What are the options of treatment?

a. Remanipulation and plaster

b. Manipulation and closed pinning

c. Manipulation with blunt wire and pinning and plaster

d Accept the reduction

Now watch the video in this link of a study from Hawaii titled

5 year old with injury to forearm due to fall in the playground

How do you manage these fractures?

a above elbow plaster

b below elbow plaster

c splints

How long will you continue immobilisation?

a 2 weeks

b 3 weeks

c 4 weeks

d 6 weeks

How often will you repeat the rays?

a. every week

b After 3 weeks

c. At week 1 and at plaster removal

Here is an attempt to find an answer to some of the questions…

What does the term tarus fractures mean

Torus is derived from Latin (tori) meaning a swelling or protuberance. Torus (buckle) fractures  of distal metaphysis of radius & ulna are the most common fractures of in lower forearm in young children

When the child falls on the outstretched hand, the bone buckles under the weight of the body.  Typically, you will see a slight bend in the bone, but only on one side.  It literally looks like the bone buckled, but didn’t break all the way through.

There is usually little if any deformity in the bone because the periosteum and cortex are intact on the side. Technically speaking, the bone has failed in ‘compression’, making the small ripple in the bone that you see on the x-ray.

Torus fractures hurt, but will not cause a visible deformity.  If you push directly on the arm where it is broken, it will hurt, and the child can localize the spot very clearly.  However, they can usually move the wrist joint without much trouble.  Because of this, many of these fractures are diagnosed late because it can be difficult for parents to tell if it is broken or not

These are generally stable fractures, meaning that the alignment will probably not change with protection such a a cast or splint.

What is the evidence from the literature

• Davidson (JBJS B 83-B 20011173-1175 ) did a RCT comparing treatment in traditional forearm cast V/S splint and concluded that there was no difference in the results of both the treatment methods.  In fact the splint treatment had major benefits in terms of cost and reduction of the number of attendances.
• Pint et al (Pediatrics. 2006 Mar;117(3):691-7) in a radomised control trial of 87 fractures : 42 in the splint group and 45 in the cast group concluded that children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures.
• Farbman KS 9Arch Pediatr Adolesc Med September 1999;153:923-5.) while evaluating the role of serial radiographs in the management of pediatric torus fractures concluded that radiographs after application of a cast for a nondisplaced torus fracture are not required. Clinical examination is appropriate during follow-up, with consideration given to repeat radiographs only at four weeks postfracture to document healing.

What are the pitfalls

• Greenstick fractures of lower radius: need to be reduced and put in cast as they can deform and redisplace. The failure in greenstick fractures in distraction and is on the side of angulation

• Eren (Journal of Pediatric Orthopaedics B:January 2009 – Volume 18 – Issue 1 – pp 35-36) reported onTorus fracture of the distal radius associated with distal radioulnar joint instability. They suggested that torus fractures of the children are not always innocent, and simple physical examination of the DRUJ for tenderness and instability is mandatory before and after roentgenographic evaluation to adequately treat these kinds of injuries and prevent malpractice. In cases of doubt, MRI examination of the wrist may also reveal the torn triangular fibrocartilage complex leading to instability.
• Some of the buckle fractures may have extension to the physis . Aminian A, Schoenecker PL (J Pediatr Orthop. 1995 Jul-Aug;15(4):495-8) reported on premature closure of the distal radial physis after fracture of the distal radial metaphysis.

So coming back to the case how do you manage the 5 year old child with the tarus fracture of distal radius and ulna?

Will wait for the responses from the readers…

References

Simple treatment for torus fractures of the distal radius

J. S. Davidson, FRCS Orth, Specialist Registrar in Orthopaedic Surgery; D. J. Brown, FRCS, Specialist Registrar in Orthopaedic Surgery; S. N. Barnes, FRCS, Specialist Registrar in Orthopaedic Surgery; and C. E. Bruce, FRCS Orth, Consultant in Paediatric Orthopaedics From Alder Hey Children’s Hospital, Eaton Road, West Derby, Liverpool L12 2AP, UK.

Journal of Bone and Joint Surgery – British Volume, Vol 83-B, Issue 8, 1173-1175.
doi: 10.1302/0301-620X.83B8.11451
Correspondence should be sent to Mr D. J. Brown at 6 Caldy Road, West Kirby, Wirral CH48 2HG, UK.

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money.

Over a six-month period, we randomised 201 consecutive patients with this injury to treatment with either a traditional forearm plaster-of-Paris cast or a ‘Futura-type’ wrist splint. All patients were treated for a period of three weeks, followed by clinical and radiological review.

There was no difference in outcome between the two groups, and all patients had a good result. Only one patient did not tolerate the splint which was replaced by a cast.

The questionnaire showed a marked variation in the way in which these injuries are treated with regard to the method and period of immobilisation, the number of follow-up visits and radiographs taken.

We suggest that a ‘Futura-type’ wrist splint can be used to treat these fractures. The patient should be reviewed on the following day to confirm the diagnosis and to give appropriate advice. There is no evidence that further follow-up is required.

This simple treatment has major benefits in terms of cost and reduction of the number of attendances.

