Abstract Rationale: Acute compartment syndrome (ACS) is a feared complication following traumatic injuries. We describe the occurrence of silent ACS of the hand in a 2-year old patient with atypical symptoms. Patient concerns: Our patient experienced massive swelling but minimal pain of the hand after a heavy bistro table with a stone tabletop had fallen on the right hand. Diagnosis: After monitoring the development of ACS for 1 night, we noted increased firmness of the swelling and impaired perfusion of the skin covering the palm and dorsum of the hand. Notably, the patient held the hand in an intrinsic minus position but did not complain of pain after administration of only a single (weight-matched) dose of ibuprofen. Our suspicion of ACS was confirmed intraoperatively because of the elevated intramuscular pressure (up to 60 mm Hg) in several hand compartments. Interventions: We performed surgical fasciotomy of all hand compartments, followed by temporary coverage of the wounds with Epigard synthetic skin substitute. The wounds were closed stepwise after 2 and 7 days, and occupational therapy was initiated after 3 weeks. Outcomes: At the 1-year follow-up, we noted unrestricted wrist and finger functions of the patient. The parents reported that there was no difference in the use of the 2 hands during daily activities. Lessons: The possible development of ACS should be borne in mind even in the absence of marked pain. Although the 3 A's (i.e., anxiety, agitation, and increased analgesic requirements) in the diagnosis of ACS in children are well established, some patients may experience only minimal pain. This challenges the correct and timely diagnosis of ACS in children, particularly if they are very young.
Reasons for impaired function of the upper extremity in the newborn are either congenital (eg, dysplasia) or caused by obstetric trauma such as clavicle fracture, humerus epiphysiolysis, plexus palsy, or dislocated elbow joint. After an unsuccessful attempt to reduce her subluxated left elbow joint a 2-day-old baby was transfered to our department straight from the orthopaedic operating room table of a district hospital. On first examination the elbow joint was swollen, the range of movement painfully restricted and additionally a slight plexus palsy was observed. Dislocated, non-articulating elbow joint surfaces were detected in initial x ray films. Magnetic resonance imaging scans in this case were inconclusive in contrast to a non-incidental case in a 4-month-old baby, whereas ultrasound scans revealed the fracture line and slipped epiphysis in both cases. The dislocated epiphysis was reduced in analgosedation under ultrasound control before an 8-shaped plaster sling was applied. Two weeks later the sling was removed and physiotherapy started. Follow-up was done by ultrasound easily and exclusively. Three months later correct joint alignment and regular bony healing on x ray films and ultrasound scans. Only slightly restricted range of movement. In conclusion, especially in the neonatal case, ultrasound was the most valuable tool for diagnosis of the slipped distal humerus epiphysiolysis making most benefit out of its advantages: bedside availability, dynamic mode, non-invasiveness, lack of radiation and avoidance of general anaesthesia.
Ninety severed flexor tendons were repaired in 24 boys and 14 girls in a four-year-period at the Department of Pediatric Surgery in Graz. Mean age was 4.9 years. In 16 patients (42%) additional lesions were found. Direct repair was performed with modified techniques of Kirchmayr (23) or Kleinert (8). In four fingers, flexor tendon reconstructions were carried out. Postoperatively, the dynamic Kleinert splint was used for early nonresistive motion, beginning on average on the second postoperative day. Intensive training of motion was performed in physiotherapeutic sessions during a mean period of five months, postoperatively. In five cases tenolysis was performed; in one case a rupture of a sutured tendon had to be corrected. 27 patients (71%) with 42 injured fingers were followed-up on average 2.7 years after the operation. In accordance with the Buck-Gramcko classification, very good results were achieved in 37 cases (88%), and a poor result in one patient (2%). Atraumatic technique, dynamic splinting, consequent physiotherapeutic training by experienced physiotherapists, and well informed parents will yield excellent results after flexor tendon repair in the paediatric age group.
The aim of this study was to establish whether a more precise classification of the different types of testicular maldescent could be made by using the measurement of pubic tubercle-centre of testicle distance. The pubic tubercle-centre of testicle distance was determined in 77 healthy children. The results were obtained in children aged 1 month to 15 years. The results were compared to the distances obtained in 47 children with testicular maldescent. The distance between pubic tubercle and centre of testicle represents an objective parameter in the examination of testicular maldescent. It is used to determine the testicular position precisely, and by comparing it to our graphs of normal values, it is possible to find pathological results. Our graphs of normal values for pubic tubercle-centre of testicle distance for different age groups, weight groups and body length groups in children can also be used to record the effect of hormonal or surgical therapy. Surprisingly there exists no obvious growth of the pubic tubercle-centre of testicle distance within the first seven years of life. By comparing the measurement of the pubic tubercle-centre of testicle distance of a child with testicular maldescent to our graphs of normal values, it is easy to find an objective parameter for the initiation of therapy, or for the decision to wait and see.
