INTRODUCTION- Anterior approach to hip is commonly used for pediatric hip disorders. LFCN is exposed and dissected in this approach before deep dissection. There is a chance of injuring LFCN if its course is altered. There is a lack of literature regarding the surgical anatomy of LFCN in paediatric population.
METHODS- A total of 31 paediatric hip surgeries (among 28 children) were done for various disorders. The anterior exposure of hips was done by bikini shaped incision of Somerville approach. LFCN was exposed and its relationship to ASIS, Inguinal ligament, Sartorius & TFL muscle was studied. Position of nerve in relation to ASIS and Inguinal ligament was observed. Distance of LFCN from ASIS was measured at three points along its course. Angle of nerve trunk with inguinal ligament was also calculated.
RESULTS- In majority of surgeries (27/31) LFCN was found as a single trunk below the inguinal ligament and medial to ASIS. In this common pattern of course the measured distances and angle of LFCN in relation to ASIS and inguinal ligament were different. Variations in the anatomical course of LCFN were observed in 4 hip surgeries. In two the nerve was not found in surgical field; in one it was lying over the ASIS, which was injured inadvertently and in one multiple branches of nerve were present at the level of ligament.
CONCLUSIONS- Variation in the course of LFCN can be found in children. Knowledge regarding course and careful dissection prevents iatrogenic injury of LFCN during anterior hip surgery.

HACEK organisms are oropharyngeal commensals and a typical cause of infective endocarditis. These bacteria can cause soft tissue abscesses, septic arthritis, and osteomyelitis in the setting of trauma. Haemophilus Influenzae was one of the most common causes of septic arthritis in children before the introduction of the vaccine. Kingella kingae is increasingly recognized as a difficult-to-culture cause of osteomyelitis. A 16-month-old infant presented with a limp and limited knee flexion which worsened progressively in the last ten days. No relevant precedents besides a superior respiratory tract infection 3 weeks before. The physical examination was normal, except for a limp and loss of knee range of motion, without pain or inflammatory signs. The child was admitted for monitoring, with a presumed diagnosis of septic arthritis. Blood and synovial fluid were collected and empiric anthibiotherapy was started. After empirical treatment and recovery, the child was discharged from hospital care, with no etiological diagnosis, since culture tests were negative. Following a hospital protocol, a second sample of synovial fluid was tested for Haemophilus Influenzae and kingella kingae with a positive result. Ten days of intravenous targeted antibiotic therapy were completed and the oral route was continued for more fourteen days. Thirty days after diagnosis, he had normal radiography with total restoration of joint activity. Diagnosis of these infections can be delayed either because of the difficulty to cultivate or because of producing little inflammatory response. We need to have a high index of suspicion and take into account as their clinical relevance.

Introduction: We aimed to evaluate the radiological results of pediatric patients who underwent intramedullary elastic nail application for shaft fractures of forearm, femur and tibia. Methods: 103 patients between the ages of 5 to 16 followed at least for 2 years were included to the study. Medical records were analyzed retrospectively. Mean age at the time of operation was 9.0 (5–15) years. 82 of the patients were male and 21 were female. 43 patients had sustained femoral shaft fractures, 34 forearm bone fractures, and 26 tibial shaft fractures. Results: The mean follow-up time was 45.5 (24-85) months. Mean union time was 8.0 (5-14) weeks. Detected complications were; irritation at the nail insertion site in 8 patients, temporary nerve damage in 1 patient, superficial infection in 1 patient, nail come back in 2 patients, nonunion in 1 patient, and re-fracture in 2 patients after implant removal. None of the patients developed deformities that required surgery. 22 of the 43 patients with femoral fractures had developed an overgrowth phenomenon. Irritation findings at the nail insertion site were mostly seen in the patient group treated for forearm fractures. Varus, valgus, antecurvatum and recurvatum angulation within acceptable limits were mostly seen after femoral fractures and at least after surgery for forearm fractures. Conclusion: Intramedullary titanium elastic nail application for the surgical treatment of long bone shaft fractures in children is a minimally invasive method, provides good functional and cosmetic results, short hospital stay, low probability of growth arrest and low complication rates.