A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children.

Abstract

OBJECTIVE:

Wrist buckle fractures are a frequent reason for emergency department visits. Although textbooks recommend 2 to 4 weeks of immobilization in a short arm cast, management varies. Treatment with both casts and splints is common, and length of immobilization varies. The objective was to determine if children with distal radius and/or ulna buckle fractures treated with a removable splint have better physical functioning than those treated with a short arm cast for 3 weeks.

METHODS:

This was a randomized, controlled trial in the emergency department of an academic, tertiary care children’s hospital. Participants were children 6 to 15 years of age with distal radius and/or ulna buckle fractures who were randomly assigned to treatment with a short arm cast for 3 weeks or a removable splint. Cast removal was at 3 weeks. A validated self-reported outcome tool, the Activities Scales for Kids performance version (ASKp), was used to measure physical functioning over a 4-week period. The main outcome was the ASKp score at 14 days postinjury.

RESULTS:

We randomly assigned 113 patients, and 87 were included in the final analysis: 42 in the splint group and 45 in the cast group. Study groups were similar in age, gender, bone fractured, and dominant hand injured. There were significant differences in ASKp score at day 14 and change in ASKp from baseline at days 14 and 20, indicating better functioning in the splint group. Splinted children had less difficulty with bathing throughout the entire study. There were no significant differences in pain between groups as measured by visual analog scale. There were no refractures.

CONCLUSIONS:

Children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast.

Are Serial Radiographs Needed in Torus Fractures in Children?

Pediatric Orthopedic Surgeon

www.ipodindia.org

The Guru Mantra

“The risks of delayed drainage far outweigh

the benefits of waiting and watching for a response to antibiotics.”

The Facts and figures

The knowledge of these general facts regarding pattern of involvement may be invaluable in diagnosis of the condition.

1.     Septic arthritis is more common than osteomyelitis in infancy and childhood.

2.     Most common joints-the hip and knee – 60 % cases

3.     Polyarticular in about 5 percent

4.     Age group 75 percent occur in children below 5 years

Pathophysiology

The organisms

It has been a traditional teaching that the most common organisms are gram-positive aerobes (80%) and approximately 20% of cases are caused by gram-negative anaerobes with Staphylococcus aureus the most common among the gram positive with less commonly implicated bacteria include  group A and group B streptococci, Streptococcus pneumoniae and Haemophilus influenza. Neonates are more susceptible to group B streptococcal infection.

Over recent years, the microbes isolated in bone and joint infections have changed. In the 1970s and 1980s. The introduction of the Haemophilus influenzae type B vaccine has resulted in a vast reduction in cases secondary to hemophilus, but a number of new organisms have appeared. Recent publications would suggest that perhaps only 40% of infections are the result of S. aureus. We have noticed a  recent upsurge of septic arthritis caused by methicillin-resistant strains of Staphylococcus aureus (MRSA). Although these infections were once thought to be predominantly hospital acquired, but of late, several cases of community-acquired MRSA also have been identified

Diagnosis

Need for an early diagnosis

The damage to the cartilage, growth plate and bone due to avasularity and enzymatic distruction sets in early.The cartilage destruction starts as early as 8 hours following the onset.The avascularity sets in within 24-48 hours of the temponade. The biggest challenge is therefore to control the  infection and drain the joint before the damage takes place

The challenges of diagnosis septic arthritis

-No single test can be relied upon

-Inflamatory markers may be normal or only slightly elevated early in the disease

-The xrays may be normal early in the disaease

-The imaging modalities such as xrays, ultrasound, bone scan  or MRI  suggest a process of inflammation and effusion but can not diagnose septic arthritis

-The laboratory investigations such as blood counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may help in suggesting that there is an infective process going on but cannot definitely confirm the diagnosis of septic arthritis.

-The only way the joint infection can be conclusively diagnosed is by demonstrating bacteria in

the fluid removed from the joint. However, an organism may only be cultured in approximately 60 percent of cases of true septic arthritis.

-Knee jerk antibiotics may blunt clinical preasentation

– Realizing the limitations of investigations in confirming the diagnosis of septic arthritis, it is imperative that treatment is commenced on the basis of a high index of suspicion. Definitive treatment

should not be withheld for want of confirmatory laboratory tests.

On the basis of a careful clinical examination, a tentative diagnosis of septic arthritis needs to be made. If joint aspiration does not yield fluid with bacteria demonstrable either in a Gram-stained smear or on culture, a presumptive diagnosis may be made with the help of the results of other laboratory tests in conjunction with clinical findings.

Kocher’s cliteria

Kocher et al  identified clinical and laboratory predictors of septic arthritis:

1.     history of fever

2.     inability to bear weight on the limb

3.     ESR _40 mm/hour

4.     White blood cell (WBC) count 12 000/mL.

The predicted probability of septic arthritis was 0.2 if none of these predictors was present. This means if none of the factors were present there was only 2 % chance of the condition being septic arthritis

The probability of a diagnosis of septic arthritis was 40, 93.1 and 99.6 percent if two, three or four of these predictors, respectively, were present.

Although Kocher noted these four risk factors and validated these risk factors in a subsequent report,  other centers have found that these four factors may not have as high a predictive value in determining a septic hip as was originally thought. In a recent paper from Melbourne it was noted that a significant number of patients had normal parameters and suggested that clinical acumen still plays a crucial role in management

Cliteria of Jung et al:

The following were identified as were identified as independent multivariate predictors of septic arthritis.

Temperature>37°C

ESR > 20 mm/hour

CRP> 1 mg/dL

WBC> 11 000/mL

An increased joint space>2 mm

Radiology

X-rays are findings are often normal.Look for soft tissue swelling around the joint, widening of the joint space, and displacement of tissue planes.

Ultrasound is very sensitive in detecting joint effusions generated by septic arthritis. It also  can be used to define the extent of septic arthritis and help guide treatment. Sometimes Ultrasound helps to differentiate septic arthritis from other conditions (eg, soft tissue abscesses, tenosynovitis) in which treatment may differ.

MRI Can show changes of marrow edema and help to differentiate between transient synovitis, inflammatory arthritis and septic arthritis by virtue of changes in marrow edema and synovial lining. It can also diagnose additional osteomyelitis. In a recent study markers of SA on MRI included  bone marrow oedema  and absence of T1-weighted and T2-weighted low signal intensity synovial tissue. Furthermore, soft-tissue oedema and reduced contrast enhancement in the epiphyses were more frequent in children with SA.

Differential diagnosis

Conditions that Mimic infection

• Transient synovitis: May be difficult to differentiate early on. The lab reports, presence of mixed echogenesity on US and severity of symptoms and signs point to infective process. When in doubt a joint aspiration should be performed
• Inflamatory arthritis: Fluid out of proportion to symptoms
• Other conditions to keep in mind
  • Malignancies:leukemia, Ewing’s sarcoma, Metastasis
  • Langerhans cell histiocytosis
  • Sickle cell disease and bone infarct
  • Storage disorders: Gaucher disease

Management

Antibiotic therapy

Aim

To control and eradicate the infective process

Which antibiotic

The antibiotic selected should be effective against the organism responsible for the infection. Since

Gram-positive organisms are most frequently responsible for the infection, an antibiotic that is

effective against these organisms should be started empirically. In hospital acquired infection a combination broad spectrum antibiotic is started to be effective against gram positive and gram negative organisms

How long?

In the past it was recommended that treatment with antibiotics should be continued for six weeks.

However, recent studies suggest that the duration of medication may be reduced to four weeks or

less without adverse outcome in the long term

To start with an IV route is preferred  Once the clinical signs improve and CRP levels touch baseline

the antibiotic may be given orally.

Monitoring the treatment

1Clinical parameters: Fever, heart rate, Pain, range of movements,Weight bearing status

2. Lab p[arameters: ESR, TC/DC, CRP Among this CRP is the best indicator of response to therapy.

3. USG to look for reduction in joint effusion

4. Xrays To look for lytic areas and joint position

Failure of CRP to fall by 1 week

1 Recollection

2. Missed multifocal septic arthritis

3. Systemic infection- pneumonitis, pleuritis, pyelonephritis, peritonitis

4. Wrong antibiotic, resistant organism

5. Associated osteomyelitis

Shortened antibiotic course

A recent paper from Melbourne suggests a shortened antibiotic regimen of 3 days Iv antibiotic with 3 week oral antibiotics in patients with childhood septic arthritis and osteomyelitis. After 3 full days of intravenous antibiotics the patients were assessed with regard to converting to oral therapy. An improvement in symptoms (pain, movement), normalization of temperature, and stabilizing CRP were defined as prerequisites for conversion. Persistent pain, fever, and rising inflammatory markers dictated that therapy should continue and that surgical exploration could be indicated. All patients were kept in hospital for 1 day after conversion to oral therapy to ensure tolerance. Oral antibiotics were continued for 3 weeks, usually at half the intravenous dose if tolerated. They found that a temperature of greater than 38.4 on admission and CRP greater than 100 were the best predictor of needing antibiotics for more than 3 days The addition of ESR, WCC, or both did not help in determining which patients will require prolonged therapy. They could successfully convert 59% of patients by day 3 and 86% by day 5 resulting in only 14% of patients requiring intravenous therapy for 6 days or more.

Surgical Intervention

Aim

1.     Joint decompression: To reduce temonade, relieve pain and spasm, and obtain sample for smear and culture

2.     Joint lavage: To washout the enzymes and debris harmful to joint cartilage

Methods

1.     Aspiration and lavage:  Minimally invasive. Repeated joint aspirations are not a good option for hip joint as it does not decompress joint adequately, prolongs antibiotic therapy and hospital stay

2.     Arthrotomy:  Allows joint inspection and complete joint clearance. Septic hips in young children are drained anteriorly to avoid disrupting the posterior blood supply to the femoral epiphysis. It is critical to do a definitive capsulotomy. Be sure that the joint is aggressively irrigated and that there is no purulent collection left behind. Some have recommended decompression of the femoral neck if there is associated osteomyelitis that has not decompressed itself into the joint