Use of polyacrylate-polyalcohol copolymer (PPC) after endoscopic correction (EC) of vesico-ureteral reflux (VUR) is highly effective but is associated with a higher risk of obstructive complications (OC) compared with other implants. We undertook a STROBE compliant retrospective investigation and studied the OC risk factors to increase the practical safety of PPC.Overall, 798 patients (464 [58.1%] girls and 334 [41.9%]) boys) from 5 hospitals in whom PPC was routinely used were evaluated retrospectively. The patients were subdivided into 2 groups. Group I consisted of 754 (94.5%) children (449 [59.5%] girls and 305 [40.5%] boys) without OC. Median age was 41 months [Q1: 18.0; Q3: 81.0]. Group II comprised 44 (5.5%) patients (29 [65.9%] boys and 15 [34.1%] girls) experiencing OC, and their median age was 21.5 months [Q1: 12.0; Q3: 43.0]. Clinical and renal ultrasound examinations were carried out 1 day and 1 month after EC, and then every 6 months after EC. At the follow-up examination approximately 6 months after EC, voiding cysto-urethrography (VCUG) was performed. All patients with OC underwent diuretic renography.OC occurred in 44 (5.5%) of 798 children, in some cases as late as 60 months after endoscopic injection of the bulking agent PPC for correction of VUR. Univariate analysis revealed that younger age (P < .001), higher grade of VUR (P < .001), male gender (P < .001), second injection (P = .003), and EC injection using hydrodistension implantation technique (HIT; P < .001) represented significant risk factors. At multivariate analysis, only male gender (P = .0078), younger age (P = .0044), HIT technique (P < .0001), and second injection (P = .04) represented significant risk factors for the occurrence of OC.We identified young age, male gender, high reflux grade, HIT technique, and second endoscopic injections as factors associated with the risk of OC after EC of VUR using PPC as a bulking agent. Thus, patients who have undergone EC with PPC must be monitored sonographically for occurrence of OC for at least 60 months after the intervention.
Pectus excavatum (PE) is the most common chest wall malformation and one of the most frequent major congenital anomalies. The surgical repair of PE in childhood is a well-established procedure. Previously used operative techniques to correct PE were largely based on the Ravitch technique. Today, the minimally invasive repair (MIRPE) by Nuss is well established. Conservative treatment with the vacuum bell to elevate the funnel in patients with PE represents a potential alternative.A suction cup is used to create a vacuum at the anterior chest wall. A patient-activated hand pump is used to reduce the pressure up to 15% below atmospheric pressure. Three different sizes of vacuum bell exist which are selected according to the individual patients age. When creating the vacuum, the lift of the sternum is obvious and remains for a different time period. The device should be used for a minimum of 30 min (2 per day), and may be used up to a maximum of several hours daily. Presently, a 12-15-month course of treatment is recommended. In addition, the device was used intraoperatively during the MIRPE procedure to enlarge the retrosternal space to ensure safer passage of the introducer in a few patients.Thirty-four patients (31 males, 3 females), aged 6-52 years (median 17.8 years) used the vacuum bell for 1 to maximum 18 months (median 10.4 months). Follow-up included photography and clinical examination every 3 months. Computed tomographic scans showed that the device lifted the sternum and ribs immediately. In addition, this was confirmed thoracoscopically during the MIRPE procedure. After 3 months, an elevation of more than 1.5 cm was documented in 27 patients (79%). After 12 months, the sternum was lifted to a normal level in five patients (14.7%). Relevant side effects were not noted.The vacuum bell has proved to be an alternative therapeutic option in selected patients with PE. The initial results proved to be dramatic, but long-term results are so far lacking, and further evaluation and follow-up studies are necessary. In addition, the method may assist the surgeon during the MIRPE procedure.
Rationale: Esophageal achalasia is characterized by impaired relaxation of the cardia and dilation of the intrathoracic part of the esophagus. We describe the late presentation of achalasia in an 11-year old girl. Patient concerns: She suffered from recurrent pneumonia, obstructive bronchitis, and problems with swallowing solid food. Her family noted a wet pillow in the morning. Diagnoses: This case report describes the typical symptoms of achalasia in children in order to facilitate earlier diagnosis of this rare disease. Our patient was admitted to a pediatric hospital for treatment of severe pneumonia, low-grade fever, and pancreatitis. A computed tomography (CT) scan of the thorax showed massive dilation of the esophagus and infiltration and partial atelectasis of the right lung. An upper gastrointestinal contrast study confirmed massive dilation of the esophagus and stenosis at the level of the cardia. Interventions: We performed laparoscopic Heller myotomy combined with Dor fundoplication. Bronchoscopic lavages were conducted in the pre- and postoperative period to relief obstruction of bronchi by purulent mucus secretions. Outcomes: A further upper gastrointestinal contrast study demonstrated patency of the cardia and fast propulsive movement of contrast agent into the stomach. At follow up 2 months after the operation, the girl had gained 3 kg of body weight, and her respiratory, gastrointestinal, and swallowing symptoms had subsided. At follow-up 12 months after the operation, no recurrent symptoms of achalasia were recorded. Lessons: Late presentation of achalasia in children can mimic respiratory and gastrointestinal diseases. Laparoscopic Heller myotomy combined with Dor fundoplication is feasible and advisable in children suffering from achalasia of the cardia.
