Vol 6, No 2 (2018)

Exchange of experience

Results of treatment of children with femoral neck fractures

Bortulev P.I., Baskov V.E., Barsukov D.B., Pozdnikin I.Y., Ovsyankin A.V., Drozdetsky A.P., Bortuleva O.V., Baskaeva T.V., Kostomarova E.A.


Introduction. Femoral fractures in children remain a topical problem because of the risk and frequency of severe complications, such as aseptic necrosis of the femoral head that causes deforming coxarthrosis and early disabilities. This type of injury accounts for approximately 1% of all skeletal bone fractures in childhood. In 80% of the cases, the cause of femoral neck fracture is severe trauma, but in 15% of patients, the fracture occurs despite inadequate trauma during physiologically normal activity of the child. With femoral neck fractures without stable osteosynthesis, consolidation of bone fragments occurs extremely rarely, and a long period of immobilization during conservative treatment is accompanied by a risk of complications caused by hypodynamia.

Aim. To conduct a retrospective analysis of the results of surgical treatment of different types of fracture of the femoral neck in children.

Materials and methods. We analyzed surgical treatment results of 5 children aged 10 to 17 years (4 boys, 1 girl) with different types of femoral neck fractures according to the Delbet and Colonna classification. The cause of the fractures in all 5 children was high-energy trauma. All patients, depending on the type of fracture, underwent a closed repositioning with osteosynthesis of the fragments using metal constructions (cannulated screws, DHS plate). Follow-up observations were performed ≤7 years after the surgical treatment.

Results. Restoration of the hip joint function, absence of pain syndrome, absence of complications, and complete social adaptation was achieved in all cases.

Conclusion. Femoral neck fractures are subject to immediate surgical treatment because there is a high risk of aseptic necrosis of the head of the femur. With the correct technical performance, it is possible to achieve stable, positive, functional, and radiologic long-term results.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):63-72
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External stabilization of the thorax in complex treatment of children with severe chest injuries: Description of clinical cases

Satyvaldayev M.N., Akselrov M.A.


Aim. To describe a proposed method of treating children with a traumatic disorder of the thorax.

Material and methods. Under the conditions of work in the Tyumen “Center of Medicine of Catastrophes”, doctors of all specialties of the Tyumen region interact with thoracic surgeons. Special attention is given to children with polytrauma. In the Tyumen region for the period 2016–2017, two travels to treat children with multiple floating fractures of the ribs on one side were made. The patients were treated by using an original method of external chest stabilization. We present the advantages of the method in the descriptions of the clinical cases.

Results. The chest structure was stabilized by using a V-shaped model of the Cramer tire to increase the area of contact with the chest. The tire was fixed with Kapron thread No 5 by using a large cutting needle, which was wound under the ribs after marking the floating section of the chest. The ribs were stitched for stable areas along the edges and for an unstable fragment of the thorax. Later, the V-shaped model of the Cramer tire was applied and fixed by threads to the chest. This method is simple and acceptable in any hospital and allows early spontaneous breathing with no purulent-septic complications.

Conclusions. This method of restoring the skeletal function of the thorax with the help of external fixation of the V-shaped model of the Cramer tire allows reliable minimally invasive stabilization of the chest wall. External stabilization of the thorax allows early transfer of the victims to independent breathing and shortens the duration of treatment in the intensive care unit. The availability and simplicity of the design makes it possible to perform this procedure everywhere. Video thoracoscopic support is needed only if there is a suspicion of a clotted hemothorax.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):73-78
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Congenital contracture of the iliotibial tract: a case report

Garkavenko Y.E., Krasnogorskiy I.N., Dolgiev B.H.


Introduction. Congenital contracture of the iliotibial tract is a rather rare pathology that causes difficulties in diagnosing and planning treatment activities. The lack of a clear idea of the causes of the disease has led to disagreement in the interpretation of the diagnosis in patients with this pathology. In the Russian-language literature, this disease is referred to as idiopathic extension and abduction contracture of a hip joint or idiopathic contracture of the dorsal gluteal muscle (a congenital contracture of the tendons of the dorsal gluteal muscles), whereas the English-language literature more often highlights congenital or idiopathic contracture of the dorsal gluteal muscles.