3.     Arthroscopy: All advantages of arthrotomy being minimally invasive

Immobilization of the joint

Aim

To relieve spasm, prevent deformity and instability

Methods

With brace, plaster or traction

Prognosis

Depends on the following factors

-Duration of disease

-Type of organism

-Age of child

-The joint involved

-Intervention

-Associated systemic disorders and immune status

Summary

We recommend high index of suspicion while diagnosing septic arthritis in children and an aggressive treatment approach. Initial investigations include blood cultures, and hematologic markers (WCC, CRP, and ESR) followed by appropriate imaging. Ultrasound should be used to confirm SA and MRI can be used in selected cases. Empirical antibiotics (Amoxycillin Clav combination with amikacin) should be commenced after prompt drainage of joint collections. Further choice of antibiotics will depend on culture report and clinical course. Short antibiotic treatment guided by improvement in clinical parameters and CRP is effective in most cases.

References

Arnold SR, Elias D, Buckingham SC, et al. Changing patterns of acute hematogenous osteomyelitis and septic arthritis: emergence of community-associated methicillin-resistant Staphylococcus aureus. J Pediatr Orthop. 2006;26:703–708

Buxton RA, Moran M. Septic arthritis of the hip in the infant and young child. Curr Orthop. 2003;17:458–464

Caird MS, Flynn JM, Millman JE, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A propective study. J Bone Joint Surg Am. 2006;88(6):1251-1257.

Jagodzinski, Kanwar, Graham K  Prospective Evaluation of a Shortened Regimen of Treatment for Acute Osteomyelitis and Septic Arthritis in Children Journal of Pediatric Orthopaedics Volume 29(5), July/August 2009, pp 518-525

Jung ST, Rowe SM, Moon ES, et al. Significance of laboratory and radiologic findings for differentiating between septic arthritis and transient synovitis of the hip. J Pediatr Orthop. 2003;23(3):368-372.

Kirkhus E, Flatø B, Riise O, Reiseter T, Smith HJ. Differences in MRI findings between subgroups of recent-onset childhood arthritis.Pediatr Radiol. 2010 Dec 7. [Epub ahead of print]

Kocher MS, Mandiga R, Murphy JM, et al. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip. J Bone Joint Surg Am. 2003;85A(6):994-999.

Kocher MS, Mandiga R, Murphy JM, et al. A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcomes of septic arthritis of the hip. J Bone Joint Surg Am. 2003;85:994–999

Kocher MS, Mandiga R, Zurakowski D, et al. Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J Bone Joint Surg Am. 2004;86A(8):1629-1635.

Luhmann SJ, Jones A, Shootman M, et al. Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms. J Bone Joint Surg. 2004;86A:956-962.

Lyon RM, Evanich JD. Culture-negative septic arthritis in children. J Pediatr Orthop. 1999;19:655–659

Moumile K, Merckx J, Glorian C, et al. Bacterial aetiology of acute osteoarticular infections in children. Acta Paediatr Int J Paediatr. 2005;94:419–422.

Vinod MB, Matussek NC, Graham HK, et al. Duration of antibiotics in children with osteomyelitis and septic arthritis. J Paediatr Child Health. 2002;38:363–367

Click here to see the presentation

What is Pulled Elbow?

Pulled Elbow or “Nursemaids Elbow” is common in young children between 1 and 4 years of age.It is rare beyond the age of 6 years. It is due to the annular ligament of the radial head becoming stretched and entrapped. There is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent.Sometimes the incident is unobserved or thought to be too trivial to have caused any injury. The child typically allows the arm to hang loosely by their side in a pronated position. They are usually undistressed unless the arm is moved.

Clinical Features

• The parents come with complaint of the child not using the affected limb
• here is usually a history of a pull on the affected arm, such as when a child tries to run off in a different direction when walking with the hand held by a parent. Although there may not be history of pull in half the cases
• Inspection: The child keeps the elbow in extension and the forearm in pronation and is distressed only on elbow movement. Usually there is no swelling, deformity or bruising of the elbow or wrist
• Palpation:  tenderness is usually absent
• Movements: marked resistance and pain with supination of the forearm.

Diagnosis

• Clinically established with a classic history and examination.
• X rays are unnecessary if there is a typical history and no visible swelling or deformity. If the child has a pulled elbow the X ray is normal. The child may have normal use of the arm on return from radiology since positioning by the radiographer may solve the problem.
• Plain radiographs are indicated when a differential diagnosis is suspected:
  • significant tenderness, swelling, bruising or deformity
  • reduction fails

Treatment

The treatment consists of reducing the ligament back to its original position

1. Have your child sit in a chair facing you or stand facing you. Ask an older sibling or adult to distract the child as that there is slight temporary pain when you treat a pulled elbow, and it will be easier to slip the ligament back into place if the child is relaxed.
2. You should support the elbow with one of your hands, placing your thumb over the radial head with some gentle pressure. Hold
   the child’s hand in your other hand as if you are shaking hands.
3. Fully supinate the forearm and then fully flex the elbow. A click is usually felt over the radial head either when the elbow is fully supinated or fully flexed. This is known as supination/flexion manoeuvre. Alternatively one can also try full pronation followed by flexion (pronation flexion manoeuvre).
   

   

   

   

4. A click is felt as the ligament moves back into the correct position. You may not always hear this happen.
5. Offer the child a toy to see if he or she will once again use his or her arm.  A good test for successful reduction is whether the child will actively reach for a toy at arms reach. Most children will use the arm normally within 5 minutes of the reduction. There may be residual pain, but overall, the child should feel much better.
6. Failure may be due to not putting the elbow through the complete range of motion. Repeat the reduction if the ligament is still out of place. This process should cure and treat your child’s pulled elbow in a few seconds, and they should be ready to play once again.
7. If the reduction has been delayed for 12 hours or longer the child may not use the arm normally for a longer period of time.  A sling ± backslab can be used for comfort, with review of whether the child will use the arm 24 hours late

Recurrant Pulled Elbow

Recurrances with pulled elbow are common till 3-4 years age. The repeat injuries are treated in the similar manner. Repeated subluxations do not produce long term problems. The problem generally disappears by 5 year age. Very rarely, in child with multiple recurrances the doctor may advice cast for 3 weeks

Updates in the management of pulled elbow

Obscure pathology of pulled elbow: dynamic high-resolution
ultrasound-assisted classificationHossam S. Diab • Manal M. S. Hamed •Yasser Allam

J Child Orthop (2010) 4:539–543

Of the 50 included children, 39 (78%) had intact,yet interposed annular ligament (classified as type I) and 11
(22%) had torn annular ligament (classified as type II). The latter underwent splinting for 7 days. Three out of the 50
children had recurrent subluxation and constituted falsenegative cases for the detection of torn ligament and represented
the reoccurrence rate of 6%.

Dr Taral V Nagda

Institute of Paediatric Orthopaedic Disorders
 www.ipodindia.org
taralnagda@gmail.com

E plate hemiepiphysiodesis is a modern method to correct the deformities of long bones in a growing child. It works on the principle that controlling the growth on one side of growth plate results in angulation on the opposite side.

In presence of deformity the growth modulation on the convex side/ apical side can result in slow controlled correction of the deformity. The advantages of such a procedure will be

• No need of immobilisation or plaster as the bone is not cut
• Earlier mobilisation and return to activities
• Slow and safe correction
• The growth resumes normally after plate removal hence can be done even at younger age
• Timing of surgery not important as long as atleast 1 year available for corection before the growth stops.
  

Indications

• Correcting angular deformity in a growing child with open physis

Prerequisites

 
• 1 year of growth remaining
• One plane deformity frontal sagital oblique
• Growth potential on opposite side
  

Contraindications

• Closed Physis
• Skeletal Maturity
• Physio logical Deformities

Case Study

8 yr old girl with renal osteodystrophy with genu valgum shows excellent correction in 1 year

Equipments needed

• C ARM
• Radiolucent table
• 1mm and 1.5 mm guide wires
• E plate
• 4.5mm self tapping cannulated screws (15-30mm)
• Stop Drill

Surgical steps

Step 1 : LOCALIZATION OF PHYSIS

• Under image intensifier 1.5 mm guide wire is passed at the center of physis
• Confirmed in both AP & Lat views

Step 2: SKIN INCISION

• About 1.5 cm centered over guide wire
• The incision is deepened till perichomdrium
• E plate is positioned with its central hole sliding over the guide wire over the perichondrium
• The plate should be along the midline of the bone axis on lateral view

Step 3 GUIDE WIRES

• 2 guide wires are passed  through the holes on either sides of the physis
• They  need not be parallel but  care should be taken is not to violate the physis

Step 4 SELF TAPPING CANNULATED SCREWS

• Screw length is measured
• Should not be too short
• Generally 15-30 mm screws are sufficient
• Cortex is drilled
• Self tapping screws are passed

Step 5 Closure and Dressing

The closure is done in layers and compression dressing is applied.

No cast or immobilization is needed

Full weight bearing supported walking and knee mobilization are started the next day

Post op Protocol

• Day care surgery
• No immobilisation
• Immediate mobilisation
• Xrays once in 3 months
• Implant removal once the deformity is corrected

Advantages of E plate over staples

• Flexi bility
• Unconstrained implant
• Load sharing
• One plate per physis
• Fully threaded cannulated screws resist pull-out forces
• Diverging screws function like a hinge to gently guide natural growth
• Easy to remove

preoperative picture the child has varus and inernal rotation

3 year old child with tibia vara  The child has varus and internal rotation deformity not correcting on serial follow up.

Proximal  Block is made with 2 K wires inserted parallel to knee joint and perpendicular to the tibia.

Distal block is made with 2 K wires inserted inserted parallel to ankle and perpendicular to distal tibia.