Methods – A prospective and retrospective study done from December 2010 to January 2018 at tertiary centre. A total of 12 knees in 7 patients were included (5 females and 2 males). 5 were bilateral and 2 unilateral. All cases were non syndromic. All attendants gave informed consent for participation in the study. All cases presented within 2 weeks of birth (range, 2 to 14 days, mean age 8 days). 4 patients required intervention in form of percutaneous needle quadriceps tenotomy in 3 and quadricepsplasty in 1 case. Outcome was measured using knee evaluation score and complications. Results – The mean degree of preoperative hyperextension was 75 (range, 40 to 110). 8 knees had flexion more than 90 degrees at presentation treated with cast application. 3 knees had flexion between 50 to 90 degrees treated with percutaneous needle tenotomy and 1 case had flexion less than 30 degrees initially treated with needle tenotomy but could not attain correction intraoperatively so quadricepsplasty was done in same sitting. Mean knee flexion at end of treatment was 130 degree (range,120 to 140 degree). At mean follow up of 37 months, overall functional outcome was good in 11 knees and fair in one patient who underwent quadricepsplasty. There was no postoperative infection and no extension lag. Conclusion – No difference in final outcome was noted between conservatively treated and percutaneous tenotomy cases. But compromised outcome was seen in case with preoperative stiff knee with flexion less than 30 degree.Key words – congenital knee dislocation

Introduction: Congenital dislocation of the knee (CDK) is a relatively rare condition. It may occur as an isolated deformity or associated with musculoskeletal anomalies such as developmental dysplasia of the hip and clubfoot, or it may occur as part of syndromes. Treatment options include serial casting to open reduction. We present our experience in managing CDK in Infants.Methods: 17 infants with 28 Knees were treated at our centre in the year 2018 to 2020. 7 children were treated by Serial casting alone and 10 children underwent Open reduction. We lost one patient who succumbed to her multiple cardiac anomalies on post-operative day 2 and hence was excluded from the final follow up.Results:At the final follow up the patients were graded based on Power of extension, pain and instability of the affected knee and graded as per the Modified Knee Functional Scoring System . 44.4 % (n=12) had excellent results, 40.7% (n=11) had good outcome, and 14.9 % (n=4) had fair results at the final follow up at the end of 6 months.Conclusion: Based on modified CDK grading, serial casting is performed in patients with Grade 1 CDK. In Grade II CDK in neonates serial casting is started. A maximum of six weekly manipulations and castings were attempted. If a range of flexion >60° is achieved, serial casting is continued; if range of flexion remains <60° it is necessary to proceed to Open reduction. Open reduction was also indicated in patients with Grade III CDK or in recurrent cases.

Introduction: Congenital femoral deficiency (CFD) is a rare birth defect that is characterized by a short femur, associated with hip and knee deformity, deficiency, or instability. During limb lengthening, it can occur knee subluxation or dislocation, a severe treatment-related complication

Case-report: A six-year-old girl with a CFD was treated with a femoral lengthening using a monolateral external fixator. After 2 months of distraction, a posterior subluxation of the knee was noted, so she removed the monolateral fixator. Over the next few years, she presented several complications, namely, fracture at the osteotomy site, failure of plate osteosynthesis, infection. Eleven years later, she had a 13cm limb-lengthening discrepancy (LLD) and coxa vara, therefore it was applied a knee spanning Ilizarov’s fixator with a double osteotomy of the femur for gradual correction.

Results: At 11 months following Ilizarov application, complete correction was achieved and the circular fixator was removed. In the postoperative teloroentgenogram, she had a 1cm LLD, with an improvement of the left limb axial malalignment.

Discussion: Almost all CFD can be assumed to have mild to moderate anteroposterior knee instability. In order to prevent subluxation during lengthening, the knee joint still has to be bridged by the external fixator. The safest way of lengthening is, therefore, the preventive bridging of the knee with a circular frame

Conclusion: Adequate surgical techniques, preventive measures and early detection of signs of subluxation can lead to good functional results. We presented a successful treatment of a rare case of CFD with knee instability.

Midtarsal joint dislocations (Chopart dislocation) are not common in children.
They are caused by high-energy trauma. They affect the talonavicular and calcaneocuboid joints and their stabilizing ligaments, involved in the inversion and eversion movements of the foot in conjunction with the subtalar joint.
Case Presentation: 14-year-old male with pain and deformity in his right foot due to a forced inversion mechanism after jumping while playing basketball.
Radiographs showed a dislocation of the Chopart joint without associated fractures.
Closed reduction and splint immobilization were performed under deep sedation. In the posterior radiographs and CT, a correct joint congruence without associated fractures was observed, so it was decided a conservative management.
Clinical and radiological follow-up was carried out in consultation, immobilization was maintained for 4 weeks and progressive joint mobilization was allowed afterwards. Partial weight bearing was authorized after 6 weeks.
9 months after the accident the patient achieved a complete inversión and eversión of the foot and normal gait with no pain, being able to return to his usual sports activity.
Conclusion: Urgent reduction and immobilization are essential in chopart dislocations in order to avoid short and long term complications. Surgery will be performed when we can not achieve an adequate joint congruence, necessary to recover the correct functionality of the foot.