Clinical сase. The results of treatment of a 6-year-old child with congenital contracture of the iliotibial tract is presented. The child exhibited lameness when walking first started, but the correct diagnosis was not established. Clinically, along with the limitation of adduction and extension in the hip joint and an induration of the soft tissue along the external surface of the right thigh, the pelvis was skewed, and there was shortening of the right lower limb and a valgus deformity of diaphysis of the right femoral bone. Ultrasonographic and magnetic resonance imaging indicated the presence of a fibrous bridle over the outer surface of the right thigh. The fibrous bridle was excised for 15 cm, and a temporary hemiepiphysiodesis of the medial portion of the distal growth zone of the right femur was performed.

Results and discussion. At the 1-year control examination, the patient did not present any complaints. There was no relapse of the contracture. According to X-ray study results, correction of the valgus deformity of the right femur was achieved, and the metal structures were removed. Despite the more frequent extension and abduction direction of the contracture of the iliotibial tract indicated by most authors, the direction and severity apparently may depend on the predominant zone of fibrous degeneration of the muscle groups. Additionally, with the predominant lesion of the dorsal gluteal muscle, a more pronounced extension component can be expected, whereas with the predominant lesion of the musculus tensor fasciae latae, a flexion component can be expected and was observed in our patient.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):79-85
pages 79-85 views

Original papers

Association of spine deformation progression in children with idiopathic scoliosis and folate cycle gene polymorphism

Filippova A.N., Baindurashvili A.G., Sogoyan M.V., Khalchitsky S.E., Kokushin D.N., Khardikov M.A.


Background. One of the most common orthopedic pathologies in children aged 10–18 years is idiopathic scoliosis, which is diagnosed in 2%–3% of cases in the general population.

Aim. To compare the distributions of the allele frequencies and folate cycle gene genotypes among the MTHFR 677 C>T (rs 1801133), MTHFR 1298 A>C (rs 1801131), MTR 2756 A>G (rs 1805087), and MTRR 66 A>G (rs 1801394) polymorphisms in patients with idiopathic scoliosis and in children without spinal deformity. To also analyze the relationship between the studied molecular-genetic markers and development of scoliosis.

Materials and methods. Clinical and genetic examinations were performed in 48 children with idiopathic scoliosis and 32 healthy children. Molecular-genetic testing was performed by polymerase chain reaction.

Results and discussion. We found that the percentage of carriers of pathological alleles and genotypes was higher in the children with idiopathic scoliosis than in the general population.

The number of pathological alleles and genotypes associated with the MTHFR (A1289C) and MTRR genes was significantly higher in patients with idiopathic scoliosis than in the control group.

Сonclusion. We found that the percentage of carriers of pathological alleles and genotypes was higher in children with idiopathic scoliosis than in the population.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):5-11
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Analysis of the physical growth and markers of connective tissue dysplasia in patients with Perthes disease

Lobov I.L., Malkov A.V., Lobov N.I.


Introduction. The pathogenesis of Perthes disease is not fully understood and requires a greater understanding of the physical development, external and internal markers of connective tissue dysplasia.

Objective. To analyze the deviations in physical development and connective tissue dysplasia in children with Perthes disease to determine its phenotypes.

Materials and methods. We examined 52 patients and 36 children (control group) aged of 4–17 years. We estimated and compared their physical and proportional growth by using centile charts and Vervec’s index and defined external and internal manifestations of connective tissue dysplasia in major organs, systems, and topographic regions. Complete genealogical histories were taken by with examining the genealogies of 52 probands, including clinical examination of 136 first and second degree relatives.

Results. Deviations in physical growth were observed in 33 patients (63.5%). The body height of 27 (51.9%) patients aged 4–17 years ranged from 1–2 lines (3–10%) and was significantly lower than that of the control group within 5 lines (p < 0.5). Six (11.6%) children had body lengths higher than the average 7th line (75–90%). Vervec’s index in 34 (65.4%) children ranged from 1.25–0.85 and represented mesomorphy, moderate brachy, or dolichomorphia. The primary pathology of external organs and systems was skeletal anomalies in 36 (69.2%) children, followed by dermal in 23 (44.2%) and organs of vision in 9 (17.3%). Among visceral disorders, the primary pathology was cardiovascular diseases in 17 (32,7%) children followed by surgical and urological pathologies in 7 (13.5%) and digestive system disorders in 5 (9.6%). Disease inheritance was sporadical in 48 (92.3%) children.