In the transverse plane the proximal wires are in axis of the knee joint ( inter epicondylar axis) and the distal wires 15 degrees internal to bimalleolar axis

The osteotomy is made at CORA with multiple drill holes made in transverse plane and completed with 5 mm osteotome

When the wires are braught parallel the varus and the rotational deformities are corrected

The wires are connected  with miniexternal fixation clamps

An antero posterior anti toggle wire is added to proximal and distal blocks

The fixator is removed once the osteotomy heals generally 6 weeks post op

Step 1

Step 2

-Taral Nagda

-Rajeev Niravane

Institute of Paediatric Orthopaedic Disorders

www.ipodindia.org

taralnagda@gmail.com

Who should do Ponseti treatment?

v      J Bone Joint Surg Am. 2009 May;91(5):1101-8.
Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot.
Janicki JA, Narayanan UG, Harvey BJ, Roy A, Weir S, Wright JG.

• The introduction of the physiotherapist-supervised clubfoot clinic has been effective without compromising the quality of care of children with clubfoot deformity.

v      Ann R Coll Surg Engl. 2007 Jul;89(5):510-2.Ponseti treatment in the management of clubfoot deformity – a continuing role for paediatric orthopaedic services in secondary care centres.Docker CE, Lewthwaite S, Kiely NT.

• Similar results between tertiary Ped ortho dept and physiotherpy dept

v      J Bone Joint Surg Br. 2006 Aug;88(8):1085-9.
Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity.
Shack N, Eastwood DM.

• Ponseti technique is suitable for use by non-medical personnel, but a holistic approach and good continuity of care are essential to the success of the programme

Can neglected CTEV be treated with Ponseti method?

v      J Pediatr Orthop B. 2009 Mar;18(2):76-8.Results of treatment of idiopathic clubfoot in older infants using the Ponseti method: a preliminary report.

Hegazy M, Nasef NM, Abdel-Ghani H.

The use of thePonseti method in older-aged infants with idiopathic congenital clubfoot seems to

be an effective method of treatment, obviating the need for extensive surgery.

v      J Bone Joint Surg Br. 2007 Mar;89(3):378-81.
Correction of neglected idiopathic club foot by the Ponseti method.
Lourenço AF, Morcuende JA. Brazil

Only 5/24 needed surgery

• Ponseti method is a safe, effective and low-cost treatment for neglected idiopathic club foot presenting after walking age.

v      Clin Orthop Relat Res. 2006 Mar;444:224-8.
Ponseti management of clubfoot in older infants.
Bor N, Herzenberg JE, Frick SL. Israel

older infants with clubfoot can be treated successfullywithout extensive surgery. Our results in older infants are similar to theresults of a previous study we conducted with younger infants

3 % rate of surgery in children less than 3 years

v      Arch Orthop Trauma Surg. 2006 Jan;126(1):15-21. Epub 2005 Nov 10.
Ponseti technique for the correction of idiopathic clubfeet presenting up to 1 year of age. A preliminary study in children with untreated or complexdeformities.
Göksan SB Turkey

• Our results show that the Ponseti technique is reproducible and effective in children at least up to 12months of age
• Only 3 % need extensive PMR

Ponseti method in post PMR cases??

v      Clin Orthop Relat Res. 2009 May;467(5):1298-305. Epub 2009 Feb 4.
Is it possible to treat recurrent clubfoot with the Ponseti technique after posteromedial release?: a preliminary study.
Nogueira MP, Ey Batlle AM, Alves CG.

• initial and final Pirani scores and range of motion of the ankle and subtalar joint. Plantigrade and fully corrected feet were obtained in 71 feet (86%); 11 feet obtained partial correction; one patient failed treatment and underwent another posteromedial release. Recurrences occurred in ninepatients (12 feet or 14%)

Does FAB give rise to femur/ knee/ tibial tortional deformities ?

v      J Pediatr Orthop. 2007 Sep;27(6):712-6.
Foot abduction brace in the Ponseti method for idiopathic clubfoot deformity: torsional deformities and compliance.
Boehm S, Sinclair M.

• Application of the foot abduction brace did not result in pathological changes of femoral anteversion or tibial torsion

Can Ponseti method avoid surgery?

v      Clin Orthop Relat Res. 2009 Apr 7.
Comparison of Ponseti versus Surgical Treatment for Idiopathic Clubfoot: A Short-term Preliminary Report.
Zwick EB, Kraus T, Maizen C, Steinwender G, Linhart WE.

• a favorable short-term outcome for the Ponseti method when compared with a traditional treatment protocol

v      Clin Orthop Relat Res. 2009 May;467(5):1271-7. Epub 2009 Jan 14.
Ponseti method: does age at the beginning of treatment make a difference?
Alves C, Escalda C, Fernandes P, Tavares D, Neves MC.

• according to their age at the  beginning of treatment; Group I was younger than 6 months and Group II was > 6 months.
• The rate of the Ponseti method in avoiding extensive surgery was 100% in Groups I and II;
• relapses occurred in 8% of the feet in older children

v      J Pediatr Orthop B. 2007 Sep;16(5):317-21.
Comparative results of the conservative treatment in clubfoot by two different protocols.
Cosma D, Vasilescu D, Vasilescu D, Valeanu M.

• The Ponseti method decreases the number of surgical interventions needed for the correction of the deformation compared with our traditional method.  5 % need surgery

v      Z Orthop Ihre Grenzgeb. 2006 Sep-Oct;144(5):497-501.
Treatment of congenital clubfoot with the Ponseti method
Eberhardt O, Schelling K, Parsch K, Wirth T.

• With the Ponseti methodthe need for extensive corrective surgery is greatly reduced. (2/41)

v      Pediatrics. 2004 Feb;113(2):376-80.
Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method.
Morcuende JA, Dolan LA, Dietz FR, Ponseti IV

• 11 % relapse
• 3 % extensive surgery rate

What are the factors affecting relapse?

v      J Child Orthop. 2009 Jun 3.
Improved bracing compliance in children with clubfeet using a dynamic orthosis.
Garg S, Porter K.

• Non-compliance with foot abduction bracing in children with clubfeet treated with the Ponseti method is the leading risk factor for deformity recurrence.
• A dynamic foot abduction orthosis is believed to result in improved compliance, fewer skin complications, and fewer recurrences

v      J Bone Joint Surg Am. 2007 Mar;89(3):487-93.
Early clubfoot recurrence after use of the Ponseti method in a New Zealand population.
Haft GF, Walker CG, Crawford HA.

• Compliance with the postcorrection abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformitytreated with the Ponseti method.
• When the parents comply with the bracingprotocol, the Ponseti method is very effective at maintaining a correction,although minor recurrences are still common.
• When the parents do not comply with the bracing protocol, many major and minor recurrences should be expected

v      Iowa Orthop J. 2007;27:82
Neuromuscular disease as the cause of late clubfoot relapses: report of 4 cases.
Lovell ME, Morcuende JA.

• Late relapses in patients with idiopathic clubfoot may represent the onset of a previously undiagnosed neuromuscular disease, and should be thoroughly evaluated.

v      J Pediatr Orthop. 2005 Mar-Apr;25(2):225-8.Use of the foot abduction orthosis following Ponseti casts: is it essential?
Thacker MM, Scher DM, Sala DA, van Bosse HJ, Feldman DS, Lehman WB

• The feet of patients compliant with FAOuse remained better corrected than the feet of those patients who were not compliant

v      J Bone Joint Surg Am. 2004 Jan;86-A(1):22-7.
Factors predictive of outcome after use of the Ponseti method for the treatment of idiopathic clubfeet.
Dobbs MB, Rudzki JR, Purcell DB, Walton T, Porter KR, Gurnett CA.

• Noncompliance and the educational level of the parents(high-school education or less) are significant risk factors for the recurrenceof clubfoot deformity after correction with the Ponseti method. The identification of patients who are at risk for recurrence may allow intervention to improve the compliance of the parents with regard to the use of orthotics,and, as a result, improve outcome

How does one treat a replapse?

v      Instr Course Lect. 2006;55:625-9.
Treatment of a recurrent clubfoot deformity after initial correction with the Ponseti technique.
Dietz FR.Department of Orthopaedics, University of Iowa, Iowa City, Iowa, USA.

• The indication for anterior tibial tendon transfer is the presence of dynamic supination during gait. After tendon transfer, bracing is no longer required because the eversion force of the transferred tendon maintainsthe correction

Is Ponseti method applicable to clubfoot with MMC?

v      J Bone Joint Surg Am. 2009 Jun;91(6):1350-9.
Early results of the Ponseti method for the treatment of clubfoot associated with myelomeningocele.
Gerlach DJ, Gurnett CA, Limpaphayom N, Alaee F, Zhang Z, Porter K, Kirchhofer M,
Smyth MD, Dobbs MB.

• Initial correction was achieved in twenty-seven clubfeet (96.4)
• Relapse of deformity was detected in 68% of the feet in the myelomeningocele group, compared with 26% of the feet in the idiopathic group (p = 0.001).
• Relapses were treated successfully without the need for extensive soft-tissue

v      Journal of Pediatric Orthopaedics. 29(4):393-397, June 2009.
Treatment of Neuromuscular and Syndrome-Associated (Nonidiopathic) Clubfeet Using the Ponseti Method
Joseph A. Janicki, MD,* Unni G. Narayanan, MBBS, MSc, FRCSC,Þ Barbara Harvey, BHScPT,

• Ponseti method is worth applying to nonidiopathic clubfeet in an attempt to avoid surgical release.
• Nonidiopathic clubfeet required significantly more casts (6.4 vs 4.8) to achieve initial correction and had a higher recurrence rate (44% vs 13%).

Is it necessary to change protocol in complex clubfoot ?

Clin Orthop Relat Res. 2006 Oct;451:171-6.
Treatment of the complex idiopathic clubfoot
Ponseti IV

• Modifying the treatment protocol for complex clubfeetsuccessfully corrected the deformity without the need for extensive correctivesurgery

Trigger thumb represents an abnormality of the flexor pollicis longus and its tendon sheath at the Al pulley. There is a palpable mass (Notta nodule), representing the flexor pollicis longus constriction at the Al pulley.

Is it always congenital?

In the past,trigger thumbs were defined as congenital. However, this

condition is acquired in the first

2 years of life, as indicated

by prospective screening of neonates who failed to yield any

trigger thumbs.

