in a compensatory fashion. The increased fragility of PACAP KO femur further supports the role of endogenous PACAP in in vivo bone formation.

[Ultrasonographic diagnosis of distal pediatric forearm fractures]

INTRODUCTION AND AIM

The aim of our prospective study was to evaluate the effectivity of sonographic diagnosis of pediatric wrist fractures and analyzing the results of two pediatric musculoskeletal centers.

METHOD

Between 2011 January and 2015 December 467 children aged 0-15 with closed wrist injuries and open growth plates were sonographically and radiologically evaluated by an orthopaedic surgeon or a resident in trainee. Sonography was performed immediately after physical examination with linear probes of 7-14 Mhz frequency. Results were compared to conventional two plane wrist x-rays.

RESULTS

We found 97 sensitivity and 96 specificity of the sonographic evaluation. Fractures with dislocations and more serious clinical consequences were never missed.

CONCLUSION

Musculoskeletal ultrasound is a very effective tool in daily routine for diagnosing or excluding pediatric wrist fractures. Orv Hetil. 2017; 158(24): 944-948.

Short, double elastic nailing of severely displaced distal pediatric radial fractures: A new method for stable fixation

RATIONALE

Short double elastic nailing is a minimal invasive, modified ESIN (elastic stable intramedullary nailing) technique for severely displaced distal radial fracture in children. The aim of this technical report is to introduce our new method and evaluate the final results of the procedure.

PATIENT CONCERNS

We reviewed retrospectively 24 patients who underwent short double elastic nailing due to distal radial fractures between November 2012 and December 2015. Indications for surgery included closed, severely displaced, unstable metaphyseal or diametaphyseal fractures of the radius.

INTERVENTION

The fractures were stabilized by 2 prebent short elastic titanium nails inserted from the distal side of the fracture. In cases of associated ulnar fracture, a classic anterograd ESIN nailing was also performed. Patients were mobilized immediately in a removable short splint which was removed after 1 to 2 weeks. There has been no additional splinting or casting.

OUTCOMES

There were 17 males and 7 females with an average age of 9.8 years (range, 4-16 years). The right hand was involved in 16 cases and the left hand in 8 cases. The average follow-up was 17.8 months (range, 7-28 months). Of the 24 patients, 3 presented irritation of the skin, which resolved after removal of the radial nail. All the patients regained full range of motion without any complications.

LESSONS

Our technique is an effective, safe, and easily learnable procedure for unstable fractures of the distal third of the radius. It achieves good functional and radiological results, and allows early mobilization without the need of casting. Avoiding the physeal plates, we reduce the risk of iatrogenic postoperative deformity. Further prospective and biomechanical investigations are necessary to verify our experience.

New dressing combination for the treatment of partial thickness burn injuries in children

Burns are among the most common causes of injury in children. Several wound dressings are available to conservatively treat second-degree burns. Seventy-three children were treated with Aquacel Ag foam and Zn-hyaluronon gel to determine their effectiveness on partial thickness burns. We applied silver nitrate solution on 25% of patients for 24 hrs, then checked burn depth. If the burn was superficial second degree, we applied the dressing under study. All dressings were removed 6-7 days later. In the remaining children we used Aquacel Ag foam dressing with Zn-hyaluronon gel at first intervention. The dressing was checked on the second day, and removed on the sixth or seventh day (unless it had spontaneously separated). Hot water scalds were the main cause of injury. Other causes included hot oil, flame and contact, among others. Wound size was on average 5% total body surface area. Burns were seen on all body parts, and in 38 cases on more than one area. None of the 73 children treated with this dressing were diagnosed with wound infection. We observed the epithelialization of the burned areas on the 6th or 7th day after primary treatment. These dressings efficiently promote epithelialization, and a further advantage of Zn-hyaluronon gel is that it enhances cell regeneration and inhibits dressing fixation into the wound. Based on our experience, with this dressing combination we can achieve gentle, child-friendly and cost-effective treatment, excellent wound healing and favourable cosmetic results.

[An unusual cause of the hand cyst: finger dirofilariasis]

Dirofilariasis is a zoonosis affecting dogs and cats. It can be transmitted to human by mosquito bites. Because of the local inflammation caused by the parasite, a lump may develop. The authors present a case of a 13-year-old boy, who was diagnosed with dirofilariasis in association with a cyst located on the middle finger of the right hand. During physical examination, a lump on the extensor surface of the middle phalanx of the right middle finger was found. Soft tissue ultrasound was performed, which indicated the presence of a worm in the cyst. The cyst was surgically removed under local anesthesia and with parasitology test Dirofilaria repens infection was confirmed. The child had no complains or symptoms during recovery after the surgery. A solitary growth developing on the fingers of the hand often presents a differential diagnostic problem. Ultrasound can be greatly helpful in the preoperative diagnosis. Orv. Hetil., 2016, 157(39), 1571-1574.

[Differential diagnosis of abdominal cysts in children]

19 children were diagnosed with abdominal cysts of different origin in the Surgical Unit of the Department of Pediatrics, Medical University of Pécs, Hungary between 2010 and 2013. The authors discuss the details of representative cases of a parovarial cyst, an intestinal duplication, and an omental cyst with emphasis on the clinical symptoms, diagnostic tools, and surgical interventions. The authors conclude that abdominal cysts often cause mild symptoms only, and they are discovered accidentally by ultrasound imaging performed for other reasons. In some cases, the cyst can cause severe complaints or even acute abdomen requiring emergency surgery. Laporoscopy may be a valuable method both in diagnosis and surgical therapy. Abdominal CT or MRI are not required in the majority of the patients.

Diaphragmatic hernia or hiatus hernia: a diagnostic problem in 5-month-old infant

Authors present a case of a 5-month-old infant, in whom following an uneventful perinatal adaptation, symptoms of recurrent respiratory infections, vomiting and growth failure developed. Based on chest X-ray, right-sided diaphragmatic hernia was suspected. However, barium swallow examination delineated the stomach above the right diaphragm. The case report draws attention to the differential diagnostic difficulties between congenital diaphragmatic and hiatal hernia. Orv. Hetil., 2011, 152, 1500–1503.