Conclusion. The Perthes disease phenotype was related to the undifferentiated form of collagenopathies.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):12-21
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Treatment approach to shoulder internal rotation deformity in children with obstetric brachial plexus palsy

Agranovich O.E., Oreshkov A.B., Mikiashvili E.F.


Introduction. Shoulder internal rotation contracture is the most common deformity affecting the shoulder in patients with obstetric brachial plexus palsy because of the subsequent imbalance of the musculature and the abnormal deforming forces that cause dysplasia of the glenohumeral joint.

Aim. To assess the effects of tendon transfers in children with shoulder internal rotation deformity due to obstetric brachial plexus palsy.

Materials and methods. From 2015 to 2017, we examined and treated 15 patients with shoulder internal rotation deformity caused by obstetric brachial plexus palsy. The children ranged in age from 4 to 17 years. We used clinical and radiographic examination methods, including magnetic resonance imaging, electromyography, and electroneuromyography, of the upper limbs.

Results. According to the level of plexus brachialis injury, the patients were divided into 3 groups: level С5–С6 (9 patients), level C5–C7 (5 children), level С5–Th1 (1 patient). All children had secondary shoulder deformities: glenohumeral dysplasia type II, 6 (40%); type III, 5 (34%); type IV, 1 (6%); and type V, 3 (20%). The Mallet score was used for estimation of upper limb function. Surgical treatment was performed in 15 children. After treatment, all patients showed improvement in activities of daily living.

Conclusion. Tendon transfers in patients with shoulder internal rotation deformities due to obstetric brachial plexus palsy improved upper limb function and provided satisfactory cosmetic treatment results without of remodeling of the glenohumeral joint.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):22-28
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Current methods of patellar instability imaging in children. Selection of the best treatment approach

Sautenko A.A., Ogarev E.V., Eltsin A.G., Merkulov V.N., Mininkov D.S.


Background. Patellar instability is a common problem in pediatric patients. Up to 2%–3% of all knee injuries are associated with acute patellar dislocation. According to the data in the literature, patients aged 10–17 years are at the highest risk of patellar dislocation and subsequent instability. These patients must be evaluated according to the proposed algorithm to select the optimal treatment method.

Aim. To diagnose patellar instability in children and subsequently select the optimal treatment method based on acquired data.

Materials and methods. The study is based on data acquired through the examination and treatment of 147 patients at the 9th Department of Pediatric Traumatology and Orthopedics. Great emphasis was put on computed tomography (CT) data, its essential parameters, which require the most thorough analysis, and assessment methods. These parameters include patellar tilt, dysplasia of the distal metaepiphysis of the femur, the tibial tubercle–trochlear groove index, and the rotational relation of the femur and tibia.

Results. A novel algorithm for patient examination using CT is proposed. Data obtained by multislice CT (MSCT) had a significant influence on the selection of the surgical method for treating patients with patellar instability.

Conclusion. The examination of patients with patellar instability using MSCT in adherence to the proposed diagnostic algorithm allows the selection of the optimal treatment method, which will increase the likelihood of rapid recovery of patients and their return to the level of activity similar to that before injury.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):29-36
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Dependence of the 8-plate position inhemiepiphysiodesis on the X-ray parameters of the epimetaphyseal bone junction

Kenis V.M., Morenko E.S., Sapogovsky A.V.


Introduction. To correct axial deformities in children at the knee joint level, the method of “guided growth” using the 8-plate is applied. Despite the widespread use of this method, the toolkit for its implementation was developed mainly for patients with idiopathic deformities and does not take into account the features of the epimetaphyseal bone junction in children with skeletal dysplasias.

Aim. To develop X-ray criteria that characterize anatomical features of the epimetaphyseal region of the bone to predict possible difficulties associated with the position of the metal structure in hemiepiphysiodesis.

Materials and methods. We developed calculations of the X-ray parameters of the epimetaphyseal junction of the bone (angle of the epimetaphyseal junction and index of the epimetaphyseal junction) in 58 patients (107 lower limbs) with axial deformities in the frontal plane at the knee level in skeletal dysplasias (main group). The control group included 50 children (67 lower limbs) with identical deformities but without a primary lesion of the growth plate in which similar calculations of the X-ray parameters were performed. In stage I of the study, all patients were admitted to the Department of the Turner Research Institute for Children’s Orthopedics for temporary hemiepiphysiodesis using the 8-plate to correct axial deformities of the lower extremities at the knee joint level. In stage 2, the metal structure position was evaluated after the operative treatment that adhered the plate to the bone metaphysis. A total of 255 plates were fixed: the hemiepiphysiodesis of the femur was performed in 138 cases and of the tibia in 117. Pearson correlation coefficient analysis was performed by using IBM SPSS Statistics version 23 software.