What causes CTT/CTF?

The cause appears to be a size mismatch between the flexor pollicis longus and the Al pulley that leads to progressive constriction. Unlike adult trigger digits, there does not appear to be an inflammatory component.

Can it be hereditary or associated with syndromes?

There is no familialinheritance pattern.30% of the cases are bilateral. Isolated trigger thumbs have no associated syndromes. However,trigger digits are seen with neurologic syndromes (trisomy18) and mucopol

ysaccharidoses.

When and how does a child with TT/TF present?

Trigger thumb patients present at ages ranging from infancy to school age. Often, the diagnosis is missed until local trauma brings attention to the thumb. In the emergency setting the flexed interphalangeal joint can be mistaken for an interphalangeal joint dislocation.Radiographs are misleading because of limited phalangeal ossification. A palpable nodule at the Al pulley is diagnostic.If the trigger is long-standing, compensatory hyperextension

of the MCP joint develops to effectively bring the thumb out of the palm. In addition, there may develop mild radial deviation of the interphalangeal joint secondary to eccentric flexor pull.

How is CTT/CTF treated?

In infants younger than 9 months of age, Dinham and Meggit found that 30% of trigger thumbs may resolve spontaneously. In infants older than 1 year of age, less than 10% of trigger thumbs resolved spontaneously. Ger et al.found lack of resolution with observation for 3 years in their patients. There is limited evidence that splinting will be of benefit, and often it is not well tolerated. Surgical release of the constricting Al pulley and flexor tendon sheath is the treatment of choice.

What are the indications for surgery

This is indicated in infants without spontaneous resolution by 1 year of age, and in any toddler or older child presenting with a locked trigger thumb.

What are the steps of the surgery?

1. Anaesthesia general with local block
2. Incision: Transversely in the digital crease to lessen scarring.
3. Deeper dissection: Perpendicular to incision. Care must be taken to avoid iatrogenic injury to the superficial digital neurovascular bundles. A1 pulley is releasd.
4. It is usually not necessary to excise a portion of this pulley nor to shave the nodule, which will disappear after the release.The oblique pulley needs to be preserved to prevent
   

   

   flexor tendon bowstringing.

5. The thumb is extended fully to be certain that the release is complete.
6. On ly the skin is closed
7. The thumb is placed in a light (child-proof) dressing for 1 week and then removed to allow return to the usual activities. No further treatment is required. The chance of recurrance are very few

How is trigger finger different from rigger thumb?

1. Trigger digits are more often multiple, and can be associated with central nervous system disorders and syndromes (trisomy 18, mucopolysaccharidoses).
2. The pathology appears to predominate at the decussation of the flexor tendons under the A2 pulley, and not at the Al pulley alone.
3. Th e tri ggering appears to occur as the flexor digitorum profundus passes through the chiasm of the flexor digitorum superficialis.
4. Surgic al recurrence is high in pediatric trigger digits. This may be because Al pulley release alone is not sufficient to solve the problem. Further opening of the chiasm or resection of a slip of the flexor digitorum superficialis is often necessary to prevent recurrence

Related Articles

The Natural History of Pediatric Trigger Thumb

Goo Hyun Baek, MD, Ji Hyeung Kim, MD, Moon Sang Chung, MD, Seung Baik Kang, MD, Young Ho Lee, MD and Hyun Sik Gong, MD

Department of Orthopedic Surgery, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea. E-mail address for G.H. Baek: ghbaek@snu.ac.kr

Investigation performed at the Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea

Background: Pediatric trigger thumb is a condition of flexion deformity of the interphalangeal joint in children. Although the surgical outcome is satisfactory, the indications for nonoperative treatment for this condition are not clear. The aim of the present study was to determine the rate of resolution of untreated pediatric trigger thumb.

Methods: Data on seventy-one thumbs in fifty-three children were collected prospectively. The dates of the first visits ranged from April 1994 to March 2004. Patients were diagnosed with pediatric trigger thumb during initial outpatient department visits. During the present study, no treatment such as passive stretching or splinting was applied. The amount of flexion deformity at the thumb interphalangeal joint was measured at every six-month follow-up visit, and the duration of follow-up was at least two years after diagnosis. The end point of follow-up was when the deformity caused pain or secondary deformity or prevented normal use of the hand. The median duration of follow-up was forty-eight months.

Results: Of the seventy-one trigger thumbs, forty-five (63%) resolved spontaneously. The median time from the initial visit to resolution was forty-eight months. There was no significant difference in the pattern of resolution between patients with unilateral and bilateral trigger thumb. Although resolution was not observed in the remaining twenty-six thumbs, flexion deformities improved in twenty-two thumbs. For the first two years after the initial visit, the mean flexion deformity significantly decreased over the one-year intervals (p < 0.05).

Conclusions: Pediatric trigger thumb can be expected to resolve without treatment in >60% of patients. Moreover, the flexion deformity can be expected to show an improving pattern in patients who do not have resolution. This information may help both parents and surgeons to make decisions regarding the treatment of pediatric trigger thumb.