Background: Scapholunate ligament (SLL) rupture remains a rare entity in the realm of paediatric injuries and can be difficult to diagnose due to the incomplete ossification of the carpal bones in young children. The treatment of such injuries can be complicated as there is the possibility of disrupting growth in the immature carpus with surgical intervention, or ongoing wrist instability with non-operative management. Case: An 11-year-old child presented after a fall unto the wrist. She was managed as a soft tissue injury and her radiographic imaging was reported as showing no injury. Initial non-operative management was unsuccessful with persistent wrist instability. Magnetic Resonance Imaging (MRI) demonstrated a rupture of the SLL. She subsequently underwent reconstruction utilising extensor carpi radialis brevis. Her follow up demonstrated a stable wrist with good range of movement. Discussion: This unusual injury is not considered in the young paediatric population. The youngest age for SLL rupture reported in literature is 7 years. Widening of the scapholunate interval on a posteroanterior radiograph indicates a diagnosis of scapholunate ligament dissociation in adults. In children, this interval is age dependent and normally appears widened during early life due to the cartilaginous carpal bones. Therefore, this poses diagnostic difficulty in this population. Conclusion: Though scapholunate ruptures are rare in prepubescent children, they can still occur. We highlight this uncommon case to raise awareness of this injury and timely management to minimise long term sequelae in this young population

Background: The purpose of this study was to evaluate the impact of the training course on the image quality of infant hip ultrasound in the contest of developmental dysplasia of the hip which is a condition that can deteriorate if the diagnosis is late or inadequate. A focused hip US training course was conducted in April 2019 to improve hip US imaging quality. Methodology: A retrospective review of 120 hips (60 infants) ultrasound images that were performed between April 2018 to April 2020. Based on internationally agreed criteria, sixty hip images obtained before the course were compared to another 60 hip images obtained after the course. Inter-raters and intra-raters’ agreements were also evaluated using interclass correlation among three critical variables. Results: The study demonstrated that the focused training had improved the percentage of images that meet the standard (48% to 82%, χ2: P<0.001). It has also improved the inter-raters and intra-raters significantly ICC=0.97. Conclusion: The study confirms the value of focused training in improving the quality of care. This should be carefully planned and targeted to address a limited shortfall or gaps in services.

Superior mesenteric artery syndrome (SMAS) is an uncommon disease resulting from compression of the third portion of the duodenum by the superior mesenteric artery. Typical symptoms are anorexia, nausea, bilious vomiting, early satiety, abdominal pain and postprandial fullness. A 20 year fibrodysplasia ossificans progressiva patient presented with 38 kilogram weight loss over 6 months. He had epigastric pain, bloating,postprandial fullness, syncope and intermittent bilious vomiting. His Jaw was not involved, he could open his mouth. He had been examined by a number physicians of with no significant clinical findings. Routine blood and urine examination were normal. Ultrasonography of the abdomen, gastroscope, echocardiography and MRI of brain were normal. Contrast enhanced computed tomography showed extrinsic compression of the third part of duodenum between aorta and SMA. The aortomesenteric distance was 4.3mm. Thus, based on the history, the weight loss may have induced the compression of the third part of the duodenum. In this case, the clinical and the imaging findings of the patient concluded the diagnosis of SMAS. He was managed conservatively over 3 weeks with peripheral parenteral nutrition and gastric decompression via a nasogastric tube. He was tolerated oral diet in the form of fractionated meals 4 weeks later and discharged with outpatient follow-up and weight monitoring.In the 12 months follow-up, the patient was asymptomatic. Chronic weight loss is a common risk factor for developing SMAS. Symptoms are non-specific and high clinical suspicion is of utmost importance, especially in patients with severe weight loss and symptoms of gastric distension.

Background: It is rare to see chronic bilateral anterior fracture dislocations as a result of seizure, and we present a case of this type and review of the literature. Case: A 16-year-old boy presented to the emergency department with reduced range of movements in both shoulders. Six weeks prior he had suffered an epileptic seizure. He had a squared appearance to both shoulders. Active and passive range of motion was symmetrically severely reduced. X-rays confirmed bilateral anterior shoulder dislocations with displaced greater tuberosity (GT) fractures. Staged open reduction was performed in the right and then left shoulder. Coracoid osteotomy with take down of the malunited GT fracture was needed to assist with gradual soft tissue contracture release and a successful relocation. Latarjet procedure was then performed and the GTs were fixed using rotator cuff anchors. Clinical Outcomes: At 6 months post operation, on the right side, he achieved forward flexion to 150 degrees and abduction to 120 degrees. On the left side, forward flexion was 110 degrees and abduction was 90 degrees. X rays showed satisfactory maintenance of the reduction without signs of avascular necrosis of the humeral head. Discussion: Our case represents the first example of chronic bilateral locked anterior fracture-dislocations requiring open reduction and coracoid osteotomy with GT take down to gain adequate exposure and allow soft tissue release to facilitate joint reduction. No other case has used anchors to achieve GT fixation, and our patient is the youngest published case with such pathology.