Results. Among the patients who underwent surgical interventions using the method of guided growth, incomplete adherence of the plate to the bone was observed in 43 (17.3%) of 255 fixed plates because of the anatomical features of the epimetaphyseal region and more often in patients with skeletal dysplasias.

Conclusion. We developed X-ray criteria for the angle of the epimetaphyseal junction and the index of the epimetaphyseal junction that are recommended for prediction of the position of metal structures.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):37-43
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Selected aspects of the epidemiology of tumors and tumor-like diseases of the spine and spinal cord in children: A 19-year regional cohort study in the Leningrad region

Snishuk V.P., Vladovskaya M.D., Vissarionov S.V., Krutelev N.A., Kaminskiy A.V., Petrova I.S.


Background. Statistical analysis of spinal tumors in children is difficult because of its rarity and different morphology. Benign tumor and tumor-like processes are not included in modern oncology literature even though intracanal tumors have the most severe prognosis and influence on a patient’s quality of life.

Aim. To evaluate the incidence, epidemiological structure (anatomical, sex, morphological structure), clinical characteristics, and survival of pediatric patients with tumors and tumor-like diseases of the spine and spinal cord in a single region of Russia.

Materials and methods. The data of 110 children with tumors and tumor-like diseases of the spine and spinal cord from the Leningrad region who received surgical treatment in Leningrad regional children's hospitals between 1998 and 2016 were included in the study. The authors evaluated the incidence, mortality, and survival rates adjusted for age, sex, morphology, and primary site of growth.

Results. The average annual morbidities of pediatric spinal tumors (including the spine and spinal canal) in the Leningradsaya oblast region from 1998 to 2016 were 1.93 per 100 000 pediatric patients and 0.3 per 100 000 for neuro-epithelial tumors of the spinal cord. The mortality rate was 0.2 per 100 000 pediatric patients. Spinal cord tumors of the cranio-vertebral and cervical zones as intramedullary low-malignant and extramedullary malignant metastatic spinal tumors had a negative effect on survival.

Conclusions. The Leningrad regional data were generally comparable with the cancer registry data of other countries. The data suggest that pediatric spinal cord patients should be treated in regional neurosurgical pediatric clinics.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):44-53
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Analytical revisit to basics helps reduce unnecessary CT scan in children with abdominal trauma: A single institution experience

Khan R.A., Hazique M., Wahab S.


Introduction. CT scan is regarded as the investigation choice for accurate depiction of blunt abdominal injuries in children and is considered as an inevitable tool in the armamentarium of the clinician before deciding for conservative management of these children. However over dependence on CT scan puts the patient to many disadvantages.

The aim of this study to devise stratification criteria for the children with blunt abdominal injury and advise CT scan to the children only who really require it.

Material and methods. All the children with blunt abdominal injury were studied prospectively over a period of two years. These children underwent clinical, biochemical and ultrasonographic assessment at presentation followed by CT abdomen. Efficacy of predefined clinical, biochemical and ultrasonographic parameters was compared with CT scan to triage the children with intra abdominal injury.

Results. A total of 84 children were registered in the study based on final diagnosis of presence or absence of intra abdominal injury the children were divided in two groups. These groups were then compared for various clinical, laboratory and ultrasonographic parameters to predict intra abdominal injury. The children having isolated abdominal injury, tenderness, raised AST, ALT and amylase and free fluid on ultrasonography were found to have more chances of intrabdominal injury (p < 0.001). These parameters were the most sensitive parameters to predict intra abdominal injury and the cumulative sensitivity of these parameters was 99.7%. The CT abdomen was negative in 74.7% of the patients.

Conclusion. Due to high negative rate of CT abdomen in children with abdominal trauma, its use as first line imaging investigation is questionable in all the children with abdominal trauma. We suggest that by utilizing clinical, biochemical and ultrasonographic parameters, the children at risk of intra abdominal injuries can identified with almost 100% accuracy mandating the use of CT scan only in these children.

Pediatric Traumatology, Orthopaedics and Reconstructive Surgery. 2018;6(2):54-